Post-operative osteopathic manipulative treatment of Morel-Lavallee syndrome assessed using infrared thermal imaging: A case report.

INTRODUCTION: The Morel-Lavallee lesion (MLL) is a closed, degloving soft-tissue injury, wherein the skin and subcutaneous tissue are separated from the underlying fascia. This syndrome causes disruption of wound healing. Infrared thermography is a noninvasive and pain-free tool that can be used to evaluate scar and the influence of osteopathic manipulative treatment. OBJECTIVE: To evaluate the influence of post-operative osteopathic manipulative treatment (OMT) of Morel-Lavallee lesions (MLL). METHODS: During four osteopathic sessions on one volunteer patient, 28-year-old male, resulting in MLL of the left knee after motorcycle accident. The effects of OMT were assessed using an infrared thermal imaging camera and qualitative palpation examination of osteopathic dysfunction, scored on a scale of 1-4. RESULTS: and discussion: Both scar and peri-scar area temperatures increased after OMT. The difference in temperature between the scar and the peri-scar area decreased after OMT. Increase in temperature was greater when the OMT was applied around the scar than when applied at a distance from the scar site. The palpation score for dysfunction of the MLL scar site decreased from 4/4 to 2/4 after the final session. CONCLUSION: Several OMT sessions focusing on the MLL scar site appear necessary to obtain noteworthy results. OMT improved mobility and increased the temperature of the scar and the peri-scar area.

U-Turn Design Metatarsal Artery Flap: Reliable Solution in Distal Forefoot Defect.

BACKGROUND: In distal forefoot defect, finding wound closure is challenging because of the distal site and small blood vessels involved. One possible resolution is the utilization of a metatarsal artery flap in a 'U-turn' design. This method offers several advantages, including its long length and a viable option for distal forefoot defect. METHODS: Thirty-six patients with forefoot injuries from metatarsophalangeal (MTP) joint to distal interphalangeal (DIP) joint due to trauma were consecutively recruited and completed the study. Outcomes were analyzed descriptively, and risk prediction modeling for edge necrosis was performed. RESULTS: The mean ± SD follow-up time was 27.3 months ±1.9. The median (IQR) MTP-to-DIP joint wound width and length were 1.8 (1.4, 3.0) and 3.2 cm (2.9, 6.2), respectively. The median (IQR) width, length, and width-to-length ratio flap dimensions were 3.6 (2.8, 6.0), 4.7 cm (4.3, 9.3), and 1.5 (1.2, 1.7), respectively. The mean ± SD operative time was 32.9 min ± 5.7. The median (IQR) intraoperative blood loss was 5.0 mL (4.0, 5.0). The mean ± SD hospital length of stay postoperatively was 4.0 days ±1.0. The mean ± SD Foot and Ankle Outcome Score and Foot Function Index were 64.1 ± 2.5 and 7.8% ± 3.3, respectively. All patients had good or excellent aesthetic satisfaction. Spontaneously resolving edge necrosis occurred in 13.9%. The mean ± SD time-to-start-ambulation was 1.7 weeks ±0.5. At the 2-year follow-up visit, all patients had reduced U-turn flap pivot point redundancy without shoe size impact, needing reoperation, or donor site morbidity. Edge necrosis was significantly associated with length-to-width ratio ( P = 0.014) but not with Foot and Ankle Outcome Score or Foot Function Index. CONCLUSIONS: Metatarsal artery flap of U-turn design was reliable and was associated with a short recovery time, alternative resolution for forefoot area due to short operation time, minimal blood loss, short hospital length of stay, and excellent availability.

Locoregional Flap Reconstruction of the Distal Third of the Leg - What Role Does it Have in a Modern Reconstructive Algorithm?

ABSTRACT: Reconstruction of traumatic defects of the lower third of the leg poses a challenge due to limited locoregional options. Failed coverage can be associated with prolonged hospital stay, infection, loss of function, and unplanned return to surgery. Over the last few decades, free tissue transfer has dominated reconstructive algorithms for such defects; however, locoregional flaps may provide equally effective coverage in select patients. In the wake of the CODID-19 pandemic, locoregional flaps gained more consideration due to limited resources. We present a literature review and discussion of locoregional flaps, with emphasis on the quality and efficacy of these reconstructive modalities compared with free tissue transfer and surgical indications.Soleus flaps, reverse sural flaps, and cutaneous perforator-based flaps are workhorses for small to medium size defects of the distal third of the leg, even in the setting of concomitant orthopedic trauma and exposed vital structures. It is important to consider such alternatives an integral part of the reconstructive algorithm as they can provide durable coverage with a favorable complication profile with less resource utilization. Appropriate patient selection requires consideration of the character of the defect, smoking status, preexisting vascular disease, and the zone of injury.

