Local Random Pattern Flap Coverage for Implant Exposure following Open Reduction Internal Fixation via Extensile Lateral Approach to the Calcaneus.

BACKGROUND: Skin necrosis and implant exposure most often appear at the corner of Extensile Lateral Approach for open reduction and internal fixation (ORIF) for displaced intra-articular fracture of the calcaneus. Flap transfer is often used for coverage of this implant exposure. We introduced a new simple local random pattern flap to cover the implant exposure. METHODS: From March 2017 to March 2020, 12 patients with implant exposure after ORIF for displaced intra-articular fracture of the calcaneus were treated with this procedure. The sizes of the defects ranged from 2 × 2 cm2 to 5 × 2 cm2. A local random pattern flap was designed according to the defect size. The lower edge of the flap was along with the wound upper edge and extended distally. The upper horizontal incision of the flap was made at the lateral malleolus level with a length of 5-7 cm depending on the wound defect. Then the random pattern flap was elevated and transferred to cover the defect area. RESULTS: The mean follow-up duration was 6.3 months (ranging 4-13 months). All 12 flaps were uneventfully healed and all patients were able to wear shoes, and no debulking procedures were required. CONCLUSION: The local random pattern flap could be a choice for surgeons when implant exposure at the corner of Extensile Lateral Approach to the Calcaneus occurs.

[Repair of soft tissue defects of lower extremity by using cross-bridge contralateral distally based posterior tibial artery perforator flaps or peroneal artery perforator flaps].

OBJECTIVE: To discuss the feasibility of repairing soft tissue defects of lower extremity with a distally based posterior tibial artery perforator cross-bridge flap or a distally based peroneal artery perforator cross-bridge flap. METHODS: Between August 2007 and February 2010, 15 patients with soft tissue defect of the legs or feet were treated. There were 14 males and 1 female with a mean age of 33.9 years (range, 25-48 years). The injury causes included traffic accident in 8 cases, crush injury by machine in 4 cases, and crush injury by heavy weights in 3 cases. There was a scar (22 cm x 8 cm at size) left on the ankle after the skin graft in 1 patient (after 35 months of traffic accident). And in the other 14 patients, the defect locations were the ankle in 1 case, the upper part of the lower leg in 1 case, and the lower part of the lower leg in 12 cases; the defect sizes ranged from 8 cm x 6 cm to 26 cm x 15 cm; the mean interval from injury to admission was 14.8 days (range, 4-28 days). Defects were repaired with distally based posterior tibial artery perforator cross-bridge flaps in 9 cases and distally based peroneal artery perforator cross-bridge flaps in 6 cases, and the flap sizes ranged from 10 cm x 8 cm to 28 cm x 17 cm. The donor sites were sutured directly, but a split-thickness skin graft was used in the middle part. The pedicles of all flaps were cut at 5-6 weeks postoperatively. RESULTS: Distal mild congestion and partial necrosis at the edge of the skin flap occurred in 2 cases and were cured after dressing change, and the other flaps survived. After cutting the pedicles, all flaps survived, and wounds of recipient sites healed by first intention. Incisions of the donor sites healed by first intention, and skin graft survived. Fifteen patients were followed up 7-35 months with an average of 19.5 months. The color and texture of the flaps were similar to these of the recipient site. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system, the mean score was 87.3 (range, 81-92). CONCLUSION: A distally based posterior tibial artery perforator cross-bridge flap or a distally based peroneal artery perforator cross-bridge flap is an optimal alternative for the reconstruction of the serious tissue defect of contralateral leg or foot because of no microvascular anastomosis necessary, low vascular crisis risk, and high survival rate.

Combined medialis pedis and medial plantar fasciocutaneous flaps based on the medial plantar pedicle for reconstruction of complex soft tissue defects in the hand.

The reconstruction of complex soft tissue defects in hands remains a difficult challenge in reconstructive surgery. In this report, we introduce a combined medialis pedis and medial plantar fasciocutaneous flaps supplied by the lateral and medial branches of the medial plantar artery, which allows a one-stage reconstruction of multiple soft tissue defects in hand. Three combined medialis pedis and medial plantar fasciocutaneous flaps were transferred for repair of the soft tissue defects including palmar and dorsal areas of hand, thumb pulp, and the dorsum of index finger in three patients. All three flaps survived uneventfully with coverage matching the texture and color of the recipients. The donor sites healed without complication. The experience from these cases proves that the combined medialis pedis and medial plantar fasciocutaneous flaps based on the medial plantar pedicle would be a valuable alternative for the reconstruction of complex soft tissue defects in the hand.

