Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap

IntroductionAchilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue.Methods7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel.ResultsThe size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage.ConclusionDistally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.     

以腓动脉远端穿支血管供血为蒂的小腿后外侧（复合）组织瓣的临床应用

目的探讨腓动脉穿支供血的小腿后外侧（复合）组织瓣在足踝部软组织缺损、骨感染修复中的临床效果。方法2007年3月至2010年9月,对23例足踝部软组织（跟腱）缺损及骨感染的患者,设计以腓动脉终末穿支为血管蒂,沿腓肠神经营养血管轴线切取皮瓣转位修复小腿下段及足踝部皮肤软组织缺损。采用腓动脉下段穿支供血携带腓肠神经逆行岛状（复合）皮瓣或肌皮瓣进行修复。皮瓣切取范围3cm×5cm～10cm×18cm。结果术后21例皮瓣完全成活,创面一期愈合,2例皮瓣边缘部分坏死,后经过二期扩创游离植皮后痊愈,平均住院时间21d。随访2～9个月,皮瓣质地优良,外观满意,无色素沉着、溃疡,皮瓣感觉恢复约S2,跟腱重建患者踝关节达功能位,恢复了劳动能力。结论以腓动脉远端穿支血管供血为蒂的小腿后外侧（复合）组织瓣血供可靠,变异率低,切取方便,供区隐蔽,可恢复部分感觉,且不牺牲肢体主要血管,是修复小腿中下部、踝关节周围及足部软组织缺损的一种良好方法。尤其对修复足踝部骨外露,骨髓炎,跟腱缺损,复合组织瓣（携带跟腱及肌肉）是一种较好的选择。     

Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications

The distally based sural neuro-veno-fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. The distal pivot point of the flap is designed at the lowest septocutaneous perforator from the peroneal artery of the posterolateral septum, which is, on average, 5 cm (4-7 cm) above the lateral malleolus. A longer neuro-veno-adipofascial pedicle would be needed to reversely reach the distal foot defect when the flap is dissected based on this perforating branch, which may result in more trauma in flap elevation and morbidity of the donor site. In this article, we explored new pivot points for this distally based flap in an anatomic study of 30 fresh cadavers. The results showed that the peroneal artery terminates into two branches: the posterior lateral malleolus artery and lateral calcaneal artery. These two branches also send off cutaneous perforators at about 3 and 1 cm above the tip of lateral malleolus, respectively, which can be used as arterial pivot points for the flap. A communicating branch between the lesser saphenous vein and the peroneal venae comitantes was found, accompanied by the perforator of the posterior lateral malleolus artery. This modified, distally based sural flap with lower pivot points was successfully transferred for repair of soft-tissue defects in 21 patients. The size of flaps ranged from 4 x 3 cm to 18 x 12 cm. All flaps survived without complications. Neither arterial ischemia nor venous congestion was noted. In conclusion, the vascular pivot point of a distally based sural flap can be safely designed at 1.5 cm proximal to the tip of the lateral malleolus. This modified flap provides a valuable tool for repair of foot and ankle soft-tissue defects.     

带髂胫束的股前外侧皮瓣游离移植一期修复跟后区组织缺损

目的评定带髂胫束的股前外侧皮瓣游离移植一期修复跟后区组织缺损的疗效。方法2000年1月~2005年1月,收治跟腱合并跟后区皮肤缺损11例。其中男7例,女4例,年龄6~45岁。6例为跟腱合并跟后区皮肤缺损,5例为跟腱、跟后区皮肤合并跟骨骨折或部分跟骨缺损。皮肤缺损范围6cm×5cm~14cm×8cm,跟腱缺损长度5~11cm。皮瓣切取范围11cm×6cm~17cm×11cm。髂胫束的切取长度7~13cm,宽度3~5cm。将髂胫束内外侧缘内翻缝合成腱状形成双层髂胫束重建跟腱。供区创面直接缝合5例,余6例行游离全厚皮片植皮。结果术后所有皮瓣均成活,伤口期愈合。获随访6个月~4年。根据尹庆水疗效评价标准优6例,良4例,可1例。Thompson试验和提踵试验均为阴性。无跟腱再断裂、跟区皮肤破溃等并发症发生,足跟部两点辨别觉6~8mm。结论带髂胫束的股前外侧皮瓣游离移植是一种有效且能一期修复跟腱合并跟后区皮肤缺损的手术方法。     

Long-term results with the proximally-based neurovascular lateral calcaneal flap.