Staged treatment with arterial reconstruction and flap transplantation for ischemic mangled extremity: An observational study.

Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged treatment for soft tissue reconstruction. This study aimed to report the outcomes of such a staged treatment. Thirteen patients underwent arterial reconstruction between February 2015 and April 2017 due to damage to the major blood vessels by the traumatic mangled extremities. Of them, 6 patients (5 males and 1 female with a mean age of 51 years, age range: 36-60 years) who underwent soft tissue reconstruction due to necrosis were retrospectively analyzed. The average Mangled Extremity Severity Score was 7.2 (range, 6-8). Injuries were found in the lower leg (4 cases), foot (1 case), and wrist and hand (1 case). Arterial reconstruction was performed using autologous venous grafts. The reconstructed arteries included the posterior tibial artery (3 cases), anterior tibial artery (1 case), dorsalis pedis artery (1 case), and radial artery (1 case). The blood circulation status of the reconstructed blood vessels was assessed using computed tomography angiography at an average of 5 weeks (range, 4-6 weeks) after arterial reconstruction. For some necrotic soft tissues, debridement and flap transplantation were performed an average of 7 weeks (range, 6-8 weeks) after arterial reconstruction. Soft tissue reconstruction was performed with an anterolateral thigh free flap in 4 cases, a local flap in 1 case, and a muscle flap in 1 case. In 5 out of 6 cases, blood circulation was maintained in the reconstructed blood vessels, resulting in the salvaging of the extremities. All the patients who underwent flap surgery survived. Notably, there were no special complications during a follow-up visit conducted at an average of 19 months post-reconstruction. To treat an ischemic mangled extremity, the limbs should first be salvaged with arterial reconstruction, followed by subsequent appropriate flap surgery when soft tissue necrosis occurs at the mangled site as a staged treatment.

Time to wound closure in facial soft tissue injuries following road traffic accidents.

The 6-hour (6-h) time to wound closure was a controversial issue as studies have shown that time was not a substantial factor. Wounds in the face are often considered to have a lower infection risk. Despite this, the cause of injury was not extensively discussed in relation to this context. The primary objective was to investigate the association between the 6-h time to wound closure and wound complications following emergency management of facial soft tissue injuries (STIs). Additionally, the secondary objective was to explore other factors contributing to wound complications. A retrospective record review was conducted in our hospital in Kuala Lumpur, Malaysia, from 1 January 2017 to 31 December 2021. Medical records of patients with facial STIs due to road traffic accidents were included. Simple random sampling was used to select records meeting inclusion criteria. Data on demographic, injury, and treatment characteristics were collected using a standardized proforma. Descriptive, univariate and multivariate analyses were performed, including chi-square tests and binary logistic regression. A total of 295 patient records were included, with most patients being males (77.3%) and of Malay ethnicity (54.9%). The median age was 31.0 years. Majority of patients were treated within 6 h of injury (93.9%). Complications were documented in 6.1% of cases, including wound dehiscence and infection. Multivariate analysis revealed a significant association between 6-h time to closure and wound complications (OR: 7.53, 95% CI: 1.90-29.81, p = 0.004). Grade of surgeon on duty (OR: 4.61, 95% CI: 1.25-16.95, p = 0.02) and diabetes mellitus (OR: 6.12, 95% CI: 1.23-30.38, p = 0.03) were also shown to have a statistically significant association with wound complications. A 6-h time to wound closure, grade of surgeon on duty and diabetes mellitus were three major factors involved in facial wound complications following road traffic accidents.

Paraumbilical Perforator Flap: A Reliable Option for Coverage of Soft Tissue Defects of Forearm and Hand.

