External fixation combined with microsurgical techniques for repairing complex foot and ankle wounds in children_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Gang , XU Qingjia , PEI Yantao , MA Zhihu , SHI Anhao ,  ZHU Lei

Department of Hand and Foot Surgery, Qilu Hospital of Shandong University, Jinan Shandong, 250000, P. R. China;

Corresponding author：

ZHU Lei, Email: zhuleijn@aliyun.com

Keywords：

Complex foot and ankle wounds; external fixation technique; microsurgical technique; child

DOI：

10.7507/1002-1892.202505023

Video：

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Objective To investigate the management strategies of external fixation combined with microsurgery for the treatment of complex foot and ankle wounds in children. Methods The clinical data of 9 children with complex foot and ankle wounds who met the selection criteria between June 2017 and December 2021 were retrospectively analyzed. There were 6 males and 3 females, aged 3-13 years, with an average of 7.4 years. The causes of injury included crush injury in 5 cases and traffic accident injury in 4 cases. The wound size ranged from 6 cm×5 cm to 25 cm×18 cm. The time from injury to surgery ranged from 3 to 8 hours, with an average of 5 hours. All cases underwent staged surgical treatment. Among the 3 cases requiring deformity correction, 2 cases initially underwent free anterolateral thigh flap transplantation for wound coverage and limb salvage, followed by circular external fixation combined with osteotomy to address postoperative limb deformity, while 1 case received osteotomy for tibial fracture realignment prior to local pedicled flap reconstruction. All the 6 cases with non-deformity correction underwent initial external fixation followed by secondary flap reconstruction for wound management. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to evaluate the foot and ankle function of children. Results All patients successfully achieved limb salvage postoperatively. Among the 6 non-deformity correction cases, all flaps survived with satisfactory wound healing and no infections observed; fractures healed within 2.5-4.5 months, after which external fixators were removed for functional rehabilitation with favorable recovery. One patient treated with circular external fixation combined with osteotomy achieved bone union 4 months postoperatively, followed by fixator removal. One patient undergoing osteotomy for tibial fracture realignment showed bone healing at 2.5 months post-correction, with subsequent fixator removal. One patient receiving bone lengthening developed infection 1 week postoperatively, which was managed with multiple debridements, ultimately achieving bone union at 16 months postoperatively and followed by fixator removal. At last follow-up, all patients demonstrated satisfactory ankle-hindfoot functional recovery, with AOFAS ankle-hindfoot scores ranging from 80 to 90 (mean, 84.2). Conclusion The combination of external fixation and microsurgical techniques demonstrates significant advantages in reconstructing complex foot and ankle wounds in children. The synergistic interaction provides both mechanical stability and biological repair, enabling early functional rehabilitation while reducing infection risks.

