Objective:To investigate the clinical effect of superthin anterolateral thigh flap(ALTF) with retrograde dissection of perforator in the interface plane between the superficial and deep layer of superficial fascia for reconstruction of soft tissue defect in the foot.Methods:The study involved 24 Side of 23 patients with foot soft tissue defects in Department of Foot and Ankle Surgery in Wuxi Ninth People’s Hospital from August 2019 to July 2021. There were 15 males and 8 females with an average of 42(range, 22-59) years old, including 9 in left foot, 13 in right foot, and 1 in both feet. The size of soft tissue defects was 4 cm×4 cm-11 cm×17 cm. The dimension of the superthin ALTF was 4 cm×5 cm-12 cm×18 cm. CTA and high-frequency CDU were used to locate the perforator in the superficial fascia plane. The perforator was exposed and dissected retrograde in the adiposal layer. The superthin ALTF was harvested to repair the foot wound. The donor site was sutured directly. All patients enter follow-up reviews at outpatient clinic or by WeChat. The appearance of flaps were recorded.Results:The superthin ALTF survived in all patients. Two cases had partial epidermal necrosis at the distal part of the flap. The thickness of the flap averaged approximately 4(range 3-6) mm. During 8-16(mean 12) months of follow-up, all superthin ALTF were soft in texture without ulceration. Two flaps required secondary defatting procedures, others showed satisfactory appearance without bulky deformity. Only linear scars left in donor areas.Conclusion:The technique of harvesting superthin ALTF with retrograde dissection of perforator in the superficial fascia plane for repairing foot wounds is reliable and is able to achieve satisfactory functional and esthetic outcome.

患者 男,45 岁,右足压砸伤,于外院多次行扩创 VSD 术,术后20 d转入我院. 入院情况:一般情况良好,右前中足足背、足底及两侧大面积皮肤软组织缺损,第 1～4 趾缺损,第 1～4 跖骨内、中、外侧楔骨及骰状骨外露伴坏死,足内在肌坏死伴感染(图1). 入院后创面分泌物细菌培养为绿脓杆菌. 根据足部影像学检查及骨组织坏死缺损范围,制定手术方案,一期行游离腓骨骨皮瓣联合股前外侧皮瓣修复重建前中足.

Objective To investigate the effect of double modified Kessler's technique combined with place and hold rehabilitation protocol on the repair of flexor tendon ruptures in zone [[.Methods From March 2009 to September 2012,36 patients with ruptures of zone Ⅱ flexor tendons in 41 fingers were treated in our unit.The ruptured flexor digitorum profundus (FDP) tendon was repaired by double modified Kessler's technique along with continuous paratenon suturing.Early active mobilization of the repaired digit with the place and hold protocol was commenced on the third day after the surgery.Total active range of motion (TAM) was measured and recorded to evaluate postoperative hand function.Results The follow-up period ranged from 3 to 12 months,with an average of 6.5 months.As indicated by the total active motion (TAM) assessment,the function was rated as excellent in 27 fingers,good in 11 fingers,and fair in 2 fingers.Tendon adhesion occurred in 1 finger.The overall good to excellent rate was 92.7％.Conclusion The double modified Kessler's technique combined with the place and hold rehabilitation protocol can effectively prevent complications after tendon repair and restore hand function.It is a safe and effective method to treat zone Ⅱ flexor tendon injuries.

Objective To investigate the clinical results of reverse interosseous adipofascial flap with delayed skin grafting in the reconstruction of defects on the dorsal hand.Methods From March 2012 to May 2014,16 patients with soft tissue defects on the dorsum of the hand were treated dorsal interosseous adipofascial flap in emergency setting.The size of the flaps ranged from 5 cm × 4 cm to 10 cm × 6 cm.The donor site at the forearm was closed directly.Seven days later,the fascial flap was covered with a full-thickness skin graft taken from the groin area.Vancouver Scar Scale was applied to assess the donor site scar.Five-point Likert scale was used to evaluate the appearance of the recipient site.Results One patient had partial loss of the flap involving 5％ of the area at the distal end.All the other flaps survived completely.The skin grafts took well in all 16 patients.The duration of postoperative follow-up ranged from 6 to 12 months,with an average of 8 months.The texture and color of the skin graft were good,and the esthetic result was satisfactory.The mean score of Vancouver Scar Scale was 0.8.The mean score of Five-point Likert scale was 17.Conclusion The described adipofascial flap transfer with delayed skin graft is rather easy to perform without causing significant functional and aesthetic deficits to the donor site.It is a good method for repairing defects of the dorsal hand.

