腓肠内侧动脉穿支蒂皮瓣修复膝和小腿上1/3软组织缺损

目的 报道应用腓肠内侧动脉穿支带蒂皮瓣修复膝和小腿上1/3软组织缺损的临床应用效果. 方法 应用腓肠内侧动脉穿支带蒂皮瓣修复膝和小腿上1/3软组织缺损16例.其中,髌前4例,前外侧2例,前内侧l例;小腿上1/3 9例.供区均选用同侧小腿.结果 手术后经过顺利,1例术后发生表浅感染,经更换敷料逐渐愈合,皮瓣全部成活.随访3.0个月至3.5年,平均1.7年.供区愈合良好,未见明显的供区功能障碍.受区皮瓣质地、厚薄及颜色均较好,功能恢复较好,取得了较满意的效果. 结论 腓肠内侧动脉穿支带蒂皮瓣以腓肠内侧动脉的肌皮穿支为血供,具有血供丰富、血管解剖恒定、血管蒂长以及皮瓣较薄的优点.带蒂移植适宜修复膝和小腿上1/3软组织缺损.     

Distally-based sural flap for reconstruction of the lower leg and foot.

A distally-based sural flap was used in four patients with soft-tissue defects in the lower leg and foot. All flaps survived completely without venous congestion. To make safe use of this flap it is important to include both the sural nerve and the lesser saphenous vein in the flap. It also seems to be important to include the surrounding fatty tissues in the pedicle and to avoid compression at the point of its angulation. This flap has the advantages that it is quick and easy to raise, and the reconstruction can be done in a single operation. It is unnecessary to sacrifice the major arteries in the leg, although the sural nerve must be sacrificed. In general this type of reconstruction of the lower leg and foot is beneficial in cases similar to those presented here.     

A single stage reconstruction of upper and lower lip by modified Bernard technique

A single stage reconstruction of the upper and lower lip by a modification of the Bernard technique is described. The nasolabial flaps which are discarded in the original procedure are raised as island flaps based on the facial arteries and used with advantage to reconstruct the upper lip and the lower gingivobuccal sulcus.     

Aesthetic reconstruction of lower leg defects using a new anterolateral lower leg perforator flap.

Our objective in this study was to report on the successful clinical use of a new perforator flap obtained from the proximal quarter of the anterolateral lower leg. Eight patients had the procedure either as a result of trauma (seven patients) or to treat Marjolin's ulcer (one patient). During the procedure, a line was drawn from the anterior fibular head to the anterior lateral malleolus. Then, using Doppler, a septocutaneous perforator from the fibular head to the proximal quarter point of the line was identified. The subfascial dissection was continued to the detected perforator. Along the perforator in the anterior intermuscular (peroneal) septum, a deep dissection was performed. The perforator was then separated and the flap harvested. The septocutaneous perforator was the perforator of the superficial peroneal nerve accessory artery in three cases, the perforator of the superior lateral peroneal artery in one case, and the perforator originating directly from the anterior tibial artery in four cases. Seven of eight cases were treated successfully. The results obtained were satisfactory, both aesthetically and functionally. This flap is a valuable alternative to the various perforator flaps from the lower leg. This flap has the advantage of being very thin, which makes it suitable for reconstruction of defects in the foot, ankle, pretibial area, and knee. However, one limitation of this procedure is that the diameter of the perforator was approximately 0.6-1.2 mm.     

Distally-based random fasciocutaneous flaps for multi-staged reconstruction of defects in the lower third of the leg, ankle and heel

Distally-based random pattern fasciocutaneous flaps were used to reconstruct defects of the lower third of the leg, the ankle and the heel in eight patients. Though a multi-staged procedure, this simplified fasciocutaneous flap design ensured safe transfer of tissue to defects in which it would otherwise have been very difficult to have obtained cover. This paper discusses the anatomical basis of the distally-based random pattern fasciocutaneous flaps and reviews the design, surgical technique, advantages, limitations and complications of these flaps.     

Cross leg posterior tibial artery fasciocutaneous island flap for reconstruction of lower leg defects.

We have utilised a posterior tibial artery flap from the opposite healthy limb for reconstruction of defects of middle and lower third of leg in 6 patients. The flap can be based either distally or proximally as the need be. The results have been quite encouraging.     

Wound coverage considerations for defects of the lower third of the leg

Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles, vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Free flaps continue to be the gold standard for the coverage of lower third leg wounds because of their ability to cover large defects with high success rates and feasibility of using it in acute situations by choosing distant recipient vessels. Reverse flow flaps are more useful for the coverage of the ankle and foot defects than lower third leg defects. The perforators in the lower third leg on which these flaps are based are often damaged during the injury. In medium-sized defects of less than 50 cm² size, local transposition flaps, perforator flaps, or propeller flaps can be used. Preoperative identification by the Doppler is essential before embarking on these flaps. Of the muscle flaps, the peroneus brevis flap can be used in selected cases with small defects. In spite of all recent developments, cross-leg flaps continue to remain as a useful technique. In rare occasions when other flaps are not possible or when other options fail it can be a life boat. In the author''s practice free flaps continue to be the first choice for coverage of wounds in the lower third leg with gracilis muscle flap for small and medium defects, latissimus dorsi muscle flap for large defects and anterolateral thigh flap when a skin flap is preferred.KEY WORDS: Free flaps, perforator flaps, lower leg defects     

Free adductor perforator flap in lower leg reconstruction.

