Objective To investigate the accuracy of positioning perforator of medial sural artery with three-dimensional ultrasound technique guided by a wide band linear matrix array volume transducer probe before operation, and the effectiveness of the flap design based on this in repairing the dorsal foot wounds. Methods Between January 2019 and December 2022, 30 patients with skin and soft tissue defects of the dorsal foot were treated. There were 19 males and 11 females, with an average age of 43.9 years (range, 22-63 years). There were 12 cases of traffic accident injury, 15 cases of heavy crushing injury, and 3 cases of machine injury. The time from injury to hospitalization was 1-8 hours (mean, 3.5 hours). The wounds in size of 5 cm×3 cm to 17 cm×5 cm were thorough debrided and covered with vacuum sealing drainage dressing. Then the wounds were repaired with the medial sural artery perforator flaps after no obvious infection observed. To obtain the complete three-dimensional image, the number and position of the medial sural artery perforator branches and the position of the main blood vessels in the muscle were detected and recorded by wide band linear matrix array volume transducer probe before operation. Suitable perforating branches were selected to design the flap and guide the flap incision on this basis. The size of the perforating flap ranged from 6 cm×4 cm to 18 cm×6 cm. The sensitivity and positive predictive value were calculated by comparing preoperative exploration with intraoperative observation of perforating branches, so as to evaluate the positioning accuracy of three-dimensional ultrasound technique. The donor sites were sutured directly in 25 cases and repaired with free skin grafting in 5 cases. Results The 60 perforating branches of medial sural artery were found before operation and 58 during operation in 30 patients. Among them, pre- and intra-operative perforations were consistent with 56. The sensitivity was 93.3% and positive predictive value was 96.6%. The intramuscular position and route of the main blood vessels were basically consistent with the pre- and intra-operative observation. All flaps survived and wounds healed by first intention. All incisions at the donor sites healed by first intention, and all skin grafts survived. All patients were follow up 9-24 months (mean, 14.7 months). The appearance, color, and texture of the flaps were good, and no obvious effect on wearing shoes and walking. At last follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind score ranged from 80 to 92, with an average of 87.5. The patient satisfaction was excellent in 29 cases and good in 1 case. Conclusion The three-dimensional ultrasound technique guided by the wide band linear matrix array volume transducer probe can accurately locate the perforating branch of the medial sural artery, and the three-dimensional imaging is more intuitive, which can be used to guide the design and incision of the medial sural artery perforator flap.
Objective To investigate the surgical methods and cl inical results of reconstructing soft tissue defects in distal dorsal is pedis with distally based medial dorsal neurocutaneous flap on foot. Methods From January 2004 to July 2007, 11 cases of soft tissue defects in distal dorsal is pedis were treated with the distally based medial dorsal neurocutaneousflap on foot, including 8 males and 3 females aged 18-55 years. Nine cases were caused by crash and 2 cases were caused by traffic accident. There were 4 cases of tendon exposure and skin defects in the distal dorsal is pedis, 6 cases of bone exposure and skin defects in and adjacent to the first metatarsal head and 1 case of bone exposure and skin defects in the distal dorsal is pedis due to the third and fourth toe damage. The area of defects ranged from 3 cm × 3 cm to 7 cm × 5 cm. Distally based medial dorsal neurocutaneous flaps on foot were incised to repair the soft tissue defects and the size of the flaps ranged from 4 cm × 4 cm to 8 cm × 6 cm. Thickness skin graft was appl ied to repair donor site. Results All the flaps survived and all wounds healed by first intention. Skin graft in donor site survived completely in 10 cases and survived partly in 1 cases (heal ing was achieved after the flap above lateral malleolus was used to repair). All cases were followed up for 6 months-1 year. The color, texture and thickness of the flaps were similar to those of recipient site. All patients returned to their normal weight-bearing walking. No skin ulceration in flaps and donor site was observed. Conclusion The operative technique of the distally based medial dorsal neurocutaneous flap on foot is simple, convenient and safe. The distally based flap is effective in repairing soft tissue defects of middle and small sized skin and soft tissue defects in distal dorsal is pedis.
