Use of a free gracilis flap for coverage of medium size defects over the ankle and foot.

We report the use of a free gracilis flap in six cases of medium size tissue loss over the ankle and foot. All the procedures were done under spinal or epidural block. A muscle flap was used twice and a musculocutaneous flap four times. The skin paddle was reliable in three cases for evaluation of the vascularity of the musculocutaneous flaps, but in one case there was necrosis of 70% of the surface. In three cases the fatty skin paddle was removed at two weeks and the entire muscle surface was mesh skin grafted. The advantages of the use of a gracilis flap are easy dissection and low donor site morbidity. This flat and thin muscle is well-suited for medium size defects from 8-15 cm. The length of the pedicle could be extended to 8 cm by dissecting it as far as the profunda femoris vessels.     

The gracilis free flap for reconstruction of parotidectomy defects

Summary Total parotidectomy causes a significant postoperative concave deformity in the retromandibular, preauricular, and infra-auricular regions of the face; many patients are concerned about this defect. Frey's syndrome (gustatory sweating) is also a well-recognized postoperative entity following parotid surgery. The incidence of Frey's syndrome ranges from 10–90%, depending on the type and complexity of the investigation used to diagnose it [5, 11]. Numerous methods have been described to correct these problems. Patients requiring total parotidectomy were recently offered the option of immediate reconstruction of the contour defect with microvascular transfer of a tailored gracilis muscle flap. Four patients are included in this preliminary series; all are extremely satisfied with the postoperative result. The defect following total parotidectomy can be reconstructed immediately with gratifying cosmetic results, a hidden donor site scar, and to date no operative morbidity.     

逆行腓肠神经营养皮瓣修复足踝部软组织缺损体会

目的观察应用逆行腓肠神经营养皮瓣修复足踝部软组织缺损的临床效果。方法应用同侧逆行腓肠神经营养皮瓣修复足踝部皮肤软组织缺损11例,并观察皮瓣存活情况及术后效果。结果11例皮瓣全部存活,1例皮瓣出现淤青、水泡,经换药愈合;1例皮瓣远端部分皮肤坏死,使用中厚皮植皮愈合;随访1～6个月,患肢能正常步态行走,皮瓣耐磨。结论逆行腓肠神经营养皮瓣切取简单,存活率高,是修复足踝部软组织缺损的较理想方法。     

外踝上动脉降支蒂逆行皮瓣修复足踝部软组织缺损

目的：评价外踝上动脉降支蒂逆行皮瓣修复踝、足部软组织缺损的临床疗效。方法：自2009年5月至2013年10月利用外踝上动脉降支蒂逆行皮瓣修复踝、足部皮肤缺损合并肌腱、骨外露12例,男9例,女3例;年龄19～58岁,平均37.5岁。足背软组织缺损10例,踝部软组织缺损2例。缺损面积最大11 cm×9 cm,最小8 cm×5 cm.结果：12例均获随访,时间3～12个月,平均7.3个月。9例皮瓣全部成活;3例皮瓣远端边缘坏死,经换药治愈。皮瓣除轻度肿胀外,无溃疡等发生。结论：外踝上动脉降支蒂逆行皮瓣修复足部软组织缺损一期手术即可完成,具有血供可靠、切取简单安全、不损伤小腿的主要血管等优点。     

近踝足部肌腱与骨裸露创面显微外科修复方法的分析

目的评价近踝足部肌腱与骨外露创面修复的简单实用手术方法。方法总结自1990年1月～2002年1月应用13种显微外科皮瓣修复治疗128例近踝足部肌腱与骨外露创面病人,取得良好效果。手术时间:急诊一期修复53例,亚急诊修复28例,晚期修复47例。结果吻合皮瓣静脉修复皮肤逆行撕脱伤26例,完全成活19例,7例部分坏死;游离皮瓣移植19例,13例完全成活,皮瓣坏死3例,皮瓣部分坏死并感染3例;带蒂皮瓣转移83例,其中带腓肠神经营养血管皮瓣58例,该组所有皮瓣无1例完全坏死,5例术后出现静脉回流障碍,松解蒂部血运恢复,4例皮缘坏死,经换药愈合;其余带蒂皮瓣25例,成活21例,部分皮缘坏死3例,感染完全坏死1例。结论带腓肠神经营养血管皮瓣,切取简单,不牺牲知名的血管,对供区侧肢体供血影响小,设计灵活,能为磨擦受压创面提供良好的覆盖,基本能够满足近踝足部肌腱与骨外露创面修复需要。     

