皮瓣修复足跟部软组织缺损疗效的研究

目的 探讨采用局部带蒂转移皮瓣或游离皮瓣对足跟软组织缺损修复的疗效.方法 手术分期进行,一期行清创术,二期根据足跟软组织缺损的大小、部位及受伤的复杂性,综合分析选择治疗方法,分别选择局部带蒂转移皮瓣和游离皮瓣修复足跟缺损.结果 31例术后经8～35个月随访(平均22个月),皮瓣全部成活;根据自行制定的评价体系综合评价得分,优8例,良12例,可8例,差3例,优良率为64.5%.结论 综合评价供区和受区的解剖学基础,灵活运用选择皮瓣是足跟软组织缺损修复的关键;感觉功能重建是足跟软组织缺损修复重建的至关重要因素.     

带血管腓骨移植及游离股前外侧皮瓣再造跟骨1例并文献复习

【】 目的 探讨应用带血管腓骨移植及游离股前外侧皮瓣再造跟骨治疗中所遇到的困难及处理方法。方法 分析1例足跟部复合组织缺损病例的治疗(一期采用逆行带血管蒂腓骨移植重建修复跟骨,游离带神经股前外侧皮瓣修复足跟部皮肤缺损,吻合皮瓣皮神经与近侧腓浅神经重建足跟感觉功能)的基础上,回顾相关文献。 结果 本例皮瓣一期成活,再造足跟外形良好,术后８月移植腓骨与受区骨骼完全愈合并取除内固定,开始部分负重行走,术后1年开始完全负重行走,经随访4年皮瓣两点辨别觉达到1.5cm,负重行走皮瓣无磨破现象,能满足日常生活需要。结论 足跟部复合组织缺损通过组织移植能得到很好的修复,后期足部功能相对较为满意,但手术方法复杂,仍存在较大改进空间。     

Functional reconstruction of complex tendo Achilles defect by free latissimus dorsi muscle flap

Managing the complex tendo Achilles defect involves reconstructing the Achilles tendon as well as providing soft tissue cover to the heel area. The advent of microsurgery has revolutionised the reconstruction of this difficult defect providing a number of options to the reconstructive surgeon. We present a case of complex tendo Achilles defect reconstructed by the latissimus dorsi free flap.KEY WORDS: Complex defect, reconstruction, tendo-Achille     

A comparison of transpositional neurovascular skin flaps for reconstruction of diabetic heel ulcerations

The diabetic heel ulcer is a common, yet difficult, entity to manage. Conservative and surgical treatments are frequently unsuccessful. Transpositional neurovascular skin flaps offer a relatively new and effective method for reconstruction of this defect. The medial plantar, dorsalis pedis, and lateral calcaneal flaps are discussed and compared for use in the diabetic patient with heel ulceration.     

腓肠神经营养血管蒂逆行岛状皮瓣的临床应用

目的探讨腓肠神经营养血管蒂逆行岛状皮瓣的临床应用.方法采用腓肠神经营养血管蒂逆行岛状皮瓣修复足跟软组织缺损8例.结果皮瓣全部成活,效果满意.该皮瓣可修复足背近1/2及足底近3/5的软组织缺损.结论该皮瓣是修复足踝部尤其是足跟软组织缺损的一种较理想的方法.     

Functional total and subtotal heel reconstruction with free composite osteofasciocutaneous groin flaps of the deep circumflex iliac vessels

Functional and esthetic reconstruction of the bony and tendinous structures with a stable, sensate soft tissue integument after complex posttraumatic defects of the heel is demanding. Cases are rare in the literature and hardly comparable due to their heterogeneity. The reconstructive approach has to consider both patient profile and the reconstructive tree, with free microvascular flaps playing a primary role. The goals are the reconstruction of both osteotendinous structures and slender soft tissue lining for proper shoe fitting for ambulation and mechanical and thermal protection. The flap should be sensate in weightbearing areas to optimize gait and to prevent long-term complications by ulcers. The osteofasciocutaneous deep inferior circumflex artery (DCIA) flap is especially suitable for complex heel defects with subtotal or total loss of the calcaneal bone as all components (iliac bone, groin skin, and fascia lata) can have a wide range of size and shape. We operated on 2 cases with this variable composite flap. One patient had a complete heel defect by war shrapnel. The complete calcaneus, soft heel, and Achilles tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and a lateral crush-induced soft tissue defect. In both patients, a stable wound closure, osseous integration, and weightbearing ambulation could be achieved.     

