【Abstract】 Objective To investigate the operative techniques and cl inical results of repairing the soft tissue defectsof forearm and hand with free peroneal perforator-based sural neurofasciocutaneous flap. Methods From May 2006 toJanuary 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 × 7 cm to 24 cm × 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 vascula anastomosis. Then the flaps were harvested and transferred to the reci pient sites with the peroneal vartey anastomosed to the radial (or ulnar) artery and the peroneal veins to one of the radial (or ulnar) veins and the cephal ic vein, respectively. The flap size ranged from 18 cm × 8 cm to 25 cm × 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 heal ing by changing dressing and anti-infective therapy. The donor sites reached primary heal ing 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, rel iable 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.
Objective To establ ish the experimental animal model of perforator sural neurocutaneous flap for laying a foundation of further study on its physiology and haemodynamics. Methods Thirty-five New Zealand rabbits were divided into four groups, weighing 2.5-3.0 kg and being male or female. In group A (n=5), vivisection was performed to observe thestarting point and arrangement of sural nerve, its concomitant vessels, posterior tibial artery and perforating vessel. In groups B and C (n=5), red latex and gelatin-lead oxide were injected into the concomitant arteries of sural nerve and the posterior tibial arteries respectively to observe their arrangement, the diameter and anatomasis. In group D, forty neurocutaneous flaps based on single perforator were elevated in the twenty rabbits with a size of 7 cm × 1 cm and a pedicle of 0.5 cm. The colour and condition of flaps were observed. Results The sural nerve originated from posterior tibial nerve, passed through the lateral head of the gastrocnemius at site of the popl iteal fossa, descended obl iquely to exterior, entered in the deep fascia at about (5.42 ± 0.15) cm above lateral malleolus, and descended vertically to lateral malleolus. Its concomitant artery originated from deep femoral artery with an initial diameter of (0.73 ± 0.11) mm and extended to the lateral malleolus along the sural nerve. A perforating branch of posterior tibial artery at the position of the calcaneus originated from the midpoint of the l ine connecting between the medial malleolus and the calcaneus with an initial diameter of (0.45 ± 0.01) mm. The perforating branch traversed the calcaneus to the region of the lateral malleolus, and anastomosed to the concomitant artery of the sural nerve, forming a vascular plexus around the sural nerve. In group D, two cases were excluded due to infection. The survival rate was 78.0% ± 1.5% in other 38 flaps 10days after operation. Conclusion The perforator based sural neurocutaneous flap in rabbit is a good experimental model,which has stable anamatic features and rel iable blood distribution.
Objective To summarize the cl inical experience of repairing soft tissue defect in dorsal pedis with reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flap, and to explore surgery matters needingattention and measures to prevent flap necrosis. Methods Between August 2000 and April 2009, 31 patients with soft tissue defects in dorsal pedis were treated with reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flaps. There were 23 males and 8 females with a median age of 34 years (range, 3-65 years). Defects were caused by traffic accident in 20 cases, by machine in 2 cases, and by crush in 2 cases. The time from injury to admission was 1-32 days (mean, 15 days). And 6 cases had chronic ulcer or unstable scar excision with disease duration of 6 months to 10 years, and 1 case had squamous carcinoma with disease duration of 5 months. The wounds were located in medial dorsal pedis in 12 cases and lateral dorsal pedis in 19 cases; including 14 wounds near the middle metatarsal and 17 wounds beyond the middle metatarsal (up to the metatarsophalangeal joint in 10 cases). All cases accompanied with bone or tendon exposure. Five cases accompanied with long extensor muscle digits tendon rupture and defect, 1 case accompanied with talus fracture, 1 case accompanied with talus fracture and third metatarsal fracture. The size of the wounds ranged from 6.0 cm × 4.5 cm to 17.0 cm × 10.0 cm. The size of the flaps ranged from 8.0 cm × 5.5 cm to 20.0 cm × 12.0 cm. The donor sites were resurfaced by skin graft. Results Seventeen flaps survived uneventfully, wounds healed by first intention. Distal epidermal or superficial necrosis occurred in 6 flaps at 5-12 daysafter operation, wounds healed by dressing change or skin graft. Distal partial necrosis occurred in 8 flaps (7 in medial dorsal pedis and 1 in lateral dorsal pedis) at 7-14 days after operation, wounds healed by skin graft in 3 cases, by secondary suture in 3 cases, by local flap rotation in 1 case, and by cross leg flap in 1 case. All skin grafts at donor sites survived uneventfully, wounds healed by first intention. Twenty-nine patients were followed up 6-29 months (mean, 19 months). The appearance was sl ightly overstaffed, but wearing shoe function and gait were normal. The texture and color of the flaps in all cases were good. There was no pigmentation and suppuration relapse. There was neither ankle plantar flexion deformity nor hammer toe deformity in 5 cases accompanied with long extensor muscle digits tendon rupture and defect. All fractures healed at 3 months after operation in 2 cases. Conclusion The reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flaps are suitable to repair most soft tissue defects in lateral dorsal pedis. When the flaps are used to repair soft tissue defects in medial dorsal pedis, avoiding tension in flaps and fascia pedicles should be noted so as to improve flap survival.
Objective To investigate the operative techniques and cl inical results of sural neurocutaneous vascular flap pedicled on the relatively higher and main perforating branch of peroneal artery in repairing small and medium-sized soft tissue defects in ankle. Methods From July 2004 to February 2007, 14 patients (9 males and 5 females, aged 19-53 years) withsmall and medium-sized soft tissue defects in ankle were treated, including 4 cases of skin necrosis caused by surgery for achilles tendon rupture, 3 soft tissue defects due to car accident, 2 crush injury due to fall ing heavy objects, 2 chronical infectious ulcer, 2 skin necrosis cuased by surgery for calcaneus fracture and 1 melanoma resection in heel. Ranging from 4 cm × 2 cm to 9 cm × 5 cm and combing with exposure of either tendon or bone, the defects were in ankle areas (12 cases) and weight-bearing heel (2 cases). The time from injury to hospital ization was 12 days to 13 months, except 3 cases of emergency hospital ization. After thorough debridement, the sural neurocutaneous vascular flaps (13 cm × 5 cm - 36 cm × 6 cm ) pedicled on the perforating branch of peroneal artery was harvested to repair the defects. The donor sites were sutured directly. Results Postoperatively all the flaps survived, and all the donor sites and wounds healed by first intention. Over a 7-23 month follow-up period, the texture, appearance and color of the flaps in all cases were good, with two-point discrimination of 7-12 mm.The function of ankle obtained satisfactory recovery with normal in-shoe gait. Conclusion With a rel iable blood supply, simple operative procedure, sound repair of wound and satisfactory recovery of l imb function, the sural neurocutaneous vascular flap pedicled on the relatively higher and main perforating branch of peroneal artery is appl icable for the repair of small and medium-sized defects in the ankle and weight-bearing area of heel, especially for patients who have no satisfactory perforating branch in lower position.