Objective To introduce the clinical types of perforator branches of anterosuperior malleolus flap and explore its application.Methods Anterosuperior malleolus flap coupling with dorsal pedal flap was used for repairing the soft tissue defect of hands in 18 patients,in which anterosuperior malleolus flap-dorsal pedal single flap in 12 cases,anterosuperior malleolus flap-dorsal pedal bilobate flap in 4 cases,anterosuperior malleolus flap-dorsal pedal trilobate flap in 2 cases;Anterosuperior malleolus retrograde island (bone) flap was used in recovering pedal soft tissue in 22 patients,the flap pedicled from stem of anterior tibial artery in 16 cases,dorsal pedal flap-anterosuperior malleolus flap in 2 cases,the flap from perforate vessels without injuring the anterior main tibial artery in 2 cases,the bone flap combined with the distal of tibia in 2 cases.Results In the 18 cases of hands,17 cases survived,and 1 case of flap mild necrosis at the distal site took a second-phase skin-grafting to repair.Twenty cases of anterosuperior malleolus retrograde island (bone) flap survived,and the other 2 cases needed secondary skin-grafting to repair the necrosis edge of flaps because of venous limited.After a follow-up from 3 to 6 months,30 cases showed the satisfied postoperative outlook,with the good healing of the donor sites.Typing the 40 cases according to the location of perforator branches of the anterosuperior malleolus flap,20 cases locate in the medial of anterior tibial muscle,16 cases locate between the anterior tibial muscle and extensor hallucis longus,4 cases locate between extensor hallucis longus and extensor digitorum longus.Conclusion Knowing the clinical types of the perforator branches of anterosuperior malleolus flap is not only helpful for the accurate processes of operations、preventing cutaneous branches,but also improving the success rate of surgery.

Objective To evaluate the outcomes of early direct repair of re-ruptured flexor digitorum tendons in Zone Ⅱ and Ⅲ.Methods We retrospectively studied 17 cases(21 digits) of re-rupture of primary flexor tendon repairs in Zones Ⅱ and Ⅲ treated between March 2008 and September 2014.Among them there were 12 males and 5 females with the mean age of 31 years (range,18 to 42 years).The rupture was in zone Ⅱ in 10 cases and in zone Ⅲ in 7 cases.The interval between the re-operation and rupture was 4 to 17 days (average 8 days).The flexor digitorum profundus tendon was repaired by triple modified Kessler's technique,and if possible,the flexor digitorum superficialis tendon in zone Ⅲ was repaired by double modified Kessler's suture.Results The follow-up period ranged from 4 to 8 months,with an average of 6 months.There was no rerupture of the tendons.According to total active motion (TAM) classification of functional assessment criteria issued by the Chinese Hand Surgery Society,the final results were good to excellent in 85.7％ of the digits.Conclusion Early repair of re-ruptured flexor tendons in zone Ⅱ and Ⅲ could still lead to satisfactory results.

Objective To summarize the clinical experience of free ilio-abdominal flap and free ilium flap in the use of repairing soft tissue and composite tissue defect of limbs, and to investigate the blood vessel type of free ilio-abdominal flap and free ilium flap. Methods From January 1996 to December 2013, 40 cases were used with free ilio-abdominal flap to repair soft tissue defect of limbs. 18 cases with superficial iliac circumflex artery was pedicle;16 cases with deep iliac circumflex artery was pedicle;6 cases with both superficial and deep iliac circumflex artery was pedicle. 42 sides of 40 cases were used free ilium flap to repair composite tissue defect of limbs. 8 cases with superficial iliac circumflex artery was pedicle;26 cases with deep iliac circumflex artery was pedicle;4 cases with both superficial and deep iliac circumflex artery was pedicle;in another 4 cases, perforating branch can not be found in deep iliac circumflex artery, and iliac flap with anterolateral thigh flap was used. Results Retrospectively analyzed the 82 cases (include 4 cases of iliac flap with anterolateral thigh flap) which were used free ilio-abdominal flap and free ilium flap to repair soft tissue and composite tissue defect of limbs From January 1996 to December 2013, we typed the supply blood vessel of free ilio-abdominal flap and free ilium flap in Ⅳtypes. TypeⅠ:mainly as superficial iliac circumflex artery, 26 cases;TypeⅡ:mainly as deep iliac circumflex artery, 44 sides of 42 cases;TypeⅢ:superficial iliac circumflex artery and deep iliac circumflex artery arose from a common stem, 10 cases; Type Ⅳ: traditional type, 4 cases. Conclusion Blood vessel of iliac abdomen mainly include superficial iliac circumflex artery and deep iliac circumflex artery, certain variations of vascular anatomy can be existed. Choice should depend on the vascular diameter, trend, and type during the operation. Fully understand of the type of blood vessel may help the transplanted tissue to survive, and improve the curative effect.