Experience with the Distally Based Sural Flap: A Review of 25 Cases

The reconstruction of soft tissue defects in the distal areas of the lower extremity remains a challenge. The distally based sural neurocutaneous flap based on the sural nerve and the superficial sural artery has been used for skin defect reconstruction of the distal third of the leg, the hindfoot, ankle, and heel. We describe our experience and evaluate the reliability of this surgical technique. From 2004-2010, 25 patients with an average age of 32.5 (6 to 70) years were treated using the distally based sural flap for reconstruction of skin defects of the lower third of the leg, the heel, the ankle, and the hindfoot. The skin defect was secondary to trauma in 20 patients (80%) and compromised tendon or bone in all cases. One venous congestion and 2 partial flap necroses were observed. The mean follow-up was 25 (9 to 46) months. The plastic result was assessed as satisfactory in all patients. The donor site morbidity was minimal. The sural flap is a good way to reconstruct soft tissue defects of the lower extremity; this surgical technique provides an alternative to microsurgical reconstruction.     

逆行岛状腓骨肌皮瓣再造足跟

目的探讨逆行岛状腓骨肌皮瓣的血供基础及足跟再造。方法应用解剖学的方法研究腓骨肌皮瓣血供及跟骨的生物力学特征,并在标本上进行摹拟手术。1998年5月为1例右足跟爆炸伤后2个月,全足跟缺损患者采用腓血管蒂逆行岛状腓骨肌皮瓣移位修复,腓骨瓣长14cm,带部分腓骨肌及(口)/(止)母长屈肌,皮瓣为14cm×12cm。结果①腓动脉下端与胫前、胫后动脉有丰富且粗大的吻合,完全可提供逆流供血;血管蒂旋转点因手术需要而定,最低点为外踝上6cm,此处血管蒂解剖可长达20cm;②该瓣的形态与跟骨的生物力学特征相适应,临床应用者术后腓骨肌皮瓣成活好,随访10个月获得满意效果。结论逆行岛状腓骨肌皮瓣可修复足跟严重缺损,尤其为跟骨及骰骨完全缺失者提供了一种新方法。     

足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部软组织缺损

目的探讨足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部皮肤软组织缺损的临床效果。方法回顾性分析2015年10月至2020年12月榆林市第二医院烧伤整形手足外科收治的足跟部皮肤软组织缺损患者的临床资料。患者经急诊清创或扩创后,应用足底内侧岛状皮瓣修复足跟部创面,腹股沟游离皮瓣修复足底内侧供区创面,腹股沟供区直接缝合。术后观察皮瓣血运及存活、皮瓣供区愈合情况,并对足跟外形与功能恢复情况进行随访。结果共纳入8例患者,男7例,女1例,年龄20~71岁,平均32.2岁。其中5例为足跟外伤,1例足跟鳞状细胞癌,1例足跟冻伤,1例足跟溃疡。足跟部创面面积4 cm×3 cm~7 cm×6 cm。手术过程顺利,足跟岛状皮瓣及腹股沟皮瓣切取范围较足跟创面扩大0.5~1.0 cm。8例患者术后皮瓣血运良好,创面均一期愈合。术后随访3~12个月,所有患者足跟弹性佳,外形无臃肿,耐磨、耐压,感觉及行走功能满意;足底内侧供区无凹陷,无瘢痕增生及挛缩,无局部皮肤溃疡;腹股沟供区仅见线性瘢痕。结论足底内侧岛状皮瓣联合腹股沟游离皮瓣修复足跟部缺损,足部外观及功能恢复良好,效果满意。     

足跟皮肤软组织缺损的皮瓣修复

目的介绍应用多种皮瓣修复足跟皮肤软组织缺损的经验。方法1993年8月-2007年4月治疗242例足跟部皮肤软组织缺损患者。男157例，女85例；年龄27～76岁。病变类型：不稳定瘢痕35例，慢性溃疡46例，鳞状细胞癌57例，恶性黑色素瘤72例，创伤引起的组织缺损32例。创面均位于足跟部，51例伴轻度感染，皮肤软组织缺损范围2cm×2cm～14cm×8cm。患者病程1h～5年。根据创面的部位、皮肤软组织缺损的范围分别选用岛状或游离（肌）皮瓣修复足跟创面，其中足跟外侧皮瓣34例，足背岛状皮瓣15例，足底内侧岛状皮瓣108例，腓肠神经营养血管皮瓣36例，隐神经营养血管皮瓣26例，游离（肌）皮瓣23例。行腓肠神经营养血管皮瓣和隐神经营养血管皮瓣感觉重建13例。切取（肌）皮瓣范围3．0cm×2．5cm～15．0cm×9．0cm。供区采用直接缝合或皮片移植修复。结果术后235例皮瓣全部成活，创面I期愈合；5例皮瓣远端部分表皮坏死，经局部换药后成活；2例切口轻度感染，经局部换药处理后创面II期愈合。供区创面均I期愈合，移植皮片完全成活。217例患者获随访，随访时间1～60个月，皮瓣色泽正常，质地较正常足跟组织柔软、可耐磨、外形轮廓满意；经训练术后6个月基本可正常负重行走，步态正常。118例肿瘤患者获随访，局部均无肿瘤复发，其中22例恶性黑色素瘤患者术后12～26个月发现有远处转移病灶，随访至60个月的32例恶性黑色素瘤患者未发现远处转移病灶。结论应用不同岛状或游离（肌）皮瓣修复足跟部创面，可达到较理想的足跟功能重建和外形重塑效果。     

