Distally based abductor hallucis muscle flap: anatomic basis and clinical application

Although rarely used, the abductor hallucis muscle has its indications in coverage of small defects at the medial aspect of the hindfoot as a proximally based muscle flap. The authors describe a 69-year-old female patient in whom the abductor hallucis muscle was used as a distally based flap to reconstruct a defect in the forefoot. An anatomic study was undertaken on two cadaveric feet to explore the practicality of the distally based abductor hallucis muscle flap before it was applied clinically. The distally based abductor muscle flap receives its blood supply from minor and major pedicles in a retrograde fashion from both the dorsal arterial network and the deep plantar system, through communicating branches with the medial plantar artery distally. Transposition of the distally based hallucis flap is only advisable in individuals who have no vascular compromise in the lower leg and foot. To the authors' knowledge, this modification has not yet been described in the available literature.     

The distally-based brachioradialis muscle flap

We describe the brachioradialis muscle flap based distally on the radial artery. It is quickly raised and provides excellent cover for soft tissue defects of the hand. In the two clinical cases the brachioradialis tendon has also been used for extensor tendon reconstruction.     

Ultrasound evaluation of the abductor hallucis muscle: Reliability study

Background

The Abductor hallucis muscle (AbdH) plays an integral role during gait and is often affected in pathological foot conditions. The aim of this study was to evaluate the within and between-session intra-tester reliability using diagnostic ultrasound of the dorso-plantar thickness, medio-lateral width and cross-sectional area, of the AbdH in asymptomatic adults.

Methods

The AbdH muscles of thirty asymptomatic subjects were imaged and then measured using a Philips HD11 Ultrasound machine. Interclass correlation coefficients (ICC) with 95% confidence intervals (CI) were used to calculate both within and between session intra-tester reliability.

Results

The within-session reliability results demonstrated for dorso-plantar thickness an ICC of 0.97 (95% CI: 0.99–0.99); medio-lateral width an ICC: of 0.97 (95% CI: 0.92–0.97) and cross-sectional area an ICC of 0.98 (95% CI: 0.98–0.99). Between-session reliability results demonstrated for dorso-plantar thickness an ICC of 0.97 (95% CI: 0.95 to 0.98); medio-lateral width an ICC of 0.94 (95% CI 0.90 to 0.96) and for cross-sectional area an ICC of 0.79 (95% CI 0.65 to 0.88).

Conclusion

Diagnostic ultrasound has the potential to be a reliable tool for evaluating the AbdH muscle in asymptomatic subjects. Subsequent studies may be conducted to provide a better understanding of the AbdH function in foot and ankle pathologies.     

Management of chronic calcaneal osteomyelitis with pull-through abductor hallucis muscle flap -a report of three cases

Three patients who had chronic osteomyelitis of the calcaneus were treated with radical debridement of all involved soft tissue and bone and obliteration of dead space with a pull-through abductor hallucis brevis muscle flap. Two patients had calcaneal osteomyelitis without soft tissue loss resulting from previous comminuted calcaneal fractures while a third patient had a large soft tissue defect and calcaneal osteomyelitis resulting from a destructive infection. All of the patients had undergone several surgical procedures for treatment of the osteomyelitis with histories ranging 18 months to 30 months. Following treatment with the pull-through muscle flap there has been no recurrence over the longterm (>two years). We believe that radical removal of all contaminated tissue and immediately coverage with a muscle flap provides an effective single stage treatment of chronic calcaneal osteomyelitis.     

Flexor hallucis brevis muscle flap

The use of muscle flaps for treatment of chronic wounds has become more widespread. The specific use of intrinsic muscle flaps of the foot for treatment of diabetic ulcerations has the potential to provide alternative ways of avoiding amputations. A case report is presented that illustrates the use of the flexor hallucis brevis flap for a chronic ulceration beneath the first metatarsal head. The technique and indications are discussed.     