We report two cases using the free adductor perforator flap in the reconstruction of defects resulting from tumour ablations in the lower leg. One of the two flaps was nourished by a perforating artery, piercing the adductor magnus muscle and the descending branch of the inferior gluteal artery. The other was supplied merely by a perforating artery through the adductor magnus muscle. In both cases, the lesions were in the posterior side of the body on the lower leg, so we did not need to change the patient's position during the surgery. The surgery could be done in the same operating field. The donor site has minimal morbidity after the harvesting of the flap. The lengths of the perforating pedicles were 5cm. By including the posterior cutaneous nerve of the thigh in the flap, the flap could be used as a sensory flap. The disadvantage of this flap is that the vessels of the pedicle are relatively small, especially, in comitantes veins.     

Aesthetic microsurgical reconstruction of the female lower leg

In the true sense of the term, “aesthetic reconstruction of lower leg” means that patients accept the appearance of their reconstructed lower leg(s) and are willing to go outside in short trousers or a knee-length skirt without feeling embarrassed. Because of this, soft tissue reconstruction of large areas of the female lower leg is especially challenging. In this paper, we focus on the “aesthetic reconstruction of the female lower leg” and discuss this problem and its solutions. Case 1 was a 25-year-old patient with an avulsion injury. A 13 × 25-cm muscle-sparing transverse rectus abdominis (TRAM) flap was used for the reconstruction. However, in addition, a free groin flap and parascapular flap were added to reconstruct the whole lower leg over a 2.5-year period. Case 2 was a 25-year-old patient with a soft tissue defect. A 15 × 30-cm muscle-sparing TRAM flap was used for the reconstruction. In retrospect, it was clear that the texture and color of the TRAM flap resembled those of the lower leg reasonably well. We suggest that the muscle-sparing TRAM flap or the deep inferior epigastric perforator flap should be a first choice of tissue for the reconstruction of the female lower leg, especially when aesthetics and donor-site morbidity are taken into consideration.     

A study on torsion of the lower leg in osteoarthritis of the knee. Measurement of leg torsion by computerized tomography

Lower leg torsion was measured by computerized tomography (CT-scan) in the knees with osteoarthritis. Materials and Methods: Experimental studies; Using the Toshiba CT/TCT-60A, the degree of torsion in five dried tibias were measured in three positions of varus, 0 degrees, 10 degrees and 20 degrees; and in two positions of flexion 0 degrees and 20 degrees. Clinical studies; The degree of tibial torsion was measured by CT-scan in 68 adult patients (85 knees) and compared with the torsion in 13 controls (24 tibias). The correlation between tibial torsion and osteoporosity was investigated by measuring CT-density of the third lumbar vertebra. Results: No statistically significant difference was found among the results of measurement obtained in five dried tibias placed in three positions of varus and in two positions of flexion. These results indicate that measurement of torsion using CT-scan is not influenced by the position when varus and flexion deformity are less than 20 degrees. Osteoarthritic knees were divided into five radiographic stages. There were significant differences between the lateral tibial torsions for each stage. The lateral tibial torsion was 23.5 degrees in normal adults, 14.1 degrees in stage II, 11.9 degrees in stage III, 7.5 degrees in stage IV and V, for an average of 11.3 degrees. The rate of decrease in lateral tibial torsion was 59.6% in the proximal tibia, 4.2% in the tibial shaft and 36.2% in the distal tibia. The decreases of lateral tibial torsion were correlated with decrease of CT-density of the third lumbar vertebra. Conclusion: It is apparent from this study that there is a correlation between decreasing lateral tibial torsion with the radiographic stage of osteoarthritis of the knee and general osteoporosity.     

A novel technique for the reconstruction of infected full-thickness chest wall defects.

BACKGROUND: Chest wall resection and reconstruction can be performed with minimal mortality and excellent functional and cosmetic results using synthetic meshes, methylmethacrylate, or other substitutes. However, these techniques are less easily applicable if chest wall resections have to be performed for infections. METHODS: We report a novel technique for this purpose using a modified latissimus dorsi flap harvested in continuity with the thoracolumbar fascia. The vascularized fascia was sutured into the chest wall defect, providing a stable base for the muscular component of the flap. Three patients requiring large full-thickness resections of the anterolateral chest wall for chronic infections were treated accordingly, two presenting with chronic radionecrosis and osteomyelitis and one with chest wall invasion by pulmonary aspergillosis. RESULTS: There were no intraoperative or postoperative complications and immediate extubation was possible in all 3 patients without the need for postoperative ventilation or tracheotomy. Healing of the infected chest wall was observed in all 3 patients. Postoperative cinemagnetic resonance imaging revealed concordant movements of the replaced segments without evidence of paradoxical motion during inspiration and expiration. CONCLUSIONS: This technique is easy and safe. It allows a stable and satisfactory reconstruction after large anterolateral full-thickness chest wall resections of infected, previously irradiated tissues, using only well-vascularized autologous tissue.     