The free peroneal perforator-based sural neurofasciocutaneous flap: a novel tool for reconstruction of large soft-tissue defects in the upper limb.

BACKGROUND: The sural neurofasciocutaneous flap has been widely used for reconstruction of soft-tissue defects in the lower leg, ankle, and foot. It can provide a large amount of tissue without compromising the function of the leg. The authors report the applications of the free peroneal perforator-based sural neurofasciocutaneous flap. METHODS: The free sural neurofasciocutaneous flap based on a single peroneal perforator is described. The peroneal perforator, which emerges from the posterior crural septum at the junction of middle and lower thirds of the fibula, was chosen as the pedicle of the flap. Six perforator-based sural neurofasciocutaneous flaps were transferred to resurface large soft-tissue defects in the upper limb. The size of the defects ranged from 15 × 6 cm to 45 × 10 cm. RESULTS: All six flaps survived completely without necrosis. The area of the flaps ranged from 16 × 8 cm to 30 × 10 cm. The average diameter of the peroneal perforator ranged from 1.0 to 1.5 mm, and the length of the perforator pedicles ranged from 4 to 6 cm. One patient developed arterial thrombosis after surgery, which was treated by removal of the thrombus and reanastomosis. No severe venous congestion was observed. All the patients were satisfied with the aesthetic outcome postoperatively at 3 to 12 months' follow-up. There were no serious donor-site complications. CONCLUSION: The free perforator-based sural neurofasciocutaneous flap is a good alternative for reconstruction of extensive soft-tissue defects in the upper limb.

The extended peroneal artery perforator flap for lower extremity reconstruction.

The peroneal artery perforator flap and its modifications have been widely used for coverage of soft tissue defects of ankle and foot in the past decade. In this article, we report on a series of upper knee, ankle, and foot reconstructions with a proximally or distally based extended peroneal artery perforator (EPAP) flap supplied by distinct perforating branches off the proximal or distal peroneal artery. Total pedicle length obtained ranged from 6 to 12 cm. Twelve patients with soft tissue defects of the lower extremity underwent reconstruction using the EPAP flap. The flaps were designed with the sizes from 10 x 6 cm to 25 x 15 cm. All 12 flaps survived completely without complications. Our experience demonstrates that the EPAP flap is reliable and versatile and can provide a large amount of soft tissue for coverage of defects in the leg anywhere from knee to forefoot obviating the need for free tissue transplantation.

Distally based extended peroneal artery septocutaneous perforator cross-bridge flap without microvascular anastomoses for reconstruction of contralateral leg and foot soft tissue defects.

A cross-leg or cross-bridge free flap is one of the choices for the reconstruction of serious leg soft tissue defects. Here, we report on six cases of leg and foot reconstruction with a distally based extended peroneal artery septocutaneous perforator cross-bridge flap without microvascular anastomoses. The vascular pedicle includes the peroneal artery, its perforator branch, and concomitant veins. The total pedicle length ranges from 10 to 14 cm, and the size ranges from 18 x 8 to 21 x 10 cm. All flaps survived completely without complications. Compared with a cross-leg or cross-bridge free flap, a distally based extended peroneal artery septocutaneous perforator cross-bridge flap without microvascular anastomoses does not require the use of some instruments or techniques for microsurgery, leading to a shorter operation duration and a lower risk of thrombosis in the vessel because microvascular anastomosis is not required.

Peroneal artery perforator chimeric flap for reconstruction of composite defects in extremities.