Soft tissue injuries of the hand or forearm often results in exposure of tendon or bone which needs coverage with a suitable flap. This prospective observational study was carried out in National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh from February 2019 to January 2020, to evaluate the use of the pedicled paraumbilical perforator flaps as a reliable flap to cover such defects. Total 34 patients having soft tissue defects in the hand and forearm with exposed tendons, bones or implant were included in this study. All the defects were covered by paraumbilical perforator flap. The defects were caused by road traffic accident (n=22), machinery injury (n=10) and burn injury (n=2). Sixteen patients had defects involving the forearm, six over dorsum of hand, another two over first web space and the rest had defects over two or more areas of forearm, hand and wrist. Lateral extent of flaps was upto anterior axillary line in 41.18% cases and upto mid-axillary line in 55.88% cases. Flap division and final inset was done in second stage after 3 weeks. Donor site closed primarily in all cases, except in two cases where it was covered by skin graft. All the flaps survived with no incidence of flap necrosis, dehiscence or infection after first stage. However, after the division of the flap, two patients developed marginal necrosis of the proximal margin which healed spontaneously by conservative treatment. The mean flap surface area utilized was 108 cm2. Donor area healed well without any major complications. Three patients developing scar hypertrophy were treated with intra-lesional triamcinolone injections. The paraumbilical perforator flap is a reliable option to cover soft tissue defects of hand and forearm due to easier planning and harvesting of the flap, adequate skin paddle and minimum donor site morbidity.

Repair of distal finger soft-tissue defects with free fibular great toe neurovascular flaps.

BACKGROUND: This work aimed to investigate the change in fingerprint depth and the recovery rule of fingerprint biological recognition function after repairing finger abdominal defects and rebuilding fingerprint with a free flap. METHOD: From April 2018 to March 2023, we collected a total of 43 cases of repairing finger pulp defects using the free flap of the fibular side of the great toe with the digital nerve. After surgery, irregular follow-up visits were conducted to observe fingerprint clarity, perform the ninhydrin test or detect visible sweating with the naked eye. We recorded fingerprint clarity, nail shape, two-point discrimination, cold perception, warm perception and fingerprint recognition using smartphones. The reconstruction process of the repaired finger was recorded to understand the changes in various observation indicators and their relationship with the depth of the fingerprint. The correlation between fingerprint depth and neural repair was determined, and the process of fingerprint biological recognition function repair was elucidated. RESULT: All flaps survived, and we observed various manifestations in different stages of nerve recovery. The reconstructed fingerprint had a clear fuzzy process, and the depth changes of the fingerprint were consistent with the changes in the biological recognition function curve. CONCLUSION: The free flap with the digital nerve is used to repair finger pulp defects. The reconstructed fingerprint has a biological recognition function, and the depth of the fingerprint is correlated with the process of nerve repair. The fingerprint morphology has a dynamic recovery process, and it can reach a stable state after 6-8 months.

Soft Tissue Coverage for Foot and Ankle Trauma.

Lower extremity trauma can result in extensive soft tissue loss, which can require a staged multispecialty approach. Flaps can be an excellent choice for significant soft tissue loss. A variety of variables goes into the selection of a flap including understanding what the recipient site needs, available donor sites, nature of trauma, and utilization of indices to predict limb salvageability in order to strategically select the correct flap option.

Outcomes and Complications of Sole Reconstruction Using Lateral Thoracic Free Tissue Transfer.

BACKGROUND: The complex structure of the sole of the foot makes the repair of extensive defects challenging. The present study, therefore, aimed to address a gap in current research by evaluating the potential of the lateral thoracic free flap, including perforator options and chimeric configurations, to be used as an advanced solution for comprehensive sole reconstruction. PATIENTS AND METHODS: We retrospectively collected the following data from the charts of patients with sole defects, due to various causes, who underwent lateral thoracic free tissue transfers: patient demographics; etiologies; comorbidities; flap types and dimensions; pedicle length; operative time; follow-up period; complications; and management. RESULTS: The present study included 54 patients who underwent lateral thoracic free tissue transfer, citing infection, trauma, tumor, and posttraumatic sequelae as the major etiologies. We used the following techniques for the reconstruction of sole defects: thoracodorsal artery perforator free flap (83.3%); latissimus dorsi musculocutaneous free flap (1.9%); and various chimeric pattern flaps (14.8%). Free tissue transfer in the lateral thoracic region offers versatility for reconstruction, as well as low donor site morbidity. Complications observed in the present study included wound dehiscence (9.3%), partial necrosis (9.3%), and pressure ulcers (22.2%), although most patients healed favorably without flap loss. CONCLUSIONS: The lateral thoracic free flap is a viable option for the reconstruction of the sole of the foot and allows for the effective reconstruction of complex defects. It contains a sustainable skin paddle, and multiple components can be easily included as a chimeric type. Further studies should seek to identify ways to prevent pressure ulcers, which was the only known long-term complication in the present study.