改良腓肠神经营养血管逆行岛状筋膜蒂皮瓣修复足踝部皮肤缺损

近年来,用腓肠神经营养血管逆行岛状筋膜蒂皮瓣修复胫前区、足、踝部大面积皮肤软组织缺损、深部组织外露,已成为临床上常用术式,效果良好。但常存在蒂部臃肿、卡压致静脉回流障碍等问题,切取面积大时,在皮瓣蒂部的远端常出现静脉危象导致皮瓣部分坏死。为此,从2006年2月至2008年2月．对此皮瓣进行改良,将皮瓣设计为水滴形,如乒乓球拍状,结扎皮瓣蒂部小隐静脉,或将皮瓣近端小隐静脉与创面周围的一条直径相当的静脉吻合,修复24例,经随访,效果良好。     

Reconstruction with distally based dorsalis pedis fasciocutaneous flap for the coverage of distal toe-plantar defects

Reconstruction of small defects in the distal portion of the foot has always been a difficult problem. A case involving a young man with a deep electric burn of the distal lateral side of the big toe, successfully treated with a distally based dorsalis pedis fasciocutaneous flap, is presented. The donor site area of the dorsum of the foot was grafted, and deambulation was reassumed three weeks later. Advantages, limits and anatomical consideration regarding the viability of the flap are also discussed.     

Use of gracilis muscle free flap for reconstruction of chronic osteomyelitis of foot and ankle

Despite low donor-site morbidity and a straightforward dissection, the gracilis muscle flap is still for many surgeons a second choice in microsurgical reconstruction of the lower extremity in cases of osteomyelitis. They underscore the difficulty of the procedure, and the problems of insufficient muscle volume and a small sized vascular pedicle. The aim of this study was to assess the reliability of the gracilis muscle free flap in the treatment of osteomyelitis of the foot and ankle. Between 1992 and 1999, 12 consecutive cases (age 9 to 71 years) of osteomyelitis of the foot and ankle were treated using a skin-grafted gracilis free muscle flap. Criteria for osteomyelitis were the presence of exposed bone, positive cultures and bone scans. The wound defect surface ranged from 9 to 90 cm2 (mean 50.5 cm2). Six flaps were applied on the weight bearing area of the foot. Flap harvesting time never exceeded 30 minutes. The mean follow-up is 15 months (range 2 to 60 months). All flaps survived completely. Secondary skin grafts were needed in two cases. One hematoma was noted at the flap donor site. Two patients (18%) had persistent osteomyelitis due to insufficient debridement in the presence of what appeared to be extensive bone involvement. Attempt to salvage the extremity was first performed but ultimately led to amputation. No patients complained of any donor site morbidity. Failure to cure the osteomyelitis was never caused by inadequate flap coverage. Gracilis muscle flap reliability in terms of vascular supply and ease of dissection made it our first choice in osteomyelitis of the foot and ankle. In the presence of extensive bone involvement, complex bone reconstruction is necessary to avoid amputation.     

穿支血管蒂螺旋桨皮瓣修复足踝部软组织缺损

目的 探讨穿支血管蒂螺旋桨皮瓣修复足踝部软组织缺损的临床疗效.方法 回顾性分析2011年9月至2013年4月,使用穿支血管蒂螺旋桨皮瓣修复并获随访的20例足踝部软组织缺损患者资料,男12例,女8例;年龄5～75岁,平均45岁;5例为轮辐伤致足跟部软组织及跟腱缺损,4例跟骨骨折内固定术后感染致皮肤坏死,2例重物砸伤致足背皮肤缺损,9例车祸伤致足踝部软组织缺损;创面软组织缺损面积2 cm×8 cm～5 cm×20 cm;病程7～60 d.其中15例采用腓动脉终末支穿支皮瓣、5例采用胫后动脉穿支皮瓣修复足踝部软组织缺损;皮瓣面积为5 cm×11 cm～7 cm×28 cm.所有穿支血管术前均在彩色多普勒超声下探查定位,穿支皮瓣的穿支口径0.8～1.0 mm.结果 超声定位术中穿支血管位置符合率为96.7％(29/30),术后供区直接缝合12例,游离植皮8例.术后24 h内1例发生静脉危象,经拆除部分缝线及放血疗法治愈.术后皮瓣均获随访,随访时间为1～18个月,所有皮瓣均存活良好,皮瓣蒂部平整,修复外形满意.结论 穿支血管蒂螺旋桨皮瓣操作相对简单,无需吻合血管,安全有效,适用于足踝部软组织缺损的治疗.     