Large bone defects of extremities, especially those associated with soft tissue defects, represent difficult reconstructive problems. Chimeric flap is a suitable option for reconstruction of complex bone and soft-tissue defects. In this report, we present the experience on use of the peroneal artery perforator chimeric flap for the reconstruction of complex bone and soft tissue defects in the extremities in 16 patients. The bone defects were located in the tibia in 8 patients, in both tibia and fibula in 1 patient, in the ulna in 2 patients, in both ulna and radius in 2 patients, and the metatarsal bone in 3 patients. The flap was created with skin paddle and fibula bone segments based on independent perforators. The sizes of flap ranged from 8 x 6 to 20 x 11 cm(2), and the length of fibular grafts ranged from 6 to 22 cm. All flaps survived completely. Bone union was ultimately obtained in all cases at 5 to 11 months, while two cases suffered from stress fractures in 12 month and 18 month after operation, respectively, which eventually healed with external fixation treatment. The follow-up time ranged from 12 to 37 months. The definite bone hypertrophy was observed from X-ray at 18 months after operation. In conclusion, our results show that the peroneal artery perforator chimeric flap is a good option for reconstruction of complex bone and soft-tissue defects of extremities, particularly for those with three-dimensional defects and bone defects exceeding 6 cm in length.

Distally based posterior tibial artery cross-bridge flap for reconstruction of contralateral leg soft tissue defects.

A cross-leg or cross-bridge free flap is frequently used for the reconstruction of leg defects in cases with no suitable recipient vessels in the vicinity of the defect. Here we report eight cases of leg reconstruction with a distally based posterior tibial artery cross-bridge flap without microvascular anastomosis technology. A distally based posterior tibial artery flap was elevated and used to reconstruct contralateral leg defects. A skin incision was made near the recipient wound to create a skin bridge, and a subcutaneous tunnel was made between the skin incision and the recipient wound for the vascular pedicle to pass over. All flaps survived completely without complications, except for a case with minor erosion in the donor site. Compared with a cross-leg or cross-bridge free flap, a distally based posterior tibial artery cross-bridge flap is reliable and versatile, leading to shorter operation duration and a lower risk of thrombosis in the vessel because microvascular anastomosis is not required.

Free peroneal perforator-based sural neurofasciocutaneous flaps for reconstruction of hand and forearm.

BACKGROUND: Sural neurofasciocutaneous flap has been popularly used as an excellent option for the coverage of soft tissue defects in the lower third of leg, ankle and foot, but its free transplantation has been rarely reported. The objective of our work was to investigate the operative technique and clinical results of repairing the soft tissue defects of hand and forearm with free peroneal perforator-based sural neurofasciocutaneous flap. METHODS: Between May 2006 and March 2007, 10 patients including 7 men and 3 women were treated. Their ages ranged from 22 to 51 years. They presented to emergency with large soft tissue defects of 16 cm x 7 cm to 24 cm x 10 cm in size in hand and forearm after injured by motor vehicle accidents (2 cases) or crushed by machine (8 cases). Thorough debridements and primary treatments to associated tendon ruptures or bone fractures were performed on emergency. And free peroneal perforator-based sural neurofasciocutaneous flaps were transplanted when the wound areas were stable at 5 to 7 days after emergency treatment. The flaps were designed along the axis of the sural nerve according to the shape and size of the soft tissue defects, with the peroneal perforator above the lateral malleolus as the pedicle and along with a part of the peroneal artery for vascular anastomosis. Then the flaps were harvested to repair the recipient sites with the peroneal artery anastomosed to the radial (or ulnar) artery and the peroneal veins to one of the radial (or ulnar) veins and the cephalic vein respectively. The flap sizes ranged from 18 cm x 8 cm to 25 cm x 12 cm. The donor areas were closed by skin grafts. RESULTS: All of the 10 flaps survived after surgeries. Marginal necrosis occurred in only 2 cases. The skin grafts survived entirely in the donor sites, and no obvious influence on the donor legs was observed. All of the transplanted flaps presented favourable contours and good functions at 9 to 12 months' follow-up. CONCLUSIONS: Peroneal perforator-based sural neurofasciocutaneous flap has favourable appearance, constant vascular pedicle, reliable blood supply, large size of elevation, and minimal influence on the donor site. The free transplantation of this flap offers a satisfactory alternative for repairing the large soft tissue defects of forearm and hand.

The linker region of Smad2 mediates TGF-beta-dependent ERK2-induced collagen synthesis.