Ulceration of the lower leg after total knee replacement a five-year review.

Ulceration of the lower leg is considered to be a hard' clinical endpoint of venous thrombosis. Total knee replacement (TKR) is a significant risk factor for venous thrombosis of the leg and therefore potentially for ulceration. We sent a postal questionnaire to 244 patients at a minimum of five years after TKR enquiring about the development of ulceration since their TKR. The overall incidence of ulceration, both active and healed, was 8.67% which is similar to that in the age-matched general population (9.6% to 12.6%), as was the prevalence of active ulceration. We also identified no clear association between venographically-confirmed postoperative deep-venous thrombosis (DVT) and the incidence and prevalence of ulcers at five years. We suggest that after TKR DVT is not a significant risk factor for ulceration of the leg and that perioperative chemical thromboprophylaxis may not be justified on these grounds.     

On the timing of soft-tissue reconstruction for open fractures of the lower leg

The timing of soft-tissue reconstruction for severe open fractures of the lower leg is considered crucial to the later outcome, and yet pertinent publications are few. The purpose of this study was to add some based on evidence arguments for the choice of the most adequate timing in the management of these injuries. Twenty-nine consecutive open fractures of the tibia, including 24 grade 3B and 5 grade 3C fractures, were treated using a protocol of immediate debridement, early definitive skeletal stabilisation and early soft-tissue reconstruction. Fifteen lower legs were reconstructed after a mean delay of 4.4 days (range 1–9 days), while 14 lower legs were reconstructed immediately, i.e. as an emergency procedure on the day of admission. Both groups were comparable for sex, age, type of trauma, associated general injuries, type of fracture, associated arterial lesion, associated tendon rupture, type of soft-tissue reconstruction and duration of follow-up. All patients were reviewed at a mean follow-up of 47 months (range 15–89 months). In the delayed reconstruction group the time to full, unprotected weight-bearing (P = 0.0021), the time to definitive union (P = 0.0049), the number of reoperations (P = 0.0001) and the infection rate (P = 0.0374) were significantly higher. The data suggest that immediate reconstruction is, the general condition of the patient permitting, the timing of choice for soft-tissue coverage. Received: 3 March 1997     

Total substitution of the lower urinary tract. A technique for either reconstruction or continent diversion.

A technique is described in which the right side of the colon is used for substitution cystourethroplasty, based on the flap valve principle, in order to produce a continent catheterisable outflow. The technique can equally well be used for continent diversion.     

A biomechanical comparison of three lower extremity tendons for ligamentous reconstruction about the knee

Purpose: The purpose of this investigation was to evaluate 3 previously unreported allograft tendons for use in knee surgery. These are the doubled tibialis anterior (TA), doubled tibialis posterior (TP), and doubled peroneus longus (PL) tendons. Type of Study: A biomechanical evaluation of the properties of the TA, TP, and PL. Methods: Sixteen fresh-frozen cadaveric lower limbs were used for testing. All specimens had the TA, TP, and PL tendons harvested. All specimens were tested in a custom-designed hydraulic testing machine using dry ice clamps. Each tendon was elongated at a rate of 1 mm/s. Load and displacement were recorded with an analog to digital interface board. Stiffness, modulus of elasticity, and stress and strain at failure were calculated. Results: The average tested lengths of the TA, TP, and PL were 37 cm (range, 13–68 cm), 33 cm (range, 7–74 cm), and 42 cm (range, 17–69 cm), respectively. The average cross-sectional areas of the doubled TA, TP, and PL were 38 mm², 48 mm², and 37 mm², respectively. The average failure loads for the doubled TA, TP, and PL tendons were 3,412 N, 3,391 N, and 2,483 N, respectively. The maximum stresses of the 3 tendons did not differ significantly (85–108 Mpa). The TA had the greatest stiffness (344 N/mm), followed by the TP (302 N/mm) and the PL (244 N/mm). Previous authors have documented the biomechanical strength of grafts for ACL reconstruction between 1,700 and 2,900 Newtons. The ultimate tensile strength and stiffness reported for the TA and TP grafts exceeded that for all previously reported grafts, including the doubled semitendinosus-gracilis. Conclusions: The TA, TP, and PL tendons showed excellent biomechanical properties when compared with historical data evaluating other graft sources. The biomechanical properties observed for the TA, TP, and PL were noted in specimens despite an average age of 78.3 years.