From 1995 to 1997, the proximally-based neurovascular lateral calcaneal flap was used in eight patients to cover defects in the Achilles tendon area or the lateral malleolar region. The mean postoperative follow-up was 40 months (range 29-51). The outcome of the operation was investigated both clinically and using a questionnaire sent to patients. All flaps healed uneventfully within a mean of 33 days. Revisional operations were required in two cases because of pain at the donor site. No flaps had broken down up to the follow-up, which was between three and five years. Two of the patients operated on were paraplegic, and the other six patients had sensate flaps. Five of the six patients with sensate flaps were able to wear normal shoes and one patient needed a shoe elevated by about 7.5 cm because of a disease independent of the flap. All but two patients were satisfied with the functional and aesthetic results. The proximally-based neurovascular lateral calcaneal flap proved to be safe and can be recommended as a good option to cover tissue defects in the Achilles tendon area or the lateral malleolar region.     

LONG-TERM RESULTS WITH THE PROXIMALLY-BASED NEUROVASCULAR LATERAL CALCANEAL FLAP

From 1995 to 1997, the proximally-based neurovascular lateral calcaneal flap was used in eight patients to cover defects in the Achilles tendon area or the lateral malleolar region. The mean postoperative follow-up was 40 months (range 29-51). The outcome of the operation was investigated both clinically and using a questionnaire sent to patients. All flaps healed uneventfully within a mean of 33 days. Revisional operations were required in two cases because of pain at the donor site. No flaps had broken down up to the follow-up, which was between three and five years. Two of the patients operated on were paraplegic, and the other six patients had sensate flaps. Five of the six patients with sensate flaps were able to wear normal shoes and one patient needed a shoe elevated by about 7.5 &#114 cm because of a disease independent of the flap. All but two patients were satisfied with the functional and aesthetic results. The proximally-based neurovascular lateral calcaneal flap proved to be safe and can be recommended as a good option to cover tissue defects in the Achilles tendon area or the lateral malleolar region.     

Radial forearm free flap for coverage of postoperative lateral heel wounds after open reduction and internal fixation of the calcaneus

For intraarticular calcaneus fractures, open reduction and internal fixation has become commonplace for the reduction of morbidity of postinjury arthritis. Despite adequate surgical results, there are often associated postoperative wound complications. The purpose of this study was to describe a unique application of the radial forearm free flap for coverage of lateral postoperative heel defects seen after calcaneal fixation. Seven lateral heel wounds after open reduction of calcaneal fractures in 6 patients were covered with radial forearm free flaps. The technique used involved passage of the pedicle of the laterally placed flap anteriorly to the Achilles tendon so that it can be anastomosed to the posterior tibial artery. Flap application was 100% successful, with good functional and cosmetic results in all patients. The radial forearm free flap provides a quick, reliable, and easily harvested source of coverage for lateral heel wounds seen after open reduction and internal fixation of the calcaneus. Tunneling of the flap pedicle anterior to the Achilles tendon is simple and provides the additional advantages of access to reliable vessels, reduced scarring, and avoidance of further wound problems often seen with incisions used to access the anterior tibial artery.     

The Distally Pedicled Peroneus Brevis Muscle Flap Anatomic Studies and Clinical Applications

Defects in the distal third of the lower leg with bone or tendon exposure may require local or free flap reconstruction. For small and moderate lesions, the distally pedicled peroneus brevis muscle flap may be an effective procedure with less morbidity than a free tissue transfer. Six cadaveric specimens were dissected to determine the location of distal pedicles and the flap type. This flap was found to be a Type IV flap, and the location of distal pedicle was always located within 6 cm from the fibula tip. This flap was performed on 6 patients to cover defects in the distal third of the lower leg. The defect areas were the pretibial region in 2 cases, the lateral malleolus in 3 cases, and the Achilles tendon in 1 case. The peroneus brevis muscle was detached from the uppermost point of the fibula to obtain enough length to cover the defect. All flaps survived except 1 that experienced distal flap necrosis. Minor complications included skin graft failure in 2 cases. However, the final results demonstrated a smooth contour that eliminated dead space. Limited donor site morbidity was obtained in all cases. The distally peroneus brevis muscle flap therefore offers an alternative for reconstructive surgeons dealing with soft tissue defects of the lower leg.     

