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.     

The thoracodorsal artery perforator flap: anatomic basis and clinical application

Based on the dissection of 20 fresh cadavers, the authors have detailed further the vascular anatomy of the thoracodorsal artery and its cutaneous perforator vessels. The thoracodorsal artery showed a constant bifurcation into a horizontal branch and a lateral branch, located on the deep surface of the latissimus dorsi muscle 4 cm (range, 3-6 cm) distal to the inferior scapular border and 2.5 cm (range, 1-4 cm) medial to the lateral free margin of the muscle. In 20 specimens there was a total of 64 musculocutaneous perforators larger than 0.5 mm. Thirty-six perforators (56%) originated from the lateral branch and 28 perforators (44%) originated from the horizontal branch. All perforators originated within a distance of 8 cm from the neurovascular hilus and ran in proximity with the horizontal or lateral branches. In 11 dissections (55%) there was also a direct cutaneous branch originating from the extramuscular course of the thoracodorsal artery before the neurovascular hilus. This cutaneous branch did not pierce the latissimus muscle but rounded the lateral muscle edge and supplied the overlying subcutaneous tissue and skin. It is hoped that the constant anatomy will encourage surgeons in the future to use the thoracodorsal artery perforator flap more often.     

Versatility of the abductor hallucis muscle as a conjoined or distally-based flap

Soft tissue coverage of the medial ankle and foot remains a difficult, challenging, and often frustrating problem to patients as well as surgeons. To our knowledge, the abductor hallucis muscle flap is not frequently used and only a few well documented cases were found in literature. The purpose of this paper is to report and to present the long-term results of a series of four patients who underwent reconstruction of foot and ankle defects with the abductor hallucis muscle flap.In two cases, the abductor hallucis muscle flap was transposed in combination with a medialis pedis flap to cover a medial ankle defect, whereas in another case it was combined with a medial plantar flap. In this latter case, the muscle flap served to fill up a calcaneal dead space after osteomyelitis debridement, whereas the cutaneous flap was used to replace debrided skin at the heel. The abductor hallucis flap was used as a distally-based turnover flap to cover a large forefoot defect in a fourth case. Follow-up period ranged between 18 and 64 months (mean 43.3). In the early postoperative period, two flaps healed completely In two patients marginal flap necrosis occurred which was subsequently skin grafted. No donor-site complication occurred in any of the patients. In all cases, protective sensation of the skin was satisfactory as early as 6 months. In two cases mild hyperkeratosis at the skin graft border to the sole skin (non-weight bearing area of medial plantar and medialis pedis flap donor site) was present, but probably related to poor foot care. All patients were fully mobile as early as 3 months after treatment. In the long-term follow-up (43.3 months), all flaps provided with durable coverage. Functional gait deficit due to consumtion of the abductor hallucis muscle was not apparent.Our long-term results demonstrated that the abductor hallucis muscle flap is a versatile, and reliable flap suitable for the reconstruction of foot and ankle defects. Utilizing the abductor hallucis muscle as a pedicled flap (distally or proximally-based) with or without conjoined regional fasciocutaneous flaps offers a successful and durable alternative to microsurgical tree flaps for small to moderate defects over the calcaneus region, medial ankle, medial foot, and forefoot with exposed bone, tendon, or joint.     

双蒂腓肠肌皮瓣修复跟腱及皮肤缺损的解剖学研究及临床应用

目的为双蒂腓肠肌皮瓣修复小腿远端跟腱及皮肤缺损和术前判断肌皮瓣能修复的范围提供解剖学理论依据。方法30侧下肢尸体标本,模拟手术时腓肠肌皮瓣的切取,观察肌皮瓣在不同膝关节屈曲时能向下滑动的距离。1993年8月～2005年4月收治12例小腿远端跟腱及皮肤同时缺损患者,小腿远端及跟腱同时缺损面积6 cm×4 cm～10 cm×6 cm,均采用双蒂腓肠肌皮瓣V-Y推进下移修复跟腱及皮肤缺损。结果不切断腓肠肌起点,膝关节伸直0°时肌皮瓣滑动距离为(1．4±0．4)cm,屈膝90°为(3．3±0．4)cm；“Z”字切断腓肠肌起点,膝关节伸直0°时滑动距离为(3．7±0．5)cm,屈膝30°为(4．9±0．7)cm,屈膝60°为(6．7±0．7)cm,屈膝90°为(9．2±0．9)cm。临床应用治疗的12例患者均获得4个月～12年随访,皮瓣全部成活,行走功能恢复,踝关节活动度为背伸11．0°±1．4°,跖屈35．0°±4．6°。结论双蒂腓肠肌皮瓣适合于修复跟腱及皮肤同时缺损。     

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。     

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.     