Dance medicine of the foot and ankle: a review

All forms of dance are highly demanding activities, with a lifetime injury incidence of up to 90%. Most dance types are stressful, particularly on the dancer's forefoot, but certainly there is no area of the foot or ankle that is exempt from potential injury. Dancers often have unusual difficulties related to the dynamic biomechanical forces required by their individual dance form. A thorough understanding of these movements guides the physician to the cause of the injury, particularly in understanding specific overuse injuries. This article discusses biomechanics of the foot and the imaging and treatment of dance-related injuries.     

Practical aspects of foot and ankle arthroscopy

Arthroscopy of the foot and ankle, although sometimes technically challenging, is a useful tool for the foot and ankle surgeon. Burman in 1931 was the first to attempt arthoscopy of the ankle joint and surmised that it was not a suitable joint for arthroscopy because of its narrow intra-articular space. With the development of smaller-diameter arthroscopes and improvements in joint distraction techniques, Watanabe was the first to present a series of 28 ankle arthroscopes in 1972. At present, arthroscopy is used not only to evaluate and treat intra-articular abnormalities but also for endoscopic and tendoscopic procedures.     

临外踝上动脉腓浅神经血管蒂皮瓣修复小腿足踝部软组织缺损

目的探讨外踝上动脉腓浅神经血管蒂皮瓣修复小腿、足踝部软组织缺损的方法。方法1999年5月～2003年10月,18例小腿足踝部软组织缺损采用带外踝上动脉腓浅神经血管蒂皮瓣顺行或逆行修复。皮瓣面积6cm×5cm～21cm×10cm。结果术后18例皮瓣完全成活,创面一期愈合,经2个月～3年随访,皮瓣外形满意,踝关节功能良好。结论外踝上动脉腓浅神经血管蒂皮瓣手术设计、操作简单。该方法扩大了小腿皮瓣面积,皮瓣血供可靠,提供了对于小腿足踝部皮肤软组织缺损修复的一种方法。     

前锯肌瓣修复足踝部软组织缺损

目的应用前锯肌瓣修复足踝部软组织缺损。方法17例足踝部软组织缺损的患者,采用前锯肌瓣游离移植,肌瓣上游离植皮的方法。结果平均手术时间(6.5±1.2)h,血管蒂长(8.31±1.48)cm。发生局部血肿的患者2例,浅感染2例。翼状肩胛1例,无症状。瘢痕疼痛2例,侧胸壁麻木1例。3例患者与对侧相比,肩关节活动幅度及活动力量下降,术后半年好转。移植后的肌瓣小而薄,与足部组织的黏附性好,患者行走功能恢复好。结论前锯肌瓣为足踝部的软组织缺损的治疗提供了优良的选择。     

The distally pedicled gracilis flap for salvage of complex knee wounds

IntroductionSoft tissue defects around the knee joint resulting from trauma or because of wound breakdown after total knee arthroplasty present a challenge in a group of patients that often suffer from other co-morbidities. A pedicled gastrocnemius muscle flap remains a workhorse for this kind of wound. However, where the defect lies in the supero-lateral aspect of the proximal knee area, an alternative solution is required. The distally based pedicled gracilis flap has been described as an option for these cases where free-tissue transfer may not be an option and the pedicled gastrocnemius is not sufficient or has already been used. The purpose of this review is to evaluate the usefulness of this flap in the nine cases in which we have utilized it in our unit.MethodsNine patients underwent reconstruction of complex proximal knee wound defects with a distally based pedicled gracilis muscle flap. The mean age was 62 years (range 23–83). Five patients had wound breakdown following total-knee arthroplasty (TKR) and four patients had wound complications after road traffic accidents (RTA). Three of the nine flaps were delayed.ResultsEight of the nine patients had successful salvage of the knee with the use of the distally based gracilis flap. Although four of the flaps suffered partial loss, this did not compromise the joint salvage. The patients were moderately satisfied with the reconstruction and achieved a mean range of movement of 75° (±12°).ConclusionThe distally based pedicled gracilis flap can be a salvage solution for complex soft tissue defects with exposed knee joint, patella or proximal part of knee or exposed knee prosthesis in cases where a pedicled gastrocnemius muscle is inadequate or the patient is not suitable for a free flap.Evidence Level IV.     