足内侧跨供区(姆)展肌肌皮瓣重建大鱼际缺损的临床研究

目的 探索肌皮瓣动力重建大鱼际缺损的手术方式,改进足底内侧肌皮瓣的设计和切取方法,更好地重建大鱼际缺损区的逼真外形和对掌功能.方法 自2010年11月至2012年1月,游离移植足内侧跨供区皮瓣联合(姆)展肌修复大鱼际缺损患者6例,重建创面和对掌功能,术后3周开始功能锻炼和康复理疗,6、12个月时对移植的肌肉行肌电图检查.结果 术后皮瓣及植皮均存活良好,外形饱满,具有类似大鱼际区掌、背双侧皮肤的外形及特点.随访12个月以上,采用中华医学会手外科学会上肢功能评价标准检测评定运动和感觉功能.术后6个月移植肌肉的肌电图最大收缩呈混合相,12个月呈干扰相.术后6个月皮瓣恢复痛、触觉;12个月两点分辨觉为7.5～11.2 mm,平均7.9mm,感觉为S3+.移植肌肉肌力恢复至M3 ～ M4.结论 改良足内侧跨区皮瓣联合(姆)展肌游离移植是一种新的肌皮瓣动力重建术式,皮瓣术后有良好的外形和痛触觉,移植的(姆)展肌获得神经再支配后具有收缩性,可以重建拇对掌功能.     

Avulsion fracture of the calcaneus at the origin of the abductor hallucis muscle

Previously reported avulsion fractures of the calcaneus have been confined to the attachment of the tendo achillis, bifurcate ligament, extensor digitorum brevis muscle, or the plantar fascia. A case report of a previously undescribed avulsion fracture of the calcaneus due to the abductor hallucis muscle is presented. The mechanism of injury, forced dorsiflexion of the forefoot, is described. A diagnostic and treatment regimen is provided. With appropriate identification of the injury, this unusual calcaneal fracture can be adequately managed.     

Distally based abductor digiti minimi muscle flap

The abductor digiti minimi muscle flap is known as good tissue coverage for the lateral ankle and heel. For reconstruction of the distal portion of the foot, the distally based flap of this muscle can be useful, effectively utilizing the blood supply through the plantar arch communication. A case of frostbite of the right fifth toe is reported, which we successfully repaired with a distally based abductor digiti minimi muscle flap. In addition, some information on distally based use of the muscles of the foot is presented.     

Harvesting the abductor digiti minimi as a muscle plug with the lateral calcaneal artery skin flap

The abductor digiti minimi muscle flap and the lateral calcaneal artery skin flap were raised as one combined flap and were used to cover plantar heel wounds with chronic osteomyelitis of the calcaneus. The combined flap was used successfully in 4 patients. The muscle component of the flap obliterated the dead space and provided a vascularized muscle over the debrided calcaneus, and the skin component acted as a sensate flap in the plantar heel.     

小趾展肌肌瓣的临床应用

目的探讨小趾展肌肌瓣修复足部偏外侧及足跟部皮肤软组织缺损的手术方法及临床疗效。方法 2002年7月-2010年10月,收治8例足部偏外侧及足跟部皮肤软组织缺损患者。男6例,女2例;年龄28～65岁,平均42岁。左足5例,右足3例。足跟部溃疡2例,跟骨骨折术后切口愈合不良致肌腱、内固定物外露1例,碾挫、挤压伤致足部偏外侧皮肤软组织坏死5例。软组织缺损范围为1.5 cm×1.0 cm～8.0 cm×2.6 cm。病程30 min～26个月。2例细菌培养呈阳性。入院后清创换药9～15 d,待感染控制后采用大小为5.6 cm×1.5 cm～7.6 cm×1.8 cm的小趾展肌肌瓣移位修复创面。供区直接缝合。结果术后7例小趾展肌肌瓣顺利成活;1例术后4 d发生肌瓣部分坏死,对症治疗后肉芽生长良好。供区切口均Ⅰ期愈合。9～21 d肌瓣表面新鲜肉芽生长良好,取小腿内后侧刃厚皮片游离移植修复肌瓣创面。一期皮片游离移植修复肌瓣创面1例,二期修复7例;修复术后皮片均成活,创面Ⅰ期愈合。术后7例获随访,随访时间9～18个月,平均11个月。创面外形、质地和感觉恢复满意。两点辨别觉为16～23 mm,平均19.5 mm。1例足跟部溃疡患者负重行走出现表皮磨损。1例术前腓骨长、短肌腱部分坏死者出现足外翻、肌力下降,其余患者关节功能正常。结论采用小趾展肌肌瓣移位修复足部偏外侧及足跟部皮肤软组织缺损具有手术操作简便,安全可靠,对供区损伤小,不影响负重,创面外形、弹性好,感觉恢复好的优点,疗效满意。     

Evaluation of twitch responses obtained from abductor hallucis muscle as a monitor of neuromuscular blockade: Comparison with the results from adductor pollicis muscle

