The remnant axial cortical length of the proximal femur in pertrochanteric fractures: a three-dimensional computed tomography study and its clinical implications.

BACKGROUND: Cortical buttress are important factors for postoperative stable reconstruction of per/inter-trochanteric fractures. The study aimed to measure the remnant axial cortical length (RACL) of the proximal circumference of the femur, and to determine which part of the RACL can be used reliably to postoperatively sustain the head-neck fragment as a cortical support pattern. METHODS: Eighty patients with trochanteric hip fractures admitted from January 2015 to January 2016 were included in a retrospective study. Their pre-operative computed tomography (CT) images were used to form 3D-CT reconstructions via Mimics software. After simulated rotation and movement for fracture reduction, the RACL, its three component parts-namely, the remnant anterior cortex (RAC), remnant lateral cortex (RLC), and remnant posterior cortex (RPC) -the γ angle between the anterior and posterior cortex, and the Hsu's lateral wall thickness (LWT) were evaluated. RESULTS: Patients with an A1 fracture (21/80) had a longer RACL (88.8 ± 15.8 mm) than those with an A2 fracture (60.0 ± 11.9 mm; P < 0.01). The RAC, RLC, and RPC of the RACL in A1 fractures were also significantly longer than those in A2 fractures (P < 0.001). However, the most significant difference among the three components of the RACL was in the RPC, which was 27.3 ± 7.8 mm in A1 fractures and 9.2 ± 6.6 mm in A2 fractures. In addition, the coefficient of variation of the RAC was only 20.0%, while that of the RPC was 75.5%. The average γ angle in A1 fractures was 16.2 ± 13.1°, which was significantly smaller than that in A2 fractures, which was 40.3 ± 14.5° (P < 0.001). There was a significant statistical difference in the LWT between A1 and A2 fractures (P < 0.001). There were significant differences in the RACL, RAC, RLC, RPC, γ angle, and LWT among the five subtypes (P < 0.001). CONCLUSIONS: The RAC is relatively stable in pertrochanteric fractures. Fracture reduction through a RAC buttress may help to enhance the postoperative stable reconstruction of per/inter-trochanteric fractures and make possible good mechanical support for fracture healing.

Insufficient proximal medullary filling of cephalomedullary nails in intertrochanteric femur fractures predicts excessive postoperative sliding: a case-control study.

OBJECTIVE: Excessive postoperative sliding is a common complication of intramedullary nails in the treatment of intertrochanteric femur fractures. The aim of this study was to identify risk factors for excessive postoperative sliding in the intertrochanteric fractures treated with an intramedullary nail. METHODS: A retrospective analysis of 369 patients with femoral intertrochanteric fractures treated with short intramedullary nails between February 2017 and September 2020 was performed. Patients were classified into an excessive sliding group (ES group) and a control group according to the sliding distance after 6 months of follow-up. The proximal medullary filling degree (MFD), fracture reduction patterns in the anteroposterior (AP) view and lateral view, and tip-apex distance (TAD) were evaluated and compared in each group. RESULTS: Thirty-three cases were included in the ES group, and 336 cases were included in the control group. No significant differences in age, sex, fracture side, AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification, Dorr classification, Singh Osteoporosis Index (SOI), American Society of Anesthesiologists classification (ASA), TAD or fracture reduction patterns in the AP view were noted between the two groups. The negative reduction pattern can strongly predict excessive postoperative sliding (OR 4.286, 95% CI 1.637-11.216, P = 0.003). The incidence of excessive postoperative sliding increased by 8.713-fold when the MFD decreased by 10% (OR 8.713, 95% CI 1.925-39.437, P = 0.005). CONCLUSIONS: A low medullary filling degree and negative fracture reduction pattern in the lateral view were both independent risk factors for excessive postoperative sliding.

Residual lateral wall width predicts a high risk of mechanical complications in cephalomedullary nail fixation of intertrochanteric fractures: a retrospective cohort study with propensity score matching.