[Modern concepts of interdisciplinary extremity reconstruction in open fractures]. / Moderne Konzepte der interdisziplinären Extremitätenrekonstruktion bei offenen Frakturen.

The orthoplastic approach involves the collaboration of orthopedic/trauma surgeons, vascular surgeons and reconstructive microsurgeons. In cases of complex limb fractures, the aims are to optimize blood flow, restore bone stability, reconstruct soft tissue defects, and enhance function and sensitivity. The early administration of antibiotics and a timely, high-quality debridement after initial interdisciplinary assessment are carried out. This is followed by fracture stabilization and temporary wound coverage in order to plan the definitive interdisciplinary procedure. This includes definitive osteosynthesis and soft tissue reconstruction, using local tissue transfer if feasible, or free tissue transfer in cases of extensive trauma zones. The orthoplastic approach allows for faster definitive stabilization, fewer operations, shorter hospital stays, lower complication and revision rates, higher cost-effectiveness and improved long-term function.

Cross-leg flaps: A nonmicrosurgical alternative treatment method in complex lower extremity trauma reconstruction.

OBJECTIVES: This study aimed to present our experiences with cross-leg flap surgery, which demonstrates successful outcomes in lower limb soft tissue defects without the necessity of microsurgical intervention. PATIENTS AND METHODS: The retrospective study included 26 patients (18 males, 8 females; mean age: 35.6±12.2 years; range, 18 to 65 years) between January 2015 and September 2019. A fasciocutaneous cross-leg flap was applied to the recipient extremity, and the extremities were immobilized by a tubular external fixator. Flap divisions were performed on the 21st postoperative day. At least two years of clinical outcomes were presented. RESULTS: Twenty-five flaps survived and recovered completely without any complication at the donor site, flaps, or the recipient area. In one diabetic patient, partial flap loss was encountered, which granulated with secondary healing. All patients demonstrated stable wound coverage, with none demanding additional soft tissue surgeries. All patients resumed normal ambulation and physical activity without any residual joint stiffness. CONCLUSION: Cross-leg flap method is an effective and respectable option for extremity salvage as a good alternative to free flaps for the management of traumatic complex lower limb defects. This method is simple, provides abundant blood supply to the wound, and does not require microsurgical experience or a good working recipient artery.

Avulsion and Soft Tissue Injuries of the Ulnar Collateral Ligament in Children and Adolescents.