Transforming growth factor (TGF)-beta1 can cause fibrosis diseases by enhancing production of collagen. However, the intracellular signaling mechanism for TGF-beta1 stimulation of this process has not been fully elucidated. The present study focused on this mechanism and the cross-talk between the MAPK and Smad pathways. Extracellular signal-regulated kinase (ERK)2 ablation by a small interfering RNA led to marked inhibition of TGF-beta1-induced collagen synthesis and enhanced phosphorylation of the Smad2 linker site in NIH/3T3 fibroblast cells. However, ERK1 ablation had minimal effects. Ablation of either ERK2 or ERK1 had no effect on the phosphorylation of the Smad2 C-terminal site. Furthermore, a Smad2 mutant with reduced phosphorylation of the Smad2 linker site inhibited TGF-beta1-induced collagen synthesis. These results indicate that ERK2, rather than ERK1, plays a predominantly positive role in TGF-beta1-induced collagen synthesis, and that ERK2 enhances collagen synthesis, at least partially, through activation of the Smad2 linker site.

[Antegrade extended peroneal artery perforator flap for knee reconstruction].

OBJECTIVE: To investigate the operative technique and clinical results of repairing the soft tissue defects of knee with antegrade extended peroneal artery perforator flap. METHODS: From October 2007 to January 2008, 3 patients (2 men and 1 woman) with the soft tissue defects of knee were treated, with the ages of 18, 31 and 42 years, respectively. The first case sustained femur and pelvis fractures and soft tissue defect over his right popliteal fossa, which were treated with open reduction and internal fixation (ORIF) and debridement of knee joint 2 weeks ago. The second case was necrosis of skin 3 weeks after ORIF for fracture of tibial plateau. The third case suffered from open fracture of tibial plateau and soft tissue defect, which were treated with external fixation and debridement 3 weeks ago. The defect sizes were 16 cm x 9 cm, 11 cm x 6 cm and 14 cm x 7 cm. The flap was raised by dividing the peroneal artery and veins distally and elevating them proximally, which covered for the defects of knee. The flaps were designed with the size of 18 cm x 10 cm, 12 cm 7 cm and 15 cm x 8 cm. The pure vascular pedicle of the flap was 10 cm to 17 cm in length, including the peroneal vessels and one or two perforator branches. The donor site is covered by a split thickness skin graft. RESULTS: All flaps survived after surgery. The donor sites healed by first intention and the skin grafts survived. After following up for 6, 8 and 11 months, the appearance and function of the flaps were all satisfactory. Based on the modified HSS knee performance system, post-operative knee functional outcomes of three patients were excellent. CONCLUSION: The antegrade extended peroneal artery perforator flap supplied by a pure vascular pedicle can be a good alternative for reconstruction of knee. The flap, with a long and thin pure vascular pedicle, could provide good texture and contour matching the recipient area.

[Compound grafting of vascularized fibular head and flaps to repair complicated lateral malleolus defects].

OBJECTIVE: To investigate the method and effect of compound grafting of vascularized fibular head and flaps to repair complicated lateral malleolus defects. METHODS: From July 2000 to April 2006, 6 patients with lateral malleolus bone defect underwent the repairing treatment. There were 5 males and 1 female, aged 9-47 years. The causes of injuries was traffic accident in 4 cases and crash in 2 cases. And 5 cases were in the left side and 1 in right side. The bone defect ranged 3.5-8.5 cm in size and the skin defect ranged 14 cm x 4 cm-18 cm x 7 cm in size. The time from injury to surgery ranged from 15 to 30 days. The complicated lateral malleolus defects were repaired by transplanting the fibular head pedicled with the lateral inferior genicular artery 5-10 cm, and the peroneal perforator flaps or latissimus dorsi flaps 16 cm x 5 cm-20 cm x 8 cm. The raw surfaces of donor site were inflated and packaged with intermediate split thickness skin graft. RESULTS: One flap with 1 cm distal edge dry necrosis healed after change of dressing and others all survived. The free skin grafts survived and the incision healed by the first intention. All the cases were followed up for 4 to 15 months, and all patients achieved the bony healing within 8-16 weeks and the transplanted fibular head grew well. The shape of reconstructed lateral ankles was similar to the normal one and the ankle mortise moved well. The texture of flaps was soft without diagnosis and abrasion. According to Baird-Jackson criterion, the results were excellent in 3 cases, good in 2 cases and fair in 1 case and the excellent and good rate was 83.3%. CONCLUSION: The fibular head pedicled with the lateral inferior genicular artery has good blood supply and the reconstructed lateral malleolus is similar to the normal. The peroneal perforator flaps and latissimus dorsi flaps have adequate blood supply and big dermatomic area. So this operation is an effective method to repair lateral malleolus defect.