Objective To investigate the operative technique and clinical results of repairing soft tissue defects of the Lateral malleolus with reverse extended lateral crural flap pedicle with peroneal artery bonecutaneou perforator. Methods 12 Patients with soft tissue defect of the Lateral malleolus were treated by reverse extended lateral crural flap pedicle with bonecutaneou perforator, which was located in the lower 1/3 of the leg from peroneal artery. The lateral cord of sural nerve was included with the flap. Results All 10 cases survived after operation. Partial inadequate venous return and distal superficial necrosis occured in only 2 cases. Which also got secondary healing by removing the pedicle suture dressing. The donor sites reached primary healing completely. After following up for 3~6 months, the appearance and function of the flaps were all satisfactory. And noinfluence to ambulation was found. Conclusion The lateral crural reverse island skin flap with perforating branches of sural artery is a good method for extramalleolus soft tissue defect.

Objective To introduce the clinical experience of the application of lateral upper arm retrograde island flap for coverage of stump wound after forearm amputation.Methods The lateral upper arm retrograde island flap was transferred to cover the wound at the stump that was resulted from forearm amputation.Results This flap was applied in a total of 10 cases.Flaps in 8 cases survived uneventfully.Compromised perfusion was observed in 2 cases which were remedied by removing stitches at the pedicle.These 2 flaps also survived completely.Sufficient follow-up was obtained in 6 cases for 3 months.The stump wounds healed well.The flaps were not bulky.The appearance and elbow function were satisfactory.The stump met requirements for prosthetic fitting.Conclusion Lateral upper arm retrograde island flap is a good option for coverage of stump wound after forearm amputation.

Objective To introduce the surgical techniques and indications of single pedicle thoracoumbilical flaps spanning chest and abdomen in the repair of upper extremity giant soft-tissue defects.Methods From 2006 to 2012,8 cases with upper extremity giant soft-tissue defects were treated with the ultra-long thoraco-umbilical flaps spanning chest and abdomen.The blood vessel chain of inferior epigastric artery→superior epigastric artery→intercostal arteries or lateral thoracic artery were included in the flap to provide double blood supply with only one vascular anastomosis.Results All of the 8 flaps survived.Wounds at both donor and recipient sites achieved primary healing.The shape of flaps was satisfactory after 6 to 18 months' follow-up.The donor site was left with a linear scar.There were no complications.Conclusion The thoraco-umbilical flap spanning chest and abdomen with inferior epigastric artery→ superior epigastric artery→ intercostal arteries or lateral thoracic artery double "chain blood supply" requires only one vascular anastomosis and is an ideal option for treatment of upper extremity giant long soft-tissue defects.

目的总结帽状原位缝合结合筋膜瓣移位治疗无再植条件的指尖离断伤疗效。方法 2011年6月-2012年1月,收治9例甲床中段平面以远的指尖离断伤患者。男6例,女3例;年龄12～60岁,平均42岁。致伤原因:机器绞伤3例,压砸伤6例。损伤指别:拇指3例,示指2例,中指3例,小指1例。受伤至入院时间为3～8 h,平均5 h。显微镜下探查明确无再植条件后,采用局部筋膜瓣移位结合帽状缝合治疗;对甲床缺损者同期行甲床扩大术。结果术后回植指体均成活,创面Ⅰ期愈合。患者均获随访,随访时间6～15个月,平均8个月。患指指端无触痛,指腹饱满,指纹恢复。指端感觉恢复良好,末次随访时两点辨别觉为8～10 mm,远侧指间关节主动活动度0～60°。指甲生长良好,较正常略小。结论对无再植条件的指尖离断伤,帽状原位缝合结合筋膜瓣移位治疗具有手术操作简便、回植指体成活率高、功能及外形可靠的优点。