BACKGROUND: Although pediatric medial epicondylar fractures and apophysitis are well studied, patterns of subapophyseal avulsion and ligamentous injuries of the medial elbow in this population merit investigation to inform optimal treatment strategies. PURPOSE: To describe the occurrence and demographic correlates of ulnar collateral ligament (UCL) avulsion and soft tissue injuries of the pediatric and adolescent elbow. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: An institutional review board-approved review was conducted to identify consecutive patients with medial elbow injuries treated in a tertiary pediatric sports medicine practice between 2016 and 2021. Radiographs were obtained during injury evaluation, and patients with nondisplaced medial epicondylar apophysitis and complete epicondylar fracture were excluded, resulting in 150 patients with soft tissue injuries occurring distal to the medial epicondyle apophysis (subapophyseal) for study. Radiographs were evaluated for bony avulsion of the UCL from either the medial epicondyle proximally or the ulnar sublime tubercle distally. Injuries without radiographic evidence of bony avulsion, but with clinical examination findings consistent with ligamentous injury, were classified as radiographically negative UCL injuries, and magnetic resonance imaging (MRI) was performed to further evaluate these injuries if moderate to severe medial swelling of the elbow or significant concern for medial structural injury was present on examination. These MRI scans were evaluated to classify the UCL injury and assess for periosteal or cartilaginous avulsions. RESULTS: A total of 150 patients (mean age, 12.5 ± 3.4 years; 70 female), 55% (150/274) of the entire medial elbow injury population, had a subapophyseal injury. Of these patients, 62 had a bony avulsion detected on radiograph, and 88 had a radiographically negative injury. In addition to the 62 radiographic avulsions, the 61 MRI scans obtained on those radiographically negative injuries revealed 33 complete UCL disruptions, resulting in 63.3% (95/150) of patients sustaining a complete ligamentous disruption. With the MRI scans, 37 (61%) cases of cartilaginous or periosteal avulsion of the UCL were diagnosed. Overall, 66% of all 150 subapophyseal injuries had a bony, cartilaginous, or periosteal UCL avulsion. Patients with cartilaginous (mean age, 10.3 years) and bony (mean age, 10.6 years) avulsions were younger than those with central ligament injury (mean age, 14.2 years) or periosteal (mean age, 14.2 years) avulsions (P = .005). There was a significant association between the mechanism of injury and the location of UCL tear identified on MRI scans: traumatic falls were associated with distal tears, and throwing injuries were associated with proximal tears (P < .001). CONCLUSION: UCL central ligament and avulsion lesions may be frequently diagnosed after injury to the pediatric medial elbow, the majority of which are complete injuries, and may require MRI for diagnosis. The mechanism of injury may predict the location of ligamentous injury, and osteocartilaginous avulsions are more likely to present at younger ages than injuries to the soft tissue of the UCL or periosteum. The prevalence of these injuries merits further investigation into best protocols of nonoperative treatment or surgical repair techniques and outcomes.

Associations of collagen type 1 α1 gene polymorphisms and musculoskeletal soft tissue injuries: a meta-analysis with trial sequential analysis.

Numerous studies have investigated the role of collagen type 1 α1 (COL1A1) polymorphisms in musculoskeletal soft tissue injuries (MSTIs), yielding conflicting results. This study was designed to synthesize existing evidence and clarify the relationship between COL1A1 polymorphisms and MSTI susceptibility. We conducted a comprehensive literature search using PubMed, Cochrane Library, Web of Science, EMBASE, and Wanfang databases. Associations were assessed using odds ratios (ORs) with 95% confidence intervals (95% CIs) across five genetic models. Subgroup analyses were performed based on ethnicity and injury type. Additionally, trial sequential analysis (TSA) was utilized to assess information size and statistical power. We analyzed a total of 16 articles from 358 retrieved studies, encompassing 2094 MSTI cases and 4105 controls. Our pooled data revealed that individuals with the TT genotype of the rs1800012 polymorphism had a significantly reduced risk of MSTIs (TT vs. GG, OR = 0.53, 95% CI 0.35-0.82, P = 0.004; TT vs. TG + GG, OR = 0.54, 95% CI 0.36-0.80, P = 0.002). Ethnicity-based stratification showed a significant association in Caucasians but not Asians. However, no significant association was observed between the rs1107946 polymorphism and MSTIs, regardless of ethnicity or injury type. TSA indicated that the sample sizes may have been insufficient to yield conclusive results. In conclusion, our study supports the protective effect of the TT genotype of the rs1800012 polymorphism against MSTIs, particularly among Caucasians. However, the rs1107946 polymorphism does not appear to influence MSTI susceptibility.

Synergistic clinical application of synthetic electrospun fiber wound matrix in the management of a complex traumatic wound: degloving left groin and thigh auger injury.

BACKGROUND: Managing complex traumatic soft tissue wounds involving a large surface area while attempting to optimize healing, avoid infection, and promote favorable cosmetic outcomes is challenging. Regenerative materials such as ECMs are typically used in wound care to enhance the wound healing response and proliferative phase of tissue formation. CASE REPORT: The case reported herein is an example of the efficacious use of an SEFM in the surgical management of a large complex traumatic wound involving the left lower extremity and lower abdominal region. The wound bed was successfully prepared for skin grafting over an area of 1200 cm2, making this among the largest applications of the SEFM reported in the literature. CONCLUSION: This case report demonstrates the clinical versatility of the SEFM and a synergistic approach to complex traumatic wound care. The SEFM was successfully used to achieve tissue granulation for a successful skin graft across a large surface in an anatomic region with complex topography.

Local or regional flaps in developing country: Experience from Eastern Bhutan.