1.	Pflüger P, Wurm M, Biberthaler P, et al. Analysis of 6851 foot and ankle injuries from 2010-2017 in an emergency department. Unfallchirurgie (Heidelb), 2022, 125(10): 801-810.
2.	Nandra RS, Wu F, Gaffey A, et al. The management of open tibial fractures in children: a retrospective case series of eight years’ experience of 61 cases at a paediatric specialist centre. Bone Joint J, 2017, 99-B(4): 544-553.
3.	Su AW, Larson AN. Pediatric ankle fractures: Concepts and treatment principles. Foot Ankle Clin, 2015, 20(4): 705-719.
4.	胡永生, 王艳杰, 谢忠存. 显微外科技术联合闭合复位外固定架固定在四肢骨折合并血管损伤中的应用价值研究. 中国实用医药, 2025, 20(14): 15-19.
5.	Qin SH, Zang JC, Jiao Sf, et al. Traumatic sequelae of lower limb//Qin SH, Zang JC, Wang YL, et al. Lower limb deformities: deformity correction and function reconstruction. Singapore: Springer Singapore, 2020: 433-470.
6.	郭保逢, 赵巍, 吴鸿飞, 等. Ilizarov跖骨延长治疗糖尿病足溃疡并跖骨头慢性骨髓炎. 中国修复重建外科杂志, 2020, 34(8): 1000-1004.
7.	Sheridan GA, Pang A, Page BJ, et al. The management of tibial bone defects: A multicenter experience of hexapod and Ilizarov frames. J Am Acad Orthop Surg Glob Res Rev, 2023, 7(8): e23.00033. doi: 10.5435/JAAOSGlobal-D-23-00033.
8.	殷海阳, 秦泗河, 石磊, 等. Ilizarov技术治疗软骨发育不全下肢畸形的研究进展. 中华骨与关节外科杂志, 2023, 16(9): 843-848.
9.	谢书强, 侯建玺, 董其强, 等. 短缩再植结合肢体延长术治疗小腿中下段严重离断伤. 中国修复重建外科杂志, 2017, 31(8): 936-940.
10.	Dayton P, Feilmeier M, Coleman N. Principles of management of growth plate fractures in the foot and ankle. Clin Podiatr Med Surg, 2013, 30(4): 583-598.
11.	Pei Y, Ibrahim Y, Wang G, et al. Patient satisfaction after lower limb replantation surgery for traumatic amputation—a qualitative study. BMC Musculoskelet Disord, 2024, 25(1): 15. doi: 10.1186/s12891-023-07076-4.
12.	Halai M, Jamal B, Rea P, et al. Acute fractures of the pediatric foot and ankle. World J Pediatr, 2015, 11(1): 14-20.
13.	Elbatawy A, Elgammal M, Zayid T, et al. Pediatric microsurgery in the reconstruction of complex posttraumatic foot and ankle defects: A long-term follow-up with a comprehensive review of the literature. J Reconstr Microsurg, 2021, 37(3): 193-200.
14.	冯彦华, 任强, 李祥, 等. 全厚与断层皮片移植修复儿童软组织创面的比较. 中国矫形外科杂志, 2025, 33(3): 207-212.
15.	Klein C, Marie-Christine P, Deroussen F, et al. Treatment options for soft tissue defects in severe foot trauma in children. J Wound Care, 2021, 30(6): 432-438.
16.	Dhar S. Ilizarov external fixation in the correction of severe pediatric foot and ankle deformities. Foot Ankle Clin, 2010, 15(2): 265-285.
17.	Humphrey JA, Gillani S, Barry MJ. The role of external fixators in paediatric trauma. Acta Orthop Belg, 2015, 81(3): 363-367.
18.	王杰, 王永标, 杨开波, 等. 游离小腿内侧Flow-through皮瓣桥接修复血管缺损性断肢六例. 中华显微外科杂志, 2013, 36(6): 584-585.
19.	王晓峰, 薛建波, 孙涛, 等. 游离股前外侧皮瓣移植在断肢再植中的应用. 中华显微外科杂志, 2015, 38(3): 278-281.
20.	Rinker B, Valerio IL, Stewart DH, et al. Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10-year review. Plast Reconstr Surg, 2005, 115(6): 1618-1624.
21.	Mistry R, Khan U. A 10-year experience of paediatric lower limb free flap surgery an evolution over time. Injury, 2025, 56(3): 112196. doi: 10.1016/j.injury.2025.112196.
22.	Kay S, Coady M. The role of microsurgery and free tissue transfer in the reconstruction of the paediatric upper extremity. Ann Acad Med Singap, 1995, 24(4 Suppl): 113-123.
23.	Hollenbeck ST, Woo S, Ong S, et al. The combined use of the Ilizarov method and microsurgical techniques for limb salvage. Ann Plast Surg, 2009, 62(5): 486-491.