特殊毁损性创面的修复与重建

目的报道特殊毁损性创面的修复与重建.方法1993年1月～2000年12月收治147例患者的毁损性创面175处,其中电烧伤96例,热压伤18例,一氧化碳中毒昏迷、癫痫发作等原因烧伤18例,药物渗漏、创面感染致深部组织坏死6例,放射性烧伤3例,化学烧伤2例,爆炸伤2例,冻伤2例.175处毁损性创面应用局部皮瓣,前臂逆行岛状皮瓣,胸大肌皮瓣,胸三角皮瓣,背阔肌皮瓣,腓肠肌肌皮瓣,胫前、胫后动脉岛状皮瓣等修复.创面缺损范围1cm×1cm～20cm×28cm,皮瓣最大22cm×30cm,最小1.5cm×2.0cm,同时行去细胞异体肌腱移植,修复缺损肌腱7例.结果169个皮瓣全部成活,创面Ⅰ期愈合;6个皮瓣远端小部分坏死,经切除坏死痂皮植皮愈合;7例去细胞异体肌腱移植全部成活.28例经4个月～8年随访,功能、外形均满意.结论根据毁损性创面部位、范围和程度,选择不同类型的皮瓣进行修复和去细胞异体肌腱移植,是恢复功能、改善患者生活质量的理想方法.     

胫前动脉踝上穿支皮瓣修复足踝部软组织缺损19例

目的探讨胫前动脉踝上穿支皮瓣修复足踝部软组织缺损的临床疗效。方法回顾性研究2018年4月至2019年6月采用胫前动脉踝上穿支皮瓣修复足踝部软组织缺损19例的资料,其中男11例,女8例;年龄为21~75岁,平均39岁。根据前踝上穿支皮瓣解剖学基础,按照足踝部软组织缺损大小和形状,在小腿下端前外侧设计并切取皮瓣转位修复创面。切取胫前动脉踝上穿支皮瓣面积为6.0 cm×5.0 cm^14.0 cm×8.0 cm,均为带蒂皮瓣转位。根据皮瓣成活、感染控制、弹性色泽、外观形态、供区瘢痕、皮肤感觉、患者认可等情况,对患者足踝部软组织缺损的修复情况进行综合评价。结果本组19例皮瓣全部成活,软组织缺损、肌腱、骨质及钢板外露均得以修复。供区均I期愈合。术后门诊随访2~16个月,皮瓣血运良好,颜色接近周围正常皮肤,臃肿不明显,患者对外观表示满意;供区皮片愈合良好,无明显增生、挛缩及溃疡,踝关节功能良好。结论胫前动脉踝上穿支皮瓣是修复足踝部软组织缺损较为理想的方法之一,手术操作简便,穿支较恒定,血供可靠,具有一定的临床应用价值。     

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.     

Experiences with the lateral calcaneal artery flap

A chronic ulcer of the posterior heel or lateral ankle can be a large problem for the patient. The lateral calcaneal artery flap is a reliable neurovascular local skin flap that can cover the defect after excision of the ulcer in this area. The flap includes the lateral calcaneal artery, sural nerve, and lesser saphenous vein. We performed seven lateral calcaneal artery flaps from 1974 to 1986 for chronic ulcers of the heel or lateral malleolus. None failed. All patients can wear closed shoes. Two donor sites showed secondary healing. One donor site showed hyperkeratosis resulting from inappropriate planning of the flap.     

Soft tissue coverage of the distal third of the tibia with fasciocutaneous propeller flaps

BACKGROUND: The distal third of the tibia is often only amenable to free tissue transfer to cover exposed bone, tendons and neurovascular structures. Using relatively constant perforators of the tibial and peroneal vessels, soft tissue coverage can be achieved with so-called propeller flaps. METHODS: 8 patients presenting with post-traumatic defects over the lateral malleolus and the Achilles tendon were included in this study. A propeller flap based on perforators from the peroneal or tibial artery was used to cover the defect. RESULTS: One case of partial flap necrosis was encountered in a diabetic patient. Transient venous congestion of the flap tip was witnessed in two instances, which resolved without further intervention. No other complications occurred. All patients were fully ambulatory within 8 weeks, except for 1 patient, who required a below-knee amputation. CONCLUSION: The propeller flap has proven to be a versatile and elegant method to obtain soft tissue coverage with local tissue. Contrary to conventional rotation flaps, direct closure of the donor site is possible. Patients are not impaired by bulky flaps and may wear normal shoes. Even in the elderly, this flap was successful.     