足踝部外伤皮肤缺损常用带蒂皮瓣的选择

目的 探讨总结足踝部外伤皮肤缺损的特点和常用带蒂皮瓣的选择,并针对修复不同部位皮肤缺损的皮瓣供区选择提供建议和参考. 方法 采用足背皮瓣、足底内侧皮瓣、跖底皮瓣、(足母)趾腓侧皮瓣、第2趾胫侧皮瓣、胫前皮瓣、小腿内侧皮瓣、腓肠神经皮瓣、跗外侧皮瓣、踝前皮瓣、腓动脉皮瓣等行带蒂转移修复前足、足背、足底及踝部皮肤缺损. 结果 术后251例皮瓣除2例坏死外全部成活.5例术后第1天、2例第2天因植皮处包扎过紧,出现血管危象,探查后血运恢复正常.135例随访3～96个月,平均16个月,足底内侧皮瓣有4例、跖底皮瓣3例,转移后出现皮瓣和足底皮肤缝合处的磨损,二期皮瓣修整,改变负重点恢复正常行走.9例小腿内侧皮瓣、6例腓肠神经营养血管皮瓣,因为皮瓣臃肿行二期整形.其余皮瓣无明显臃肿,外形良好,不需要二期整形.其中足底内侧皮瓣和躅趾腓侧皮瓣、第2趾胫侧皮瓣顺行转移均带感觉神经,供区为非负重部位,不影响患者行走及负重功能,术后皮瓣感觉正常,两点辨别觉4 ～10 mm. 结论 足底内侧皮瓣、跖底皮瓣、(足母)趾腓侧皮瓣及第2趾胫侧皮瓣修复前足跖侧较好,皮肤耐磨,感觉好;足背皮瓣、胫前皮瓣、小腿内侧皮瓣、腓肠神经营养血管皮瓣、跗外侧皮瓣、踝前皮瓣、腓动脉皮支皮瓣、腓动脉皮瓣等皮瓣可以切取的面积较大,修复足背及踝关节周围皮肤缺损,具有皮瓣较薄、色泽接近和锯剖位置恒定等优点.以上皮瓣均操作简单,修复效果好,是修复足踝部皮肤缺损的良好方法.     

带蒂皮瓣治疗小腿和足踝部皮肤软组织缺损

目的探讨小腿和足踝部皮肤软组织缺损的手术方法及其疗效评价。方法1997年6月至2005年12月,43例小腿及足踝部皮肤软组织缺损的患者,男38例,女5例;年龄7～63岁,平均35岁;皮瓣面积4cm×3cm～25cm×15cm。采用9种带蒂的肌皮瓣和筋膜皮瓣进行治疗:(1)腓肠肌内、外侧头肌皮瓣带蒂转移修复小腿中上1/3合并膝关节前及内侧皮肤软组织缺损2例;(2)小腿前内侧交腿皮瓣修复小腿中段胫前皮肤软组织缺损2例;(3)带隐神经小腿内侧交腿皮瓣修复前足足底缺损1例;(4)带胫后动脉小腿内侧逆行岛状皮瓣修复足背部皮肤软组织缺损1例;(5)小腿内侧远端蒂筋膜皮瓣修复小腿中下1/3胫前皮肤软组织缺损2例;(6)腓肠神经营养血管蒂逆行岛状皮瓣修复小腿中下1/3、踝部及足跟皮肤软组织缺损17例;(7)隐神经营养血管蒂逆行岛状皮瓣修复小腿中下1/3、踝部及足背皮肤软组织缺损14例;(8)外踝上动脉逆行岛状皮瓣修复足背皮肤软组织缺损2例。(9)足内侧远端带蒂岛状筋膜皮瓣修复第一跖骨头处皮肤软组织缺损2例。结果43例皮瓣中有37例术后全部成活,创面一期愈合,1例皮瓣浅层坏死,5例皮瓣远端边缘少许坏死,经短期换药后愈合。所有病例均得到随访,皮瓣全部良好。结论治疗小腿和足踝部皮肤软组织缺损应严格掌握手术适应证,合理选择皮瓣种类。腓肠神经和隐神经营养血管蒂岛状皮瓣是较理想的修复小腿及足踝部软组织缺损的材料。     

胫后动脉穿支皮瓣修复足踝部皮肤缺损

严重的小腿外伤,常导致足踝部软组织缺损,肌腱、骨外露,由于该处软组织较少,修复比较困难。传统采用胫后动脉岛状瓣或小隐静脉腓肠神经筋膜蒂岛状皮瓣,但两种皮瓣各有优缺点。2005年4月至2007年6月采用胫后动脉穿支皮瓣修复足踝部皮肤缺损6例,取得满意疗效,报告如下。     