[Clinical application of free peroneal perforator-based sural neurofasciocutaneous flap].

OBJECTIVE: To investigate the operative techniques and clinical results of repairing the soft tissue defects of forearm and hand with free peroneal perforator-based sural neurofasciocutaneous flap. METHODS: From May 2006 to January 2007, 6 patients including 5 males and 1 female were treated. Their ages ranged from 22 years to 51 years. They were injured by motor vehicle accidents (2 cases), or crushed by machines (4 cases), with skin defect of hand in 1 case, skin defect of hand associated with tendon injuries and metacarpal fractures in 2 cases, skin defect of forearm in 2 cases, and forearm skin defects with fractures of radius and ulna in 1 case. The areas of soft tissue defect ranged from 16 cm x 7 cm to 24 cm x 10 cm. The debridement and the primary treatment to tendons or bones were performed on emergency. And free flaps were transplanted when the wound areas were stable at 4 to 7 days after the emergent treatment. During the operation, the flaps were designed along the axis of the sural nerve nutrient vessels according to the shape and size of the soft tissue defects, with the peroneal perforator above the lateral malleolus as the pedicle and along with a part of the peroneal artery for vascular anastomosis. Then the flaps were harvested and transferred to the recipient sites with the peroneal varley anastomosed to the radial (or ulnar) artery and the peroneal veins to one of the radial (or ulnar) veins and the cephalic vein, respectively. The flap size ranged from 18 cm x 8 cm to 25 cm x 12 cm. The donor areas were closed by skin grafts. RESULTS: The 5 flaps survived after the surgery. Partial inadequate venous return and distal superficial necrosis happened in only 1 case, which also got secondary healing by changing dressing and anti-infective therapy. The donor sites reached primary healing completely. The followed-up in all the patients for 6 to 13 months revealed that the appearance and function of the flaps were all satisfactory, and no influence on ambulation of donor site was found. CONCLUSION: Peroneal perforator-based sural neurofasciocutaneous flap has the advantages of favourable appearance, constant vascular pedicle, reliable blood supply, large size of elevation and minor influence on the donor site. And the free transfer of this flap is an ideal procedure to repair the large soft tissue defects of forearm and hand.

Functional reconstruction of traumatic loss of flexors in forearm with gastrocnemius myocutaneous flap transfer.

Reconstruction of flexor function of forearm remains a challenge in the reconstructive surgery. With development of microsurgical techniques, reconstructive surgeons have been able to envision muscle transplantation for restoration of function and not simply for provision of soft tissue coverage. In this report, we present our experience in three patients of successful treatment of traumatic flexor loss in the forearm with the microsurgical medial gastrocnemius myocutaneous flap. At 18- to 24-months follow-up, the detected action potential (Latency and Amplity) in the transferred muscle was significantly improved in the EMG examination. The strength of the digital flexion reached to III degree in one case, IV degree in two cases. No complications were noted in the donor legs. We conclude that the microsurgical medial gastrocnemius myocutaneous flap transfer can be an ideal alternative for functional reconstruction of the forearm flexor muscle in three posttrauma patients.

A reversed superficial peroneal neurocutaneous island flap based on the descending branch of the distal peroneal perforator: clinical experiences and modifications.

The distally based neurocutaneous flaps have been popular for lower leg and foot reconstruction. On the basis of pre-existing anatomic studies and clinical experiences, we designed a reversed superficial peroneal neurocutaneous island flap with the descending branch of the distal peroneal perforator as the pedicle. The flap is supplied through both axial perforator and longitudinal chain-linked vascular plexuses. This modified neurocutaneous island flap, measuring around 5 cm x 4 cm to 12 cm x 13 cm in size, was transferred for coverage of foot soft-tissue defects in 21 cases with a low complication rate. Compared to the original neurocutaneous flap, the rotation point of this flap is more distal and the pedicle is thinner. It could provide good texture and contour matching to the recipient area. In conclusion, the modified neurocutaneous island flap provides a reliable tool for repairing soft-tissue defects of the ankle and foot.