The twitch responses evoked from the abductor hallucis muscle (AHM) and the adductor pollicis muscle (APM) were examined simultaneously in 20 anesthetized patients following a single bolus intravenous administration of 0.04 mg·kg⁻¹ of vecuronium bromide. The mean onset time of vecuronium-induced depression of AHM twitch responses was significantly slower than that of APM twitch responses (4.9±1.5 minvs 3.7±1.2 min, mean±SD,P<0.001), and when the clinical duration times of vecuronium were compared, AHM twitch responses recovered more quickly than APM twitch responses (15.3±4.1 minvs 19.6±6.7 min,P<0.01), although there was no statistically significant difference in the spontaneous recovery time between AHM and APM (9.8±2.9 minvs 10.0±3.6 min). It is concluded that the twitch responses of AHM may be a useful monitor of neuromuscular blockade in anesthetized patients in whom setting the blockade monitor on the patient's arms is difficult, although monitoring of twitch response of AHM is less sensitive than that of APM in case of vecuronium administration.     

Histochemistry of abductor hallucis muscle in children with idiopathic clubfoot and in controls

The histochemical composition of the abductor hallucis (AH) muscle was investigated in 39 children with idiopathic clubfoot (CF), aged 0-11 years, and in 42 controls. In the youngest group of patients (0-2 years) the percentage of type 1 (slow twitch, tonic) fibers was significantly higher than in controls. In older groups, there was no difference between patients and controls. The relative predominance of type 1 fibers could be due to immobilization, passive shortening or stretching, or primary overactivity of this muscle in CF promoted by an unknown neural factor. None of these interpretations could be proven.     

Hallux adductor or abductor muscle?

Anatomists classify the muscle located medially to the plantar region that passes from the posterior tuberosity of the calcaneus to the base of the hallux as either an adductor or an abductor according to whether reference is made to the sagittal plane or the body or the axis of the second digital ray of the foot, respectively.Clinicians, on the other hand, always refer to the sagittal plane: hallux valgus, metatarsus primus varus, hallux varus, metatarsus adductus (or varus), etc.Definition of an axis intrinsic to the foot is a reference, by analogy, to the hand, whereas it is more logical to refer to the sagittal axis and classify this muscle as an adductor.     

Influence of the abductor hallucis muscle on the medial arch of the foot: a kinematic and anatomical cadaver study

BACKGROUND: Most studies of degenerative flatfoot have focused on the posterior tibial muscle, an extrinsic muscle of the foot. However, there is evidence that the intrinsic muscles, in particular the abductor hallucis (ABH), are active during late stance and toe-off phases of gait. The purpose of this study was to analyze the kinematic effect of a simulated contraction of the abductor hallucis muscle on a cadaver lower limb specimen. METHODS: Eight below-knee cadaver specimens were prepared. The abductor hallucis muscle was exposed and the entire muscle-tendon unit excised. A suture secured to the calcaneal origin of the muscle and tendon was passed through a pulley at the ABH sesamoid attachment. The specimen was mounted on an experimental rig in a 'standing' position. Motions in the first metatarsal, tibia, and calcaneus were tracked using the 'Flock of Birds' motion analysis system (Ascension Technology, Burlington, VT). Muscle contraction was simulated by applying tension on the suture. RESULTS: All eight specimens showed an origin from the posteromedial calcaneus and an insertion at the tibial sesamoid. All specimens also demonstrated a fascial sling in the hindfoot, lifting the abductor hallucis muscle to give it an inverted 'V' shaped configuration. Simulated contraction of the abductor hallucis muscle caused flexion and supination of the first metatarsal, inversion of the calcaneus, and external rotation of the tibia, consistent with elevation of the arch. CONCLUSIONS AND CLINICAL RELEVANCE: The abductor hallucis muscle acts as a dynamic elevator of the arch. Understanding this mechanism may change the way we understand and treat pes planus, posterior tibial tendon dysfunction, hallux valgus, and Charcot neuroarthropathy.     

Microneurovascular free abductor hallucis muscle transplantation for resuscitation of facial paralysis in one stage]

After study of local anatomy in fresh cadaver the authors carried out free abductor hallucis muscle transplantation successfully in three patients with facial paralysis. In one patient the plantaris medialis vessels were anastomosed to the contralateral facial vessels and the plantaris medialis nerve was anastomosed to buccal branch of the contralateral facial nerve. In two patients the plantaris medialis vessels were anastomosed to the ipsilateral facial vessels and the plantaris medialis nerve was anastomosed to the myloidens branch from ipsilateral trigeminal nerve. The authors described the local anatomy and operative methods in details. The advantages of this operative method were also discussed.