目的 介绍股前外-膝上外侧逆行岛状皮瓣修复小腿软组织缺损的临床应用经验. 方法 对小腿大面积软组织缺损患者7例,采用股前外侧-膝上外侧逆行岛状皮瓣修复,术中皮瓣下端以膝上外侧动脉及降支终末支为蒂作带蒂转移,皮瓣上端以旋股外侧动脉降支或横支、高位皮支为蒂,在皮瓣转移后与小腿下段由足背动、静脉返流的胫前动、静脉作吻合. 结果 术后皮瓣均顺利完全成活,3～6个月随访皮瓣外观满意、伤口愈合良好、骨折在愈合中. 结论 利用股前外-膝上外侧逆行岛状皮瓣是修复小腿大面积软组织缺损的好方法。

目的探讨带两套血供的足内侧皮瓣修复老年患者趾跖趾关节附近皮肤软组织缺损的疗效。方法 2011年6月-2012年3月,收治9例（9趾）趾跖趾关节附近皮肤软组织缺损老年患者。男7例,女2例;年龄60～70岁,平均65.4岁。致伤原因：挤压伤5例,交通事故伤4例。伤后至手术时间为3 h～5 d,平均35 h。创面污染,均伴骨或肌腱外露;创面范围为2.0 cm×1.5 cm～2.5 cm×2.0 cm。采用大小为2.0 cm×1.7 cm～3.0 cm×2.2 cm的带两套血供的足内侧皮瓣修复创面,足背内侧神经与趾神经吻合重建皮瓣感觉。供区植皮修复。结果术后皮瓣及供区植皮均顺利成活,创面均Ⅰ期愈合。9例均获随访,随访时间6～8个月,平均7个月。皮瓣质地柔软,外观满意。末次随访时,皮瓣两点辨别觉为12～16 mm,平均14 mm。患足行走正常。供区植皮无瘢痕挛缩,穿鞋无磨损。结论带两套血供的足内侧皮瓣不损伤趾动脉和神经,切取简便,术后皮瓣血运良好,是修复老年患者趾跖趾关节附近皮肤软组织缺损的较好方法之一。

目的 探讨接合两侧指背神经的指动脉终末背侧皮支皮瓣修复指端缺损的方法和临床疗效.方法 2008年8月-2011年8月,采用接合两侧指背神经的指动脉终末背侧皮支皮瓣修复2～5指指端缺损6例,其中食指2例,中指1例,环指2例,小指1例,皮瓣切取面积最大22 mm×20 mm,最小10mm×9 mm.结果 6例6指皮瓣全部成活,术后经6～24个月随访,平均13个月,皮瓣外观及手指功能恢复满意,感觉恢复S3,皮瓣两点辨别觉6～9 mm,平均7.6 mm,供区无并发症.结论 接合两侧指背神经的指动脉终末背侧皮支皮瓣具有血供可靠,不破坏重要血管,且有可供接合的神经,操作简便等优点,是修复手指指端缺损较为理想的方法.

2009年6月至2012年1月,我们对9例手指近节皮肤缺损的患者,采用掌背动脉穿支皮瓣修复,同时以腕背皮支蒂V-Y推进皮瓣对供区进行修复,疗效较好. 一、临床资料 本组共9例,男5例,女4例;年龄18 ～ 69岁,平均30岁.冲床伤4例,电刨伤3例,链条伤2例.其中急诊修复4例,1周内亚急症修复5例.患指近节皮肤缺损面积为2.0 cm ×4.2 cm～2.5 cm×6.0 cm,掌背岛状穿支皮瓣切取面积为2.3 cm×4.5 cm ～2.5 cm×6.5 cm,腕背皮支V-Y推进皮瓣切取面积为3.5 cm×4.5 cm～5.5 cm×6.0 cm.

外伤性第1足趾趾端缺损是临床常见损伤,创面多伴有骨及肌腱外露,以往普遍行残端修整,手术方法简单但会造成患趾进一步短缺,患者很难接受.2010年6月-2012年1月,笔者单位收治9例第1足趾趾端缺损的患者,均采用第1足趾胫侧趾动脉背侧皮支蒂趾背神经营养皮瓣进行修复,获得较好疗效,现介绍如下. 1 临床资料 本组患者中男7例、女2例,年龄17～65岁.致伤原因:热压伤5例、车祸伤2例、摩擦伤2例.手术时间为伤后3～8h.每例患者1处创面共计9处,均为第1足趾趾间关节以远趾端皮肤软组织缺损,且均伴骨或肌腱外露,面积1.8 cm×1.0 cm～2.2 cm×2.0cm.