PURPOSE: The purpose of this study is to determine whether the integrity of the entry portal of head-neck implant is related to postoperative mechanical complications. METHODS: We retrospectively reviewed consecutive patients with pertrochanteric fractures in our hospital treated from January 1, 2018, to September 1, 2021. Based on the integrity of the entry portal for head-neck implants on the femoral lateral wall, patients were divided into two groups, including the ruptured entry portal (REP) group and the intact entry portal (IEP) group. After 4:1 propensity score-matched analyses were used to balance the baseline of the two groups, a total of 55 patients were extracted from the original participants, including 11 patients in the REP group and 44 matched patients in the IEP group. The anterior to posterior cortex width on the mid-level of the lesser trochanter was measured and defined as the residual lateral wall width (RLWW). RESULTS: Compared with the IEP group, the REP group was correlated with postoperative mechanical complications (OR = 12.00, 95% CI 1.837-78.369, P = 0.002) and hip-thigh pain (OR = 26.67, 95% CI 4.98-142.86). RLWW ≤ 18.55 mm indicated a high likelihood (tau-y = 0.583, P = 0.000) of becoming the REP type postoperatively and being more likely to suffer from mechanical complications (OR = 30.67, 95% CI 3.91-240.70, P = 0.000) and hip-thigh pain (OR = 14.64, 95% CI 2.36-90.85, P = 0.001). CONCLUSION: Rupture of entry portal is a high-risk factor for mechanical complications in intertrochanteric fractures. RLWW ≤ 18.55 mm is a reliable predictor of the postoperative REP type.

In response to letter to the editor: calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures.

We appreciate the interest by Drs. Hagiyama and coauthors in our work entitled "Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures". They discussed several pertinent points and it is our pleasure to respond their concerns in order. Firstly, we agree that calcar fracture gap and anteromedial cortical support are different concepts, though both of them were used to evaluate the displacement of fracture reduction quality. Secondly, our primary outcome parameter was the threshold distance of calcar fracture gapping in anteroposterior and lateral fluoroscopies, which was calculated based on sensitivity and specificity by receiver operating characteristic curves. Thirdly, we took immediate post-operative fluoroscopic images in 3 views to describe the initial reduction quality as baseline to compare and calculate the changes with three-dimensional computed tomography, which was taken about one week after operation for confirming secondary stability after head-neck sliding and impaction. Lastly, the parameters selected in multivariable analysis. Future work with better study-design is needed to improve the prediction of patient outcomes.

Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures.

BACKGROUND: Maintaining anteromedial cortical support is essential for controlling sliding and decreasing postoperative implant-related complications. However, adequate fracture reduction with cortical support in immediate postoperative fluoroscopy is not invariable in postoperative follow-ups. This study was conducted to investigate the risk factors leading to anteromedial cortical support failure in follow up for pertrochanteric femur fractures treated with cephalomedullary nails. METHODS: This retrospective study enrolled 159 patients with pertrochanteric fractures (AO/OTA- 31A1 and 31A2) that fixed with cephalomedullary nails. All patients were evaluated as adequate fracture reduction in immediate postoperative fluoroscopy before leaving the operation theater. The patients were separated into two groups based on the condition of the anteromedial cortex in the postoperative 3D CT with full-range observation: those with calcar support maintained in Group 1 and those with calcar support lost in Group 2. Demographic information, fracture classification, TAD (tip-apex distance), Cal-TAD, Parker ratio, NSA (neck-shaft angle), reduction quality score, and calcar fracture gapping were collected and compared. Logistic regression analysis was conducted to explore the risk factors leading to anteromedial cortex change. RESULTS: Anteromedial cortical support failure was noted in 46 cases (29%). There was no significant difference between the two groups concerning age, sex, side injury, TAD, Cal-TAD, Parker ratio, or NSA. There was a significant difference in the AO/OTA fracture classification in univariate analysis but no difference in the multivariable analysis. The reduction quality score, calcar fracture gapping in the AP (anteroposterior), and lateral views were significantly associated with anteromedial cortical support failure in follow-up after cephalomedullary nailing in the multivariable analysis. The threshold value of calcar fracture gapping for the risk of loss was 4.2 mm in the AP and 3.8 mm in the lateral fluoroscopies. Mechanical complications (lateral sliding and varus) were frequently observed in the negative anteromedial cortical support group. CONCLUSIONS: Good reduction quality was a protective factor, and larger calcar fracture gapping in the AP and lateral views were risk factors leading to the postoperative loss of anteromedial cortical support. Therefore, we should pay close attention to fracture reduction and minimize the calcar fracture gap during surgery.

Perforator Detection by Thermographic Imaging Augmented With Tourniquet-Reperfusion: A Modified Approach and Preliminary Report in Distal Lower Leg Reconstruction.