Soft tissue reconstruction plays an integral part in orthopaedic surgery. For developing country like Bhutan, where no micro-surgical or plastic surgeons are available, orthopaedic surgeons perform the local or regional flaps for the soft tissue defects. In this paper, we describe the use of different kinds of local and regional flaps and its outcome at Eastern Regional Referral Hospital, Bhutan.

Application of Human Acellular Dermal Matrix with Skin Graft for Lacunar Soft-Tissue Defect of Lateral Heel after Calcaneal Fracture.

OBJECTIVE: To investigate the clinical effect of human acellular dermal matrix (HADM) combined with split-thickness skin graft in repairing lacunar soft tissue defects of the lateral heel after calcaneal fracture. METHODS: From June 2018 to October 2020, providers repaired 11 cases of lacunar soft tissue defects at the lateral part of the heel using HADM combined with split-thickness skin graft. After thorough debridement, the HADM was trimmed and filled into the lacunar defect area. Once the wound was covered, a split-thickness skin graft and negative-pressure wound therapy were applied. Providers evaluated the appearance, scar, ductility of the skin graft site, appearance of the donor site, healing time, and any reoperation at follow-up. RESULTS: Of the 11 cases, 8 patients achieved successful wound healing by primary intention. Three patients showed partial necrosis in the edge of the skin graft, but the wound healed after standard wound care. Evaluation at 6 and 12 months after surgery showed that all patients had wound healing and mild local scarring; there was no obvious pigmentation or scar formation in the donor skin area. The average healing time was 37.5 days (range, 24-43 days). CONCLUSIONS: The HADM combined with split-thickness skin graft is a simple and effective reconstruction method for lacunar soft tissue defect of the lateral heel after calcaneal fracture. In this small sample, the combination demonstrated few infections, minor scar formation, few donor site complications, and relatively short hospital stays.

Fixation with multiple K-wires and PRP injection as an effective way to manage heel pad avulsion.

The treatment of acute heel pad avulsion differs significantly from managing other soft tissue injuries due to its unique soft tissue structure. This case report outlines a scenario involving a male in his 20s who suffered heel pad avulsion without a calcaneal fracture but with an ipsilateral medial malleolus fracture after a twisting injury to the ankle caused by a road traffic accident. Immediate action was taken within 24 hours of the injury, involving thorough debridement of the wound, fixation to the calcaneum using multiple K-wires, primary suturing and internal fixation of the medial malleolus with two cannulated cancellous screws. Postoperative care included PRP (platelet-rich plasma) injections into the wound twice, removal of K-wires after 6 weeks and allowing walking with full weight bearing after 8 weeks. A year later, the wound had completely healed, and the patient was comfortably walking pain-free with full weight-bearing capabilities.

[Application of three-dimensional ultrasound technique in repairing dorsal foot wounds with medial sural artery perforator flaps].

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.

Anatomy, evolution, and clinical aspects of the superextended-intercompartmental-supraretinacular artery perforator flap (SISAP-flap): A proof of concept.

BACKGROUND: Extended soft tissue defects of the fingers-irrespective of their origin-are challenging to treat. In cases of missing amputates or crush injuries, the options are often limited to further amputation, ray resection, or free tissue transplantation. The SISAP-flap was developed to add an extra option to treat finger avulsion injuries or otherwise extended soft tissue finger defects. METHODS: Cadaveric SISAP-flaps were individually dissected, tested for arterial perfusion using red ink and radiopaque dye, and transposed into artificially created same-size defects. After introducing this flap in the clinic, which was partially successful in the first patient, we modified the flap to its definite design. RESULTS: Average cadaver flap size ranges between 11 cm and 22 cm in length, allowing dorsal wrapping of the flap over the fingertip and way back to the palmar metacarpophalangeal-joint. The flap is based on the distal web space perforator, which is commonly used by a dorsal metacarpal artery flap and supercharged using an intercompartmental, supraretinacular artery. Donor sites were closed primarily with little tension. Application of the flap in the clinic resulted in satisfactory functional and esthetic outcomes. CONCLUSION: The SISAP-flap is a new option for the reconstruction of extended finger defects and should be added to the reconstructive surgeon's armamentarium of pedicled flaps, providing relatively short operating times and promising clinical outcomes.