Distally based radial forearm flap with preservation of the radial artery: anatomic,experimental, and clinical studies

In this article we report on the anatomical, experimental, and clinical investigations of the distally adipofascial pedicled radial forearm flap based on the small perforators around the radial styloid process. There are about 10 small perforators (0.3-0.5 mm in diameter) from the distal radial artery around the radial styloid process. The longitudinal chain-linked vascular plexuses (suprafascial, paraneural, and perivenous) formed by the forearm ascending and descending branches of septofasciocutaneous perforators meet and cross over with the transverse carpal vascular plexuses around the radial styloid region. Based on these directional-oriented plexuses, distally based adipofascial pedicled radial forearm fasciocutaneous and adipofascial flaps were designed and successfully applied in 34 clinical cases. The pivot point was located at 1-2 cm above the radial styloid. The skin island plus adipofascial pedicle measured between 9-18 cm in length, with the adipofascial pedicle 3-4 cm in width. The length-to-width ratio is 3-5:1. The venous drainage of this distally based flap was investigated anatomically and experimentally. The cephalic vein has no positive role for venous drainage in distally based flaps. The difference between distally based flaps and reverse-flow flaps, clinical selection of fasciocutaneous and adipofascial flaps, advantages and disadvantages, and technical tips for operative success are discussed.     

Distally based peroneus brevis muscle flap: A single centre experience

Purpose: Defects around the distal one third of the leg and ankle are difficult to manage by conservative measures or simple split thickness skin graft. Distally based peroneus brevis muscle flap is a well described flap for such defects.Methods: This is a retrospective analysis conducted on 25 patients with soft tissue and bony defects of distal third of lower leg and ankle, which were treated using distally based peroneus brevis muscle flap from January 2013 to January 2018. Information regarding patient demographics, etiology, size and location of defects and complications were collected. All patients were followed up for at least 3 months after surgery.Results: There were 21 males and 4 females with the mean age of 39 (5-76) years. The most common cause of injuries was road traffic accident, followed by complicated open injury. The average size of defects was 20 (4-50) cm2. The mean operating time was 75 (60-90) min for flap harvest and inset. We had no patient with complete loss of the flap. Five patients (20%) had marginal necrosis of the flap and two patients have graft loss due to underlying hematoma and required secondary split thickness skin grafting.Conclusion: The distally based peroneus brevis muscle flap is a safe option with reliable anatomy for small to moderate sized defects following low velocity injury around the ankle. The commonest complication encountered is skin graft loss which can be reduced by primary delayed grafting.     

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.     

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.     

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.     

Distally based lateral calcaneal flap

In our cadaver dissection, the connection between the lateral calcaneal artery, the lateral tarsal artery, and the branch of the lateral plantar artery was corroborated, indicating possible reverse blood flow in the lateral calcaneal artery. The distally based lateral calcaneal flap has been successfully used in 2 patients. Vascular anatomy, indication, and technical points of the surgery as well as advantages and disadvantages of the flap are discussed.     

游离比目鱼肌穿支皮瓣的应用解剖与临床应用

目的 探讨比目鱼肌肌皮穿支应用解剖特点及比目鱼肌穿支皮瓣游离移植在临床中的应用. 方法 6例12侧下肢标本经灌注后解剖观测小腿外侧穿支特点及比目鱼肌皮穿支血管的走行分布特点.自2002年7月至2010年10月,应用比目鱼肌肌皮穿支为蒂的比目鱼肌穿支皮瓣游离移植修复体表皮肤软组织缺损14例,其中前足及足背侧皮肤组织缺损8例,踝前部组织缺损2例,手部缺损2例,肘部缺损2例.皮瓣面积5 cm×6cm～12cm×20cm. 结果 小腿外侧中上段恒定存在比目鱼肌皮穿支,多在腓骨头下5～ 24 cm,位置恒定.肌皮穿支外径在动脉起始部为(1.08±0.12)mm,静脉外径(1.20±0.32)mm.14例比目鱼肌肌皮穿支供血的穿支蒂皮瓣均成活,经6～12个月(平均8个月)随访,皮瓣质地优良,外观及功能恢复良好. 结论 直接肌支供血的比目鱼肌穿支皮瓣游离移植避免了暴露腓动脉,且切取简便,吻合管径适宜,是修复组织缺损的一种理想选择.     