BACKGROUND: Dynamic infrared thermography provides a new imaging method of perforator detection. This study introduces an augmented technique to improve its accuracy by tourniquet-reperfusion and reports its preliminary use in the distal lower leg reconstruction. METHODS: A tourniquet (450 mm Hg) was applied for 3 minutes on proximal thighs. After the tourniquet release, the rewarming rate and pattern of hotspots were observed by thermography to delineate the location and quality of perforators. The results were compared with those detected by computed tomographic angiography. Clinically, the local transferred posterior tibial artery or peroneal artery propeller perforator flap was performed in 9 patients for the distal lower leg reconstruction. RESULTS: There was a 20- to 140-second "perforator observing window" after the tourniquet release. Tourniquet-reperfusion augmented thermal imaging method (TRATIM) had a sensitivity of 90.3% and a positive predictive value of 93.3%. The TRATIM and computed tomographic angiography had an excellent concordance with a kappa index value of 0.839 (P < 0.001). Based on the TRATIM, 9 propeller perforator flaps were successfully designed and raised for the distal lower leg resurfacing. All flaps survived entirely, except one with size of 1.0 cm × 2.0 cm that had terminal necrosis. CONCLUSIONS: The TRATIM is a quick, easy, cheap, and reliable approach for perforator detection in the lower leg. With the aid of TRATIM, a customized propeller perforator flap could be raised efficiently for the distal lower leg reconstruction.

A new fluoroscopic view for evaluation of anteromedial cortex reduction quality during cephalomedullary nailing for intertrochanteric femur fractures: the 30° oblique tangential projection.

BACKGROUND: Anteromedial cortex-to-cortex reduction is a key parameter for stable reconstruction of the fracture fragments during the intertrochanteric fracture fixation. This paper introduces the oblique fluoroscopic projection as a novel method to evaluate the quality of anteromedial cortical apposition. METHODS: Three proximal femur specimens were marked with steel wires along five anatomic landmarks: Greater trochanter, Lesser trochanter, Intertrochanteric line, Anterolateral tubercle and the Anteromedial cortical line. After obtaining the standard femoral neck AP and lateral fluoroscopic images, the C-arm was rotated by every 5°increments until a clear tangential view of the antero-medial-inferior corner cortex was observed. 98 cases of intertrochanteric hip fractures were enrolled from April 2018 to October 2019. After fixation with the nails, the intra-operative anteromedial cortex reduction quality was evaluated from the AP, the true lateral, and the new anteromedial oblique fluoroscopic images. The fluoroscopic results were compared with the post-operative 3D-CT reconstruction images. RESULTS: The specimen study showed that internal rotation of the C-arm to approximately 30 ° can remove all the obscure shadows and clearly display the antero-medial-inferior cortical tangent line. Clinically,the positive, neutral and negative apposition of different cortices via intra-operative fluoroscopic images showed79, 19 and 0 cases of medial cortical apposition in AP views; 2, 68 and 28 cases of anterior cortices in lateral views;and 22, 51 and 25cases of anteromedial cortical apposition in oblique views respectively. The post-operative 3D-CT reconstruction images revealed that the final anteromedial cortical contact was noted in 62 cases (63.3%), and lost in 36 cases (36.7%). The overall coincidence rate between intra-operative fluoroscopy and post-operative 3D-CT was 63.3% (62/98) in AP view,79.6% (78/98) in lateral view, and 86.7% (85/98) in oblique view(p < 0.001). Negative cortical apposition in oblique view was highly predictive of a final loss of cortical support on 3D CT (24/25 cases, 96%).And non-negative cortical apposition in oblique view was highly associated with true cortical support on 3D CT images (61/73 cases, 83.6%) (p < 0.001). CONCLUSIONS: Besides the AP and lateral projections, an anteromedial oblique view of 30° certifies to be a very useful means for evaluation of the fracture reduction quality of anteromedial cortical apposition.

Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region.