1. Pflüger P, Wurm M, Biberthaler P, et al. Analysis of 6851 foot and ankle injuries from 2010-2017 in an emergency department. Unfallchirurgie (Heidelb), 2022, 125(10): 801-810.
2. Nandra RS, Wu F, Gaffey A, et al. The management of open tibial fractures in children: a retrospective case series of eight years’ experience of 61 cases at a paediatric specialist centre. Bone Joint J, 2017, 99-B(4): 544-553.
3. Su AW, Larson AN. Pediatric ankle fractures: Concepts and treatment principles. Foot Ankle Clin, 2015, 20(4): 705-719.
4. 胡永生, 王艳杰, 谢忠存. 显微外科技术联合闭合复位外固定架固定在四肢骨折合并血管损伤中的应用价值研究. 中国实用医药, 2025, 20(14): 15-19.
5. Qin SH, Zang JC, Jiao Sf, et al. Traumatic sequelae of lower limb//Qin SH, Zang JC, Wang YL, et al. Lower limb deformities: deformity correction and function reconstruction. Singapore: Springer Singapore, 2020: 433-470.
6. 郭保逢, 赵巍, 吴鸿飞, 等. Ilizarov跖骨延长治疗糖尿病足溃疡并跖骨头慢性骨髓炎. 中国修复重建外科杂志, 2020, 34(8): 1000-1004.
7. Sheridan GA, Pang A, Page BJ, et al. The management of tibial bone defects: A multicenter experience of hexapod and Ilizarov frames. J Am Acad Orthop Surg Glob Res Rev, 2023, 7(8): e23.00033. doi: 10.5435/JAAOSGlobal-D-23-00033.
8. 殷海阳, 秦泗河, 石磊, 等. Ilizarov技术治疗软骨发育不全下肢畸形的研究进展. 中华骨与关节外科杂志, 2023, 16(9): 843-848.
9. 谢书强, 侯建玺, 董其强, 等. 短缩再植结合肢体延长术治疗小腿中下段严重离断伤. 中国修复重建外科杂志, 2017, 31(8): 936-940.
10. Dayton P, Feilmeier M, Coleman N. Principles of management of growth plate fractures in the foot and ankle. Clin Podiatr Med Surg, 2013, 30(4): 583-598.
11. Pei Y, Ibrahim Y, Wang G, et al. Patient satisfaction after lower limb replantation surgery for traumatic amputation—a qualitative study. BMC Musculoskelet Disord, 2024, 25(1): 15. doi: 10.1186/s12891-023-07076-4.
12. Halai M, Jamal B, Rea P, et al. Acute fractures of the pediatric foot and ankle. World J Pediatr, 2015, 11(1): 14-20.
13. Elbatawy A, Elgammal M, Zayid T, et al. Pediatric microsurgery in the reconstruction of complex posttraumatic foot and ankle defects: A long-term follow-up with a comprehensive review of the literature. J Reconstr Microsurg, 2021, 37(3): 193-200.
14. 冯彦华, 任强, 李祥, 等. 全厚与断层皮片移植修复儿童软组织创面的比较. 中国矫形外科杂志, 2025, 33(3): 207-212.
15. Klein C, Marie-Christine P, Deroussen F, et al. Treatment options for soft tissue defects in severe foot trauma in children. J Wound Care, 2021, 30(6): 432-438.
16. Dhar S. Ilizarov external fixation in the correction of severe pediatric foot and ankle deformities. Foot Ankle Clin, 2010, 15(2): 265-285.
17. Humphrey JA, Gillani S, Barry MJ. The role of external fixators in paediatric trauma. Acta Orthop Belg, 2015, 81(3): 363-367.
18. 王杰, 王永标, 杨开波, 等. 游离小腿内侧Flow-through皮瓣桥接修复血管缺损性断肢六例. 中华显微外科杂志, 2013, 36(6): 584-585.
19. 王晓峰, 薛建波, 孙涛, 等. 游离股前外侧皮瓣移植在断肢再植中的应用. 中华显微外科杂志, 2015, 38(3): 278-281.
20. Rinker B, Valerio IL, Stewart DH, et al. Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10-year review. Plast Reconstr Surg, 2005, 115(6): 1618-1624.
21. Mistry R, Khan U. A 10-year experience of paediatric lower limb free flap surgery an evolution over time. Injury, 2025, 56(3): 112196. doi: 10.1016/j.injury.2025.112196.
22. Kay S, Coady M. The role of microsurgery and free tissue transfer in the reconstruction of the paediatric upper extremity. Ann Acad Med Singap, 1995, 24(4 Suppl): 113-123.
23. Hollenbeck ST, Woo S, Ong S, et al. The combined use of the Ilizarov method and microsurgical techniques for limb salvage. Ann Plast Surg, 2009, 62(5): 486-491.

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