陈旧性跟腱断裂合并皮肤缺损的修复

目的探讨陈旧性跟腱断裂合并皮肤缺损的修复方法。方法通过对1995年2月～2001年12月10例陈旧性跟腱断裂手术病例回顾性随访，分析术式的选择、注意事项及效果。其中采用腓肠肌肌皮瓣3例，足外侧皮瓣4例，内踝上皮支皮瓣2例，腓肠神经皮瓣1例；采用跟腱直接缝合8例，Lindholm法缝合2例。结果所有皮瓣及肌皮瓣均成活，8例愈合良好，2例裂开。跟腱术后功能按尹庆水的疗效评定标准：优5例，可4例，差1例。结论用显微外科技术修复跟腱合并皮肤缺损可取得良好效果，对减少关节挛缩或僵硬，挽救足跖屈及小腿向前推进能力有重要意义。     

Reconstruction of Compound Loss of Lateral Malleolus and Lateral Ankle Ligaments with Double-Bundle Achilles Tendon–Bone Allograft

Open ankle fracture, including compound loss of the lateral malleolus, lateral ankle ligaments, and overlying skin, is a severe injury and can result in ankle instability and permanent disability. Treatment of this injury is challenging and requires bone grafting and soft tissue reconstruction. In the present report, we describe a unique reconstruction technique for compound loss of the lateral malleolus, lateral ankle ligaments, and the overlying skin using a double-bundle Achilles tendon–bone allograft combined with a reverse sural fasciocutaneous flap. The patient obtained a stable ankle with nearly full range of motion and displayed satisfactory function during the follow-up period.     

Reconstruction of soft tissue defects in the Achilles tendon region with perforator-based fasciocutaneous flaps

Background

Reconstruction of soft tissue defects in the Achilles tendon region can be technically demanding. Perforator-based flaps can be an effective local solution, replacing like-for-like skin. We report our experience with perforator-based flap reconstruction of the Achilles tendon region with or without rupture of the Achilles tendon.

Methods

Between January 1999 and 2011, 11 patients had perforator-based flaps based on peroneal and posterior tibial perforators. There were six V-Y advancement flaps, four propeller flaps and one peninsular flap. The mean defect size was 19.3 (range 9–36)?cm². One patient had reconstruction of a composite Achilles tendon defect.

Results

There were no flap failures. Mean follow-up was 26.4 (range 3–120)?months. Post-operative complications included haematoma in one patient and dehiscence of wound because of further sloughing of the tendon—at the distal edge of a V-Y advancement flap. This patient needed a second local flap. There were no wound breakdowns, painful sensitivity or difficulty with walking. All patients who had skin and soft tissue reconstruction only were partially weight bearing by 2 weeks and gradually increased weight bearing and fully weight bearing by 4 weeks.

Conclusions

Perforator-based flaps are a robust method of covering small- to medium-sized defects in the Achilles tendon region. Presence of multiple perforators on either side of the Achilles tendon invites a number of flap designs, tailored to the defect. Level of Evidence: Level IV, Therapeutic study.     

The forearm flap as a free neurovascular flap for treatment of an extensive bone/soft-tissue defect in the calcaneal part of the foot

A discussion is presented on the case of a 28-year-old motorcyclist who had an accident and got caught in the spoked wheel of her vehicle. The result was an extensive soft-tissue injury of the metatarsus and calcaneal part of the foot, a defect fracture of the calcaneus, an osseous disinsertion of the Achilles tendon, a lateral malleolus Weber type-A fracture, and a fracture of the second metatarsal bone. The primary treatment consisted in extensive débridement of the strongly contaminated soft parts and refixation of the Achilles tendon on the calcaneus with two osteosynthesis screws. The bruised skin flaps remaining were adapted in a tension-free manner. However, this was possible only in a considerable talipes equinus position. In the further course, the patient developed an extensive skin and soft-tissue necrosis over the calcaneal part of the foot. A neurovascularly pedicled forearm flap was freely grafted in order to maintain the load capacity of the calcaneal part of the foot, to prevent osteitis of the calcaneus, to correct the talipes eqinus position, and to achieve a resensibilization in the load zone of the sole. The healing result was good, and it was possible to achieve extensive correction of the talipes equinus position as well as prevention of calcaneus osteitis; the function of the Achilles tendon was also maintained. Moreover, there was satisfactory resensibilization of the calcaneal part of the foot, so that the patient can now walk in ready-made shoes with a fully molded arch support.     