A single-stage reconstruction of a complex Achilles wound with modified free composite lateral arm flap

Composite defect of the posterior aspect of the heel, including the Achilles tendon, usually is very difficult to reconstruct as we face the problems of controlling infection, resurfacing the deficient skin defect, and restoring plantar flexion. With the latest advances in microsurgery, several free composite flaps have been used to reconstruct the defect in the Achilles tendon region to achieve stable and functional soft tissue coverage. We report such a single-stage reconstruction of a complex Achilles wound using the modified neurosensory lateral arm free flap including the triceps tendon strip and the posterior cutaneous nerve. Authors' rolled-up triceps tendon strip method is presented for the one-stage reconstruction of the Achilles tendon and soft tissue defect, providing good contour, strong tension, and protective sensation. The follow-up has proved a satisfactory outcome.     

足底内侧皮瓣在足跟部恶性黑色素瘤的应用

目的探讨足跟部恶性黑色素瘤的手术切除和修复重建的方法。方法5例老年足跟部恶性黑色素瘤患者，手术行局部扩大切除，切缘距病损2cm，深度达跟骨骨膜，足跟部软组织缺损Ф5～9cm，根据缺损大小，用带足底内侧血管神经束的皮瓣移位修复，皮瓣面积8cm×6cm-10cm×8cm。结果5例皮瓣全部成活。随访2年6个月～5年，患者均健在，肿瘤未见局部复发，皮瓣感觉功能良好，患足功能与对侧相比无明显差异。结论足跟部恶性黑色素瘤应行局部扩大切除术，切除范围应距肿瘤边缘不小于2cm为宜，在切缘阴性的基础上进行修复重建，应用足底内侧皮瓣移位修复，临床疗效满意。     

Instep free flap for plantar soft tissue reconstruction: indications and options

Pedicled instep flaps are frequently used in weight-bearing plantar reconstruction, but may not be available after severe foot injuries. Although free instep flaps offer a viable option, they have scarcely been reported. A posttraumatic plantar forefoot defect was reconstructed with a sensate, instep free flap, because local flaps were not available and defect size did not require a distant free flap, and the current literature was reviewed for therapeutic options. The instep free flap yielded an excellent functional and aesthetic long-term result. In the literature, pedicled instep flaps are advocated for moderate size defects of the weight-bearing heel and sole, while free flaps from distant sites are preferred for large defects. Although skin-grafted muscle flaps and fasciocutaneous flaps yield similar results, reconstruction by like tissues appears favorable. We suggest the instep free flap for weight-bearing plantar foot reconstruction, when pedicled instep flaps are not available and distant free flaps are avoidable.     

足跟部皮肤恶性肿瘤切除术后皮瓣修复的临床疗效分析

目的探讨足跟部皮肤恶性肿瘤切除术后的创面采用皮瓣修复的临床疗效。方法本组11例患者中，患恶性黑色素瘤者8例、交界痣恶变者2例、慢性溃疡恶变者1例。对所有患者的肿瘤部位首先行距病灶边缘0．5～2．0cm广泛切除，然后分别采用四种不同类型带蒂皮瓣进行修复。结果术后随访患者6个月至3年10个月，所有皮瓣均存活，皮瓣感觉恢复良好，有2例患者肿瘤局部复发。结论为避免肿瘤局部复发，切除足跟部皮肤恶性肿瘤时，需距病灶边缘2cm以上行扩大切除。修复切除后的创面不宜应用局部旋转皮瓣。采用足底内侧皮瓣对足跟部负重功能的修复效果较好，足跟部外侧和内侧的创面可采用足外侧皮瓣或内踝上皮瓣修复。腓肠神经伴营养血管蒂皮瓣可修复整个足跟部创面。     

A challenging treatment for an ischaemic ulcer in a patient with Buerger's disease: vascular reconstruction and local flap coverage.

An ischaemic heel ulcer in a patient with Buerger's disease was reconstructed using an in situ saphenous vein graft combined with a local flap. The bypass was sufficient to restore blood supply to the ischaemic limb but a flap was necessary to cover the persistent heel ulcer, which remained after revascularisation. One month after bypass surgery the ulcer was debrided and the resulting defect was covered with a lateral supramalleolar flap. The postoperative course was uneventful and the flap donor site healed well. When treating ischaemic ulcers in a patient with Buerger's disease, vascular reconstruction should be considered first in order to salvage the limb. After revascularisation, a local flap can be used to cover a persistent defect but very few local flaps have been reported. This report is the first published case of successful local flap transfer after bypass surgery in a patient with Buerger's disease. We think that a local flap is one possible treatment for a non-healing ulcer after revascularisation.     

Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps

Soft tissue heel defects reconstruction represents a challenge for plastic surgeons because of the poor availability of regional tissue to perform the reconstruction. We divide the heel on the anterior or weight-bearing heel and the posterior or non-weight-bearing heel. Our preferences are the fasciocutaneous instep flap for anterior heel defects and the reverse sural flap for posterior heel defects. We have performed 11 reconstructions of the heel. The complications were total necrosis of 1 instep flap in a previously irradiated patient and 1 case of partial tip necrosis in a reverse sural flap. Functional recovery has been very satisfactory for both procedures. Regional island flaps are for us the first therapeutic option because the skin is similar to the lost one and less time consuming than a free-flap reconstruction.     

Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm², and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.     

Single-stage Achilles tendon reconstruction using a composite sensate free flap of dorsalis pedis and tendon strips of the extensor digitorum longus in a complex wound

The reconstruction of the posterior heel including a wide defect of the Achilles tendon is difficult as a result of complicated infection, deficient soft tissue for coverage, and functional aspects and defects of the tendon itself. As a single-stage procedure, various methods of tendon transfer and tendon graft have been reported along with details of local flaps or island flaps for coverage. With advances in microsurgical techniques and subsequent refinements, several free composite flaps, including tendon, fascia, or nerve, have been used to reconstruct large defects in this area without further damaging the traumatized leg. The authors report such a single-stage reconstruction of a composite Achilles tendon defect using the extensor digitorum longus tendon of the second to fourth toe in combination with a dorsalis pedis flap innervated by the superficial peroneal nerve. The follow-up of this case has proved a satisfactory outcome to date.     

Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: Long-term outcome

OBJECTIVE: To assess long-term outcome and prognostic factors for extreme surgery by vascular and plastic surgical teamwork for leg salvage in patients with critically ischemic large tissue defects. SUMMARY BACKGROUND DATA: Combined vascular reconstruction and microvascular free-flap transfer has been used to improve distal perfusion and cover large tissue defects caused by the critical limb ischemia (CLI) in few dedicated centers during the past 15 years. Comorbidities compromise the results of these demanding operations, and it is unclear how far this mode of treatment should be extended. METHODS: During 1989 to 2003, altogether 2157 vascular or endovascular revascularizations for CLI manifested as tissue lesions were performed. These included 81 revascularizations combined with microvascular free flap transfers in 79 patients (37-85 years). All the patients were candidates for major amputation. The patients were followed up at least 2 years or to death (mean follow-up, 62 months; SD, +/-34 months). RESULTS: One- and 5-year leg salvage rates were 73% and 66%, survival rates 91% and 63%, and amputation-free survival rates of 70% and 41%, respectively. Male gender and American Society of Anesthesiologists score 4 were associated with an increased risk of death, whereas the involvement of the heel mostly with calcaneal osteomyelitis and a large size of defect predicted major amputation. CONCLUSIONS: A combined vascular reconstruction and free-flap transfer offers an option for advanced limb salvage in a selected group of patients with CLI and a major tissue defect. Poor general condition, the involvement of the heel, and a large defect would indicate an amputation over extreme attempts for limb salvage.     

Covering small defects on the weight bearing surfaces of the foot: the free temporal fasciocutaneous flap.

Although defects in the weight bearing area of the heel can be covered by local flaps, radiodermatitis is a contraindication to these flaps. Thin free flaps, as grafted fascial or muscles flaps and thin fasciocutaneous flaps, are usually the option of choice in these particular defects. These reconstructions are prone to shearing strains resulting in ulceration, hypertrophic scars and hyperkeratosis. The authors present a retrospective study of the reconstruction of six small heel defects with the fasciocutaneous temporal free flap performed between 1996 and 2001. The mean size of the defect was 20 cm(2). All arterial anastomoses were performed end to side on the posterior tibial artery. Despite the flap thinness, swelling was present during 12-25 months and one debulking had to be performed. With a mean follow-up of 32 months, all flaps regained protective sensibility after 7 months. No sliding of the flaps could be noted but there was one transient hyperkeratosis. Although the amount of hair on the transferred flaps decreased spontaneously with time, laser hair removal was performed in two patients for psychological reasons. In conclusion, it seems that in selected cases where local flaps are contraindicated, the fasciocutaneous temporal free flap can offer an excellent alternative for heel reconstruction. Due to its particular architecture, it resembles the complex tissue of the sole of the foot resulting in fewer complications and maintenance of flap durability.