组合带血管髂骨串联皮瓣重建第一、二跖骨及前足缺损

目的 研究解决第二跖骨及前足缺损的重建与修复。方法 采用显微外科技术,用带血管髂骨及游离皮瓣串联组合移植重建第一、二跖骨及前足部分缺损。结果 修复后足的负重及行走功能恢复较好,外型满意。结论 带血管髂骨为跖骨缺损重建校为理想供骨,采用带血管骨、皮瓣组织移植为修复前足操作缺损的最佳方式。e     

Lateral supramalleolar flap for coverage of ankle and foot defects in children

The lower part of the leg, the ankle and the foot, is a difficult region to cover especially with exposure of bones or tendons. There are many options for covering soft tissue defect in these areas. The supramalleolar flap is an interesting procedure. The lateral supramalleolar flap was used in 8 cases for the reconstruction of skin defects of the ankle, heel, and foot that compromised the Achilles tendon and the osteoarticular system. Of the 8 patients, 5 were males and 3 were females, with an average age of 6.4 (range 2 to 10) years. The skin defect was secondary to trauma in all cases. The mean follow-up period was 31 (range 19 to 47) months; at the last follow-up visit, the region had been successfully covered in all cases. No necrosis of the flap was reported. The donor site morbidity was minimal. The lateral supramalleolar flap is an interesting surgical technique to salvage the lower extremity in children because this flap has a large skin paddle and a wide rotation arc and is based on a secondary vascular axis.     

股前外侧肌皮瓣修复足踝侧方组织缺损

目的 探讨总结应用股前外侧肌皮瓣修复足踝侧方软组织合并内、外踝组织缺损中重建踝关节稳定性的疗效与作用.方法 对13例因足踝侧方软组织合并内、外踝组织缺损伤病例应用股前外侧肌皮瓣修复,将组织瓣中的阔筋膜两侧部分折叠与受区相邻软组织间断缝合固定,旋股外侧血管降支与受区血管吻合,移植股前外侧肌皮瓣面积最大为20 cm×12 cm,术后3个月石膏继续固定维持踝关节于功能位.随访时间1.5至20年.从患者主观感受、临床症状与体征和影像学检查评估踝关节稳定情况.结果 术后早期3个月内踝关节稳定性仍需外固定维持扶助,半年后即可稳定.13例中获得5年以上随访10例、10年以上6例、15年以上3例(分别为15年、18年、20年).5年后均有影像学踝关节创伤性改变,但临床症状与之不完全呈现相关性,13例中目前尚无1例因功能受限需行关节融合术.结论 股前外侧肌皮瓣是修复足踝侧方软组织合并内、外踝组织缺损重建并维持踝骨关节稳定、避免早期关节融合,特别对青少年伤者是一种良好选择.

Abstract：

Objective To explore the long-time clinical results and effection of free anterolateral thigh musculocutaneous flap for repairing the complex defects involving lateral or medial malleolar of the ankle and heel,especially for reconstructing stability of the ankle joints. Methods Thirteen patients with complex tissue defects,involving lateral or medial malleolar of the ankle and heel,were treated by free anterolateral thigh fasciomusculocutaneous flap.The fascia lata which was involved in the flap was fixed with the adjacent tissue of the recipient area.The descending branches of the lateral circumflex femoral vessels were anastomosed with the vessels in the recipient area.The largest area of the flap was 20 cm × 12 cm.The ankle joint was fixed in functional position with plaster in the early 3 months post-operatively.The following time ranged from 1.5 years to 20 years.The stability of the ankle joint were evatuated with the patients' objective feeling and clinical symptoms and imaging study.Results The stability of the ankle should be protected by external fixation in the early 3 months postoperatively,and was restored at 6 months usually.In all cases,ten cases were followed over 10 years,six cases were followed over 6 years,three cases were followed over 15 years.Though radiological discovering suggesting traumatic esteoarthritis exited in 3 cases with a follow-up more than 5 years,the clinical manifestations were fair and no one need undergo arthredesis. Conclusion Using ant erolateral thigh musculocutaneous flap for reconstructing the complex defects involving lateral or medial malleolar of the ankle and heel repairing stability of the joint and ovoiding off early arthrodosis of the joint is one of the favorable choice,especially for the teen-agers.