BACKGROUNDS: Distally based perforator propeller flap from the lower leg region is a versatile local reconstructive technique for the foot and ankle defects. However, flap venous congestion remains a tough nut to crack. We hypothesize that raising an adipofascial flap with turnover mode of transposition can improve venous drainage and enhance flap safety. METHODS: Based on the 2 rows of septocutaneous perforators in the posterior distal third of the lower leg, distally based adipofascial flap was raised from medial sural region nourished by 1 perforator bundle from the posterior tibial artery or from the lateral sural region from the peroneal artery. The superficial dissection was performed in subdermal plane and deep in to the subfascial space. The flap was nourished by perforator-plus-adipofascial pedicle and turned over 180 degrees upside down to reach the distal wounds. One week later, a split-skin graft was used to cover the exposed fascial flap. Postoperatively, flap survival, complications, and patient functional recovery were evaluated. RESULTS: Distally based sural turnover adipofascial flaps were used in 12 cases with complicated wounds of the distal third lower leg, foot, and ankle region. All wounds were caused by trauma and experienced fracture implants fixation and 5 with osteomyelitis. The comorbidities include diabetes in 9 cases and smoking in 7. There were 8 medial ural flaps and 4 lateral sural flaps. The adipofiscial flaps measured from 6.0 cm × 5.0 cm to 17.0 cm × 6.0 cm (mean, 61.3 cm). Postoperatively, all flaps survived uneventfully without any complication such as flap ischemia and/or necrosis. Two minor donor site complications were encountered, one was postoperative hematoma, and another was hyperproliferative scar. After a mean of 14.6 months of follow-up, the adipofascial flap plus skin graft showed a durable esthetic coverage, with normal shoe wearing and walking. CONCLUSIONS: Distally based sural adipofascial turnover flap is a simple and reliable wound coverage technique. It avoids venous congestion as usually seen in distally based fasciocutaneous flaps.

Lesser Trochanteric Fragments in Unstable Pertrochanteric Hip Fractures: A Morphological Study Using Three-Dimensional Computed Tomography (3-D CT) Reconstruction.

BACKGROUND The lesser trochanter (LT) posterior cortical extension (LTPE) fragment is important for joint stability during reconstruction in unstable pertrochanteric hip fractures. This study aimed to investigate the morphological characteristics of the LT fragments using three-dimensional computed tomography (3-D CT) reconstruction and to compare clinical outcomes in different subgroups of 31A2 fractures. MATERIAL AND METHODS A retrospective study included CT images of 58 cases of 31A2 type unstable pertrochanteric fractures, using the Arbeitsgemeinschaft für Osteosynthesefragen and Orthopedic Trauma Association (AO/OTA) classification. After 3-D CT reconstruction, all the displaced fragments were reduced and the morphologic parameters of the LT fragments were measured. RESULTS At the mid-level of the LT, the mean cortical extension of the LT fragment was 33.5 mm in the posterior wall (83%), 19.0 mm in the medial wall (53%). The mean distal cortical extension from the lower edge of the LT was 13.0 mm. The LT fragment occupied 38% of the whole cortical circumference. Comparison of the subgroups showed that the LT fragment of A2.3 had a larger cortical extension in the posterior, medial, and distal cortex. The mean fracture collapse was 4.7 mm in A2.2 fractures and 5.4 mm in A2.3 fractures (p=0.311). Despite the increased size of the LT fragment in subtype A2.3 fracture compared with subtype A2.2 fracture, this did not influence the clinical outcome. CONCLUSIONS The 3-D morphology of the LT fragment from CT imaging provided a better understanding of the characteristics of subgroups of unstable pertrochanteric fractures, which may improve and guide implant choice.

Correction to: Does increased femoral antetorsion predispose to cartilage lesions of the patellofemoral joint?

Unfortunately, the following reference was not included in the original publication of the article.

Long non-coding RNA MALAT1 promotes oral squamous cell carcinoma development via microRNA-125b/STAT3 axis.

Oral squamous cell carcinoma (OSCC), as the most common type of oral cancer, is responsible for almost 3% of all malignant tumors worldwide. Non-coding RNAs such as lncRNAs and microRNAs have been involved in many cancers including OSCC. Recently, lncRNA metastasis-associated lung adenocarcinoma transcript-1 (MALAT1) has been reported to play an oncogenic role in OSCC metastasis. However, the underlying mechanism of MALAT1 in regulating OSCC progression remains unclear. The aim of this study was to investigate the specific role of MALAT1 in OSCC development. It was observed that MALAT1 was upregulated in OSCC cell lines. Inhibition of MALAT1 can prevent OSCC proliferation while overexpressing MALAT1 promoted OSCC progression. In addition, bioinformatics search was used to identify that miR-125b was a direct target of MALAT1, which indicated a negative correlation between MALAT1 and miR-125b. Besides these, STAT3 was predicted as a binding target of miR-125b in OSCC. Overexpression of MALAT1 was able to suppress the tumor inhibitory effect of miR-125b mimics via upregulating STAT3. Moreover, the function of MALAT1 in OSCC development was further investigated by using in vivo assays. The established nude mice models revealed that downregulated MALAT1 greatly inhibited OSCC tumor growth and reversely upregualated MALAT1 promoted OSCC development via miR-125b/STAT3 axis, respectively. In conclusion, MALAT1 can function as a competing endogenous RNA (ceRNA) to modulate STAT3 expression by absorbing miR-125b in OSCC and could be used as a novel therapeutic target in OSCC diagnosis and treatment.

Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction.

PURPOSE: Anteromedial cortical support reduction is favourable for secondary stability after limited sliding in unstable pertrochanteric fractures. The aim of this study was to compare the accuracy and agreement between intra-operative fluoroscopy and post-operative 3D reconstruction. MATERIALS AND METHODS: A retrospective analysis of 28 patients (mean 81.6 years) treated with short cephalomedullary nails was performed. All patients had full sets of intra-operative fluoroscopy and post-operative 3D CT images. Observation was focused on the position of the anteromedial cortices of the inferior corner between the head-neck fragment and femoral shaft, and their relationship was categorised into three types: positive, neutral and negative. The percentage of subsequent changes in cortical reduction quality between fluoroscopy and 3D CT was calculated and compared. RESULTS: There were 24 positive (85.7%), four neutral and no negative positions in the anteroposterior (AP) view and one positive, 20 neutral (71.4%) and seven negative positions in the lateral view from fluoroscopy. On post-operative 3D CT images with a full range of rotation, definitive anteromedial cortical contact (positive and neutral support) was observed in 18 cases (64.3%). Ten cases lost the anteromedial cortical buttress. With the posteromedial region of the lesser trochanter detached, a positive AP cortical position combined with a positive/neutral lateral position on fluoroscopy (17 cases) was highly predictive of reliable, definitive cortical support (15 cases, 88.2%) on 3D CT. A negative lateral position on fluoroscopy (seven cases), regardless of the combination in the AP view, was likely to predict the final loss of cortical support (six cases, 85.7%) on 3D CT; a positive/neutral lateral position (21 cases) was only associated with loss of support in four cases (19.1%) (p < 0.05). CONCLUSIONS: A lateral negative position of the anterior cortex on fluoroscopy for unstable pertrochanteric fractures may be highly predictive of post-operative final loss of the anteromedial cortical buttress, which should be avoided during operation.

Does increased femoral antetorsion predispose to cartilage lesions of the patellofemoral joint?

PURPOSE: The purpose of this study was to investigate whether there was a relationship between femoral neck antetorsion and the presence and pattern of osteoarthritis of the patellofemoral joint. It was hypothesized that an increased femoral neck antetorsion (1) correlates with osteoarthritic changes of the lateral facet of the patellofemoral joint and (2) correlates with an increased lateral trochlear height and a decreased sulcus angle. METHODS: Seventy-eight formalin-embedded cadaveric lower extremities from thirty-nine subjects with a median age of 74 years (range 60-88) were used. Surrounding soft tissues of the lower limb were removed. The femoral neck antetorsion was measured and referenced to the transepicondylar axis and the posterior condylar line. The height of the medial and lateral facet of the trochlea and the sulcus angle was measured. The location and the degree of patellofemoral cartilage degeneration were recorded. A Pearson's correlation analysis was performed to correlate the femoral neck antetorsion with the measured knee parameters. RESULTS: No significant correlation could be found between the femoral antetorsion and cartilage degeneration of the lateral patellofemoral joint (n.s.), the height of the lateral trochlea (n.s.) and the sulcus angle (n.s.). CONCLUSION: This study could not document that the femoral neck antetorsion and subsequent internal rotation of the distal femur correlated with the degree of degeneration of the lateral facet of the patellofemoral joint. Clinically, femoral internal rotation may play a minor role in the development of lateral patellofemoral joint degeneration.

Comparison of tip apex distance and cut-out complications between helical blades and lag screws in intertrochanteric fractures among the elderly: a meta-analysis.

PURPOSE: To investigate whether helical blade implant systems have advantages in terms of tip apex distance (TAD) and cut-out rate in comparison to conventional lag screws for intertrochanteric fractures in a geriatric population. Methods: Relevant articles were sourced from the MEDLINE, Embase, Ovid and Cochrane Library databases from inception through March 2015. All randomized controlled trials (RCTs) comparing outcomes between helical blade and lag screw implant systems were selected. Mean TAD values and reported cut-out complications were noted. Each author independently assessed the relevance of the enrolled studies and the quality of the extracted data. Data were analyzed using R software. RESULTS: Ten studies including 1831 patients were eligible for this review, seven of which were included in a combined analysis of dichotomous outcomes and five in a combined analysis of continuous outcomes. The results revealed that, compared with lag screw implantations, the use of helical blades led to a lower rate of cut-out complications (95 % CI: 0.28­0.96, P = 0.036). Patients who experienced cut-out complications had a significantly greater tip apex distance (95 % CI: 0.68­1.34, P < 0.001). However, the actual tip apex distances were similar between the screw group and blade group (95 % CI: −0.44­0.79, P = 0.58). CONCLUSIONS: No difference in TAD values was found between blades and screws. In addition, the cut-out risk in the blade-design group was lower than that of the screw group. Therefore, TAD is not an accurate predictor of cut-out risk.