2009年6月至2012年3月,我们对20例拇指指端缺损的患者采用拇指背侧皮神经营养皮瓣进行修复,术后获得满意疗效. 一、一般资料 本组共20例20指,男14例,女6例;年龄17～68岁,平均35岁.挤压伤15例,电刨伤4例,烧烫伤1例.本组均为拇指IP以远指侧、指背、指腹皮肤软组织缺损,并伴有骨或肌腱外露,缺损面积为1.0 cm×1.8 cm～2.0 cm×2.2 cm.

Objective To introduce the clinical experience to harvest reverse-flow posterior interosseous artery forearm island flaps when there exists vascular variation.Methods A total of 400 cases of forearm reverse island flap pedicled with antebrachial branch of the posterior interosseous artery carried out in our department from 1990 to 2012 were summarized.Vascular variatiom existed in 30 cases which were retrospectively analyzed.These variations included the following types.Instead of giving off a dominant terminal branch,the posterior interosseous artery was thin and diffused distally.There was no obvious cutaneous branch into the flap.The perforators took off at the beginning of the posterior interosseous artery and entered the flaps proximally.This vascular variation occurred in 14 cases.The posterior interosseous artery had no dominant terminal branch and no cutaneous branch into the flap.The perforators took off at the proximal 1/3 forearm level and coursed between extensor carpi radialis and extensor digitorum comminus in 8 cases.In the third vascular variation the posterior interosseous artery was absent.The anterior imerosseous artery gave off a thick perforator at the junction of middle and distal 1/3 of the forearm level between extensor hallucis longus and extensor digitormn comminus.This variation occurred in 8 cases.Results There were 30 cases that had vascular variation of the posterior intemsseous artery.Complete survival and primary healing were seen in 24 flaps.Venous drainage compromise occurred in 4 flaps with the proximal perforator variation.Removal of the stitches at the pedicle rescued the flaps.There was partial distal necrosis in 2 flaps with the radial cutaneous branch variation.Healing occurred after full thickness skin grafting.Of the 30 cases,20 had 3 to 6 months follow-up.Appearance of the flaps was satisfactory.The donor site skin graft healed uneventfully.There were no complications with the posterior intemsseous nerve.Conclusion Correct understanding of vascular variations of the reverse-flow posterior interosseous artery forearm island flaps can help to avoid surgical abandon and increase the success rate of the surgery.

目的 总结外增压膝内侧-小腿内侧上部逆行岛状皮瓣修复小腿中下段软组织缺损的疗效. 方法 2009年1月-2011年12月,收治7例小腿中下段软组织缺损患者.男6例,女1例;年龄50～64岁,平均57岁.其中外伤致软组织缺损6例,伤后至入院时间2 h～3周;1例为外伤后广泛贴骨瘢痕形成、局部溃疡1年余,经久不愈.创而范围20 cm×5 cm～30 cm×7 cm.采用大小为18cm×6cm～30cm×8cm的外增压膝内侧-小腿内侧上部逆行岛状皮瓣修复创面,供区游离植皮修复. 结果 术后皮瓣及供区植皮均成活,创面Ⅰ期愈合.4例患者获随访,随访时间4～6个月,平均5个月.皮瓣外观满意,膝关节功能活动良好.术前慢性溃疡患者随访期间无复发. 结论 外增压膝内侧-小腿内侧上部逆行岛状皮瓣具有皮瓣切取面积大、手术操作简便等优点,是修复小腿中下段软组织缺损的较好方法.

目的 介绍不同穿支蒂足(底)内侧逆行岛状皮瓣修复前足底软组织缺损的临床经验.方法 对前足底不同部位软组织缺损8例,采用不同穿支蒂足内侧或足底内侧逆行岛状皮瓣修复:对4例前足底内侧软组织缺损,采用以足底内侧浅支在第一跖骨颈的穿支为蒂的足内侧逆行岛状皮瓣修复;对2例前足底中部软组织,采用足底内侧动脉深支或足背动脉足底深支的穿支为蒂的足底内侧逆行岛状皮瓣修复;对2例前足底外侧软组织缺损采用足底外侧终末穿支或足底动脉的穿支为蒂的足底内侧逆行岛状皮瓣修复.结果 术后7例皮瓣顺利成活,1例皮瓣术后部分坏死,将坏死皮瓣清除后经扩创,肉芽生长良好后,取髂腰部带真皮下血管网皮肤植皮.有5例患者经4～6个月随访,皮瓣血供良好,外观满意,感觉恢复至6～8mm,恢复正常行走功能;另3例失访.结论 采用不同穿支蒂足内侧或足底内侧逆行岛状皮瓣是修复前足底不同部位软组织缺损的好方法.