阴股沟皮瓣的解剖及其在男性会阴部修复重建中的应用

目的明确阴股沟皮瓣解剖基础,为临床设计和应用此皮瓣提供解剖依据和手术方法。方法解剖研究15具成年男尸阴股沟区的血供和神经支配情况。依据研究结果为男性会阴部修复重建患者设计合理的皮瓣。结果阴股沟区动脉血液供应充足,静脉回流丰富,神经支配可靠。该区的动脉血供有阴部外浅动脉、闭孔动脉前皮支、阴囊后动脉的主干和外侧支,并且位置均比较恒定。三组血管网贯穿了皮瓣的上、中、下部。临床应用阴股沟皮瓣23例,皮瓣切取最大为17cm×9cm,最小8cm×5cm,均取得理想的治疗效果。结论阴股沟皮瓣血运丰富,切取方便,供区隐蔽,在修复、重建男性会阴部时,可以取上、中、下蒂皮瓣。术后皮瓣成活率高,外形及神经感觉均取得理想结果。     

Distally based sural neurocutaneous pedicle flap

The distally based sural neurocutaneous flap is technically simple and characterised by limited morbidity. It is one of the therapeutic alternatives for the coverage of small ormiddle-sized soft-tissue loss in the distal third of the leg, at the level of the ankle and of the heel. This flap is based on a retrograde flux originating from the superficial sural artery. It depends on the perforating arteries originating from the peroneal artery. It can be harvested as a skin paddle or as an island flap. It will not lead to major artery sacrifice. It is a reliable flap, which can be performed on diabetic as well as arteritic patients. Its best indication is for the coverage of heel decubitus ulcer. Finally, it can be used for management of soft-tissue defects, especially related to osteomylitis with the filling of bone cavities.     

A modified longitudinally split segmental rectus femoris muscle flap transfer for facial reanimation: anatomic basis and clinical applications.

The present study was conducted to investigate the intra-muscular neurovascular anatomy and the intra-muscular tendon distribution of the rectus femoris muscle to reassess the reliability of technique of harvesting a longitudinally split segmental muscle flap, and to present our clinical experience on usefulness of the longitudinally split segmental rectus femoris muscle flap as a method for reconstruction of the paralysed face in a series of 25 patients. Twenty fresh cadavers were systemically injected with lead oxide, gelatin and water. Based on the anatomy of intra-muscular neurovascular structure in the rectus femoris muscle, 25 consecutive patients with established facial paralysis were treated by using a two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting. Follow-ups were 15-24 months. All of the 25 patients showed significantly improvement in the appearance of the oral commissure and oral competence. Satisfactory results of facial reanimation were obtained in 23 patients. Among these cases, near-natural facial expression was achieved. Recovery continued up to 2 years postoperatively. There were two cases having poor movement of transferred muscle 2 years postoperatively. No complications occurred in the donor site. In conclusion, the present study has demonstrated the suitability for subdivision of the segment muscle flap of the rectus femoris into two functional units with a common neurovascular pedicle. This series has further demonstrated the safety and reliability of using the rectus femoris muscle flap for facial reanimation.     

小腿外侧穿支皮瓣的解剖与临床应用

目的 通过解剖学研究,分析腓动脉穿支特点,评价其临床应用的可行性. 方法 通过解剖40侧新鲜小腿标本,使用明胶氧化铅灌注技术,行一次性全身动脉造影、容积螺旋CT扫描,构建三维可视化模型,重点观察小腿.解剖后统计小腿外侧穿支出现数量、穿出位置、各穿支的管径、血管蒂的长度,归纳其规律性.针对2005年7月至2009年10月的43例中等面积的手、足皮肤缺损进行了游离腓动脉穿支皮瓣移植修复手术,并统计成活率,术后就外观和功能随访6个月到2年.结果 小腿外侧腓动脉穿支为2～9支,平均4支,在腓骨小头下方(9.80±0.93)cm、(13.40±0.90)cm、(17.20±1.13)cm、(21.30±0.77)cm四处出现率较高,动脉穿支直径分别为(1.33±0.39)mm、( 1.30±0.46)mm、(1.17±0.30)mm、(1.22±0.23)mm,血管蒂长分别为(5.87±0.73)cm、(5.83±1.73)cm、(5.44±1.09)cm,(5.10±1.93)cm.临床应用43例游离腓动脉穿支皮瓣,成活42例,1例皮瓣坏死.所有病例随访6个月到2年,皮瓣术后外观满意36例,术后臃肿需要二期修整的7例.供区小腿外观、功能均正常.结论腓动脉有四处穿支出现基本恒定,其中小腿中1/3段的穿支血管(第2、3条穿支)管径较粗,蒂长度5～7cm,适合进行游离皮瓣设计.