[Cross-bridge vascular anastomosis free tissue transplantation in repairing tissue defects of extremities].

OBJECTIVE: To investigate the application and effect of the cross-bridge vascular anastomosis free flap transplantation for tissue defects of extremities. METHODS: From May 1982 to November 2005, 110 cases of tissue defects of extremities were treated with cross-bridge vascular anastomosis free tissue transplantation. Of 110 patitents, 80 were male and 30 were female with a median age of 30 years(5 to 54 years). Tissue defects were caused by traffic accidents (59 cases), machine injuries (32 cases) and mangled injuries (19 cases). The locations were the forearms in 2 cases and the legs in 108 cases. And 69 cases had simple soft tissue defects, 6 cases had simple bone defects, and 35 cases had complicated defects. The length of bone defect ranged from 5 cm to 19 cm and the area of soft tissue defect ranged from 6 cm x 10 cm to 15 cm x 35 cm. The graft tissue included latissimus dorsi musculocutaneous flap, vastus anterolateral flap,cutaneous fibula flap, osseous fibula flap, and cutaneous iliac flap. The cross-bridge of the two lower extremities was performed in 106 cases, the cross-bridge of the two upper extremities in 2 cases, and the cross-bridge of the upper-lower extremities in 2 cases. The composite tissue transplantation was used if the graft tissues were two or more. The wounds of donor site was directly sutured in 67 cases, and partly sutured with skingrafting in 43 cases. RESULTS: Vascular crisis occurred in 9 cases. Vascular crisis was relieved in 5 cases and grafting tissues was survival after exploring the vessel; 4 cases failed. The graft tissue was survival in 101 cases, and the survival rate was 96.4%. The follow-up time was 4 months to 22 years with an average of 6.3 years. Graft bone healed and mean healing time was 4 months. The flap appearance was satisfactory and extremity function was restored to normal. One case became necrosis in the edge of the flap and cured by debridement, dressing and skingrafting, the other got primary healing at 2-3 weeks after operation. CONCLUSION: The application of the cross-bridge vascular anastomosis free tissue transplantation for tissue defects of extremities is an effective method, when extremities have no vessel anastomosed.

Reconstruction of thumb loss complicated by skin defects in the thumb-index web space by combined transplantation of free tissues.

OBJECTIVE: To introduce a new technique of 1-stage reconstruction for thumb loss complicated by thumb-index web space contracture and to report its clinical effectiveness. METHODS: From November 1994 to September 2004 there were 11 patients with thumb loss and contracture in the thumb-index web space who had a combined transplantation of free tissues to reconstruct the missing thumb and to rebuild the web space. The reconstructive procedure used the second toe and the anterolateral thigh flap in 5 patients, the second toe and the scapular flap in 2, the big toe wraparound flap and the anterolateral thigh flap in 3, and the big toe wrapround flap and the scapular flap in 1. The 2 independent free tissues were connected together by a vascular combination to form an assembly with 1 common vascular pedicle, which then was anastomosed to the selected vessels in the recipient hand. In this vascular series the dorsalis pedis artery and the greater saphenous vein served as the common vascular pedicle of the flap transfers and the radial artery and the cephalic vein provided the recipient vessels. The outcomes of the reconstructions were evaluated using the Michigan Hand Outcomes Questionnaire. RESULTS: The flaps survived completely in all patients except 1. In this patient a small area in the distal part of the transplanted anterolateral thigh flap became necrotic but healed after dressing changes without the need for further surgical intervention. A mean follow-up period of 3.6 years showed a mean increase of 4.3 cm in the width of the thumb-index web space and a considerable improvement in overall hand function was noted on the Michigan Hand Outcomes Questionnaire with effect sizes of greater than 3 (large effect) in all domains. CONCLUSIONS: Combined transplantation of the second toe or the big toe wraparound flap and a free skin flap is suitable to reconstruct a missing thumb and repair the associated skin defect in the adjacent thumb-index web space. We found good functional recovery and an acceptable appearance in this series of patients. Type of study/level of evidence: Therapeutic, Level IV. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.