小腿筋膜皮瓣及小腿内侧逆行轴形皮瓣在下肢创伤修复时的选择及评估

目的:探讨两种小腿皮瓣(小腿筋膜皮瓣及小腿内侧逆行轴形皮瓣)在下肢创伤后皮肤软组织缺损修复时的选择及评估。方法:①在小腿设计局部随意筋膜皮瓣,皮瓣大小范围4cm×6cm～7cm×15cm,转移修复同侧或对侧小腿皮肤软组织缺损并骨外露;②以胫后动脉内踝上发出的皮动脉穿支为轴,在小腿内侧设计逆行轴形皮瓣,皮瓣大小范围4cm×12cm～6cm×15cm,转移修复同侧或对侧足底、踝部、小腿皮肤软组织缺损并肌腱或骨外露。结果:临床共选用11个皮瓣,其中6例为筋膜皮瓣,5例为小腿内侧逆行轴形皮瓣,修复同侧或对侧下肢皮肤软组织缺损并肌腱或骨外露。11例皮瓣术后均成活良好,创面修复效果良好,随访6～12个月,伤肢外形及功能恢复满意。结论:小腿筋膜皮瓣,设计灵活,切取便利,不损伤主要血管,血供丰富,尤其在局部主要血管受损时是修复下肢严重创伤的有效方法之一。小腿内侧逆行轴形皮瓣可切取皮瓣距离长,面积大,血供恒定可靠,成活率高,是修复足底、踝部、小腿严重创伤的最佳选择。此两种皮瓣的应用应针对小腿创面的部位、面积及其创伤特点进行合适的选择,可达到满意的修复效果。     

Combined free fibular osteocutaneous-lateral calcaneal fasciocutaneous flap for reconstruction of composite oromandibular defects

The free fibular osteocutaneous flap is often used in the reconstruction of composite oromandibular defects. In contrast, the lateral calcaneal flap has never been used in oromandibular reconstruction. On the basis of their anatomic continuity, the authors combined the free fibular osteocutaneous flap with the lateral calcaneal skin paddle to obtain 2 adjoining flaps in different anatomic areas with the same vascular axis. The authors report their experience in 3 patients with composite oromandibular defects. In 1 patient without an outer skin defect, only a sensory lateral calcaneal skin paddle with a fibular osseus flap was harvested. The lateral calcaneal flap carried the sural nerve as a sensory flap in 2 patients, and the result was passable. Only 1 patient encountered superficial flap tip necrosis at the lateral calcaneal skin paddle, and recovered well after wound care. In conclusion, a flap with many specific features is a feasible choice for reconstruction of composite oromandibular defects.     

Distally based superficial sural fasciomusculocutaneous flap: a reliable solution for distal lower extremity reconstruction

The objective of this study is to present a simple and rapid approach to elevate a consistent superficial sural fasciomusculocutaneous flap and show its clinical applications. All the patients with lower limb defects who underwent reconstruction using the distally based fasciomusculocutaneous sural flap were included in the study. The flap was elevated with a cuff of gastrocnemius muscle under the skin paddle, and the distal pedicle was dissected until 5 cm over the lateral malleolus. The donor site is primarily closed or skin-grafted. From March 2004 to August 2006, this distally based superficial sural fasciomusculocutaneous flap was applied to nine patients. All the defects resulted from traumatic injuries of the distal third of the leg, ankle, or foot, combined with bone or tendon exposure. Two flaps developed minor distal skin necrosis that recovered uneventfully with conservative therapy. The other flaps had an adequate postoperative evolution with good blood supply, contour, and function. The superficial sural fasciomusculocutaneous flap is a simple and consistent alternative for distal lower limb reconstruction, particularly when microsurgery is not available.