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures.

PURPOSE: To introduce the concept of fracture reduction with positive medial cortical support and its clinical and radiological correlation in geriatric unstable pertrochanteric fractures. METHODS: A retrospective analysis of 127 patients (32 men and 95 women, with mean age 78.7 years) with AO/OTA 31A2.2 and 2.3 hip fractures treated with cephalomedullary nail (PFNA-II or Gamma-3) between July 2010 and June 2013 was performed. They were classified into three groups according the grade of medial cortical support in postoperative fracture reduction (positive, neutral, and negative). The positive cortex support was defined that the medial cortex of the head-neck fragment displaced and located a little bit superomedially to the medial cortex of the shaft. If the neck cortex is located laterally to the shaft, it is negative with no cortical buttress, and if the two cortices contact smoothly, it is in neutral position. The demographic baseline, postoperative radiographic femoral neck-shaft angle and neck length, rehabilitation progress and functional recovery scores of each group were recorded and compared. RESULTS: There were 89 cases (70 %) in positive, 26 in neutral, and 12 in negative support. No statistical differences were found between the three groups among patient age, sex ratio, prefracture score of activity of daily living, walking ability score, ASA physical risk score, number of medical comorbidities, osteoporosis Singh index, fracture reduction quality (Garden alignments), and the position of lag screw or helical blade in femoral head (TAD). In follow-up, patients in positive medial cortical support reduction group had the least loss in neck-shaft angle and neck length, and got ground-walking much earlier than negative reduction group, with good functional outcomes and less hip-thigh pain presence. CONCLUSION: Fracture reduction with nonanatomic positive medial cortical support allows limited sliding of the head-neck fragment to contact with the femur shaft and achieve secondary stability, providing a good mechanical environment for fracture healing.

Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique.

BACKGROUND: Distally based perforator propeller sural flaps that pedicled on an isolated perforator from the peroneal artery or posterior tibial artery are a versatile local reconstructive option for defects of the foot and ankle region. However, flap venous congestion is yet a difficult problem after operation. We hypothesize that containing some adipofascial tissues around the axial perforator can preserve some tiny venous return routes, improve venous drainage, and ultimately enhance flap safety in distally based sural flaps. METHODS: A prospective case series of 12 patients undergoing distally based perforator sural flaps for foot and ankle coverage were included in this study from January 2008 to December 2010. There were 7 posterior tibial artery perforator flaps from the posteromedial sural region and 5 peroneal artery perforator flaps from the posterolateral sural region. After identifying the proper viable perforator during operation as the pivot point, the whole flap was designed in an eccentric propeller shape. The proximal larger blade was a fasciocutaneous flap, whereas the distal smaller blade was a subdermal vascular plexus flap, preserving at least a quarter area of adipofascial tissue intact around the perforator. Postoperatively, flap swelling was classified into a 5-grade assessment scale. Flap survival, complications, and patient functional recovery were evaluated. RESULTS: The proximal fasciocutaneous flap measured 4 × 8 to 6 × 18 cm (mean, 57.8 cm), and the distal subdermal cutaneous flap measured 2 × 2 to 4 × 4 cm (mean, 9.2 cm). The flaps were rotated 160 to 180 degrees. Postoperatively, flap swelling was noted under grade 2 in 9 cases, grade 3 in 2, and grade 4 in 1 with some distal superficial skin necrosis, which occurred in the largest flap in our series. All flaps survived uneventfully. After a mean of 13 months of follow-up, the wounds were cured successfully. All patients recovered walking and shoe wearing function. CONCLUSION: Keeping a quadrant adipofascial tissue around the distal pivot perforator to form a perforator-adipofascial-pedicle can preserve more venous return routes and relieve flap swelling. This technique should be recommended in distally perforator-pedicled propeller flaps because it enhances flap safety yet does not increase the difficulty of 180-degree rotation.