OBJECTIVETo investigate the surgical methods and effectiveness to use the iliac flap combined with anterolateral thigh flap for repair of the first metatarsal bone and large skin defect.METHODSBetween January 2013 and January 2016, iliac flap combined with anterolateral thigh flap was used to repair the first metatarsal bone and large skin defect in 9 patients. There were 5 males and 4 females, with a median age of 15 years (range, 10 to 60 years). The causes included traffic accident injury in 6 cases and crush injury of machine in 3 cases. The average time from injury to operation was 3 hours to 14 days (mean, 7 days). The size of skin soft tissue defect ranged from 10 cm×6 cm to 20 cm×10 cm. The size of first metatarsal bone defect ranged from 2 cm×1 cm to 5 cm×1 cm. The size of iliac flap was 3.0 cm×1.5 cm to 6.0 cm×1.5 cm, and the size of anterolateral thigh flap was 10 cm×6 cm to 20 cm×10 cm. The donor site was directly sutured or repaired by free skin graft.RESULTSAfter operation, the composite flaps survived with primary healing of wound; the skin grafts at donor site survived and the incision healed by first intention. All patients were followed up 6 months to 2 years (mean, 1.6 years). X-ray examination showed that the bone healing time was 3.5-5.0 months (mean, 4 months). The flap had soft texture, good color and appearance. All patients could normally walk. According to the American Orthopaedic Foot and Ankle Society (AOFAS) standard, the foot function was excellent in 6 cases and good in 3 cases, and the excellent and good rate was 100% at last follow-up.CONCLUSIONSThe iliac flap combined with anterolateral thigh flap for repair of the first metatarsal bone and large skin defect is a practical way with good shape at one stage.

Objectives To approach the method and clinical effect on tendo calcaneus and complex tissue defect with microsurgery repair.Methods Retrospective summary the methods of 356 cases with tendo calcaneus and complex tissueserious defect,which repaired by different microsurgery from June 1994 to March 201 1.Two type were divided on account of different degree of serious tendo calcaneus and complex tissue defect.Type A:the length of tendo calcaneus defect was less than 3 cm,and cutaneous deficiency is less than 3 cm × 20 cm.Direct suture (166 cases) or Abraham retrograde "V-Y" method (72 cases)was used to repair endo calcaneus defec,anfregional flap metastasis was used to repair cutaneous deficiency.Two hundred and thirtyeight cases were used by those methods,including of lateral heel flap repair(23 cases),medial plantar island flap(58 cases),instep island flap(40 cases),above medial malleolus flap(48 cases),above ateral malleolus flap (24 cases),sural nerve nutrient vessel flap (29 cases) gastrocnemius muscle flap (16 cases).Type B:the length of tendo calcaneus defect was more than 3 cm,and cutaneous deficiency was more than 3 cm × 20 cm.Direct suture could not repair tendo calcaneus,the complex tissue flap free grafting was used to primary repair tendo calcaneus and complex tissue defect.One hundred and erghteen cases were used by those methods,including of tensor fasciae latae flap free grafting (52 cases),lateral above knee complex tissue flap free grafting (26 cases),latissimus dorsi muscle fascia flap free grafting (24 cases),rectus abdominis muscle front sheath flap free grafting (16 cases).Three hundred and fifty-six cases were repaired by these methods,including 238 cases of regional flap transfer 118 cases of tissue flap free grafting.Results In 238 cases of regional flap transfer,two hundred and twenty-six cases were successful,and 12 cases were partly success,which were wound healing by change dressings.In 118 cases of tissue flap free grafting,one hundred and nine cases were successful,and blood vesse articulo were happened to 8 casess,which were success by operations research,and 1 case was failure which had to use another tissue flap.Follow-up visit was dane from 1.0 year to 4.5 years after operation (average 3.2 years).Functional assessment according to the Thermann ralted the results as excellent in 240 csaes,good in 86 cases,common in 22 cases and worse in 8 cases.The fineness rate was 91.6％.Conclusion Microsurgical repair is a good method to tendo calcaneus and complex tissue defect,different method and strategy selected actively by tissue defect degree of tendo calcaneus and complex tissue can achieve satisfactory functional rehabilitation purpose.

OBJECTIVE:To investigate the operative method and effectiveness of repairing defects at medial malleolus in children with vascularized fibular head composite flap.METHODS:Between November 2008 and January 2011, 8 children with bone and soft tissue defects at the medial malleolus were treated. There were 5 boys and 3 girls, aged 2-9 years (mean, 4.6 years). Injuries were caused by machine twisting in 2 cases and by wheel twisting in 6 cases. Soft tissue defect area ranged from 3.5 cm x 3.0 cm to 7.0 cm x 4.5 cm; defect was total in all medial malleolus. The disease duration from injury to admission was 2-8 hours (mean, 4.5 hours). Defects were repaired with vascularized fibular head composite flap carrying the skin around the head of the fibula in 5 cases, and with vascularized fibular head composite flap and skin flap above the medial malleolus in 3 cases having too large defect (> 5 cm x 4 cm). The donor sites were repaired with direct suture in 2 cases and with skin graft in 6 cases.RESULTS:All 8 fibular head composite flaps and 3 skin flaps above the medial malleolus survived completely. Wounds healed by first intention; the skin grafts at donor sites survived in the other cases except 1 case having local necrosis, with healing of incision by first intention. The patients were followed up 10 months to 3 years (mean, 22 months). The color and elasticity of the flaps were good. All the children had equal leg length. Of 8 cases, 6 had no joint valgus; 2 cases had progressive ankle varus after 1 year of operation. The ankle flexion and extension function returned to normal in 5 cases, and was slightly limited in 3 cases; horizontal side, forward and backward movements had no difference compared with normal side. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle function evaluation criteria, the results were excellent in 5 cases, and good in 3 cases at 10 months after operation. X-ray film showed that the ankle hole gap development of both sides was similar; no premature closure of the epiphysis or bone bridge formation of the medial malleolus was observed in 6 cases, and bone bridge formed in 2 cases after 1 year of operation.CONCLUSION:The satisfactory short-term effectiveness can be obtained in repairing children medial malleolus and soft tissue defects by vascularized fibular head composite flap, and the reconstructed medial malleolus can develop with the growth of children. Long-term effectiveness still need more follow-up study.

Objective To introduce a new procedure for 2nd toe plasty by transferring local flap from the 3rd toe in 2nd toe-to-thumb/finger reconstruction. Methods In 26 cases of 2nd toe transfer to reconstruct the thumb or fingers,a flap from the 3rd toe based on an anastomosing branch from the 2nd dorsal metatarsal artery or the 2nd plantar metarsal artery was harvested and insetted to the fibular side of the middle phalanx of the 2nd toe to increase the circumference of the transplant. A pulp flap was also designed based on the anastomosis between the dorsal digital arteries,between the dorsal and plantar arteries.or between the plantar arteries.It was transfefred and insetted in the plantar aspect of the 2nd toe to eliminate middle stenosis.The pre-fabricated 2nd toe was transferred to reconstruct the thumb and fingers. ResultsAll 76 flaps of 38 toe transfers in the 26 cases survived.There was no compromise of the blood circulation to the 3rd toe.The appearance of the reconstructed finger was satisfying. Conclusion Transfer of local flap from the 3rd toe in 2nd toe-to-thumb/finger reconstruction can improve the appearance of the 2nd toe transplant and is thus a good procedure.