Objective To summarize the cl inical experience of repairing soft tissue defect in dorsal pedis with reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flap, and to explore surgery matters needingattention and measures to prevent flap necrosis. Methods Between August 2000 and April 2009, 31 patients with soft tissue defects in dorsal pedis were treated with reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flaps. There were 23 males and 8 females with a median age of 34 years (range, 3-65 years). Defects were caused by traffic accident in 20 cases, by machine in 2 cases, and by crush in 2 cases. The time from injury to admission was 1-32 days (mean, 15 days). And 6 cases had chronic ulcer or unstable scar excision with disease duration of 6 months to 10 years, and 1 case had squamous carcinoma with disease duration of 5 months. The wounds were located in medial dorsal pedis in 12 cases and lateral dorsal pedis in 19 cases; including 14 wounds near the middle metatarsal and 17 wounds beyond the middle metatarsal (up to the metatarsophalangeal joint in 10 cases). All cases accompanied with bone or tendon exposure. Five cases accompanied with long extensor muscle digits tendon rupture and defect, 1 case accompanied with talus fracture, 1 case accompanied with talus fracture and third metatarsal fracture. The size of the wounds ranged from 6.0 cm × 4.5 cm to 17.0 cm × 10.0 cm. The size of the flaps ranged from 8.0 cm × 5.5 cm to 20.0 cm × 12.0 cm. The donor sites were resurfaced by skin graft. Results Seventeen flaps survived uneventfully, wounds healed by first intention. Distal epidermal or superficial necrosis occurred in 6 flaps at 5-12 daysafter operation, wounds healed by dressing change or skin graft. Distal partial necrosis occurred in 8 flaps (7 in medial dorsal pedis and 1 in lateral dorsal pedis) at 7-14 days after operation, wounds healed by skin graft in 3 cases, by secondary suture in 3 cases, by local flap rotation in 1 case, and by cross leg flap in 1 case. All skin grafts at donor sites survived uneventfully, wounds healed by first intention. Twenty-nine patients were followed up 6-29 months (mean, 19 months). The appearance was sl ightly overstaffed, but wearing shoe function and gait were normal. The texture and color of the flaps in all cases were good. There was no pigmentation and suppuration relapse. There was neither ankle plantar flexion deformity nor hammer toe deformity in 5 cases accompanied with long extensor muscle digits tendon rupture and defect. All fractures healed at 3 months after operation in 2 cases. Conclusion The reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flaps are suitable to repair most soft tissue defects in lateral dorsal pedis. When the flaps are used to repair soft tissue defects in medial dorsal pedis, avoiding tension in flaps and fascia pedicles should be noted so as to improve flap survival.
Objective To provide the anatomic basis for thedesign of the intermediate dorsal neurocutaneous flap on the foot and to reportthe clinical results. Methods On 32 adult cadaver lower limb specimens perfused with red latex, the origins, diameters, courses, branches, and distributions of the intermediate dorsal cutaneous nerve of the foot and its nutrient vessels were observed. On this anatomic basis, from June 2004 to October2005, 5 flaps were developed and applied to the repair of the soft tissue defect in the feet of 4 patients. Results The intermediate dorsal cutaneous nerve of the foot was found to arise from the superficial peroneal nerve. Crossing the intermalleolar line, it was located 1.3±0.6 cm lateral to the midpoint of the line with a diameter of 2.05±0.56 mm. The nerve stem divided into branches 2.8±1.3 cm distal to the line. They distributed the dorsal skin of the second, third and fourth metatarsal and toe. On average, 5.1 perforators per specimen were identified. At least 3 nutrient vessels were always found in each. They originated from the cutaneous branches of the anterior tibial artery and the dorsalis pedis artery in the proximal end and the dorsalis metatarsal artery in the distal end. They perforated the deep fascia 4.3±0.4 cm proximal to the intermalleolar, 1.6±0.3 cm proximal to the tip of the third toe webspace and 1.5±0.3 cm proximal to the tip of the forth toe webspace, respectively. The external diameters of them were 0.82±0.13, 0.42±0.07 and 0.49±0.09 mm, respectively. The patients were followed up for 4-10 months. All theflaps survived completely. Their appearance and function were satisfactory. Conclusion The distallybased intermediate dorsal neurocutaneousflap on the foot has an abundant blood supply. This kind of flap is especially useful in repair of the soft tissue defect in the foot.