| Objective:The purpose of this study is to provide the innovative pedicled compound anterior malleolar and anterior tibilis flap for skin defect of anterior foot,based on the research of the anatomical study and possible clinical application. The front foot damage due to the avulsion injury ,crush injury and seriously contaminated wound,coupled with bad blood circulation of the foot, often contuributes to the bare tendons, ligaments, joints and bones and the defects of skin,and then leads to the loss or destruction of transverse arch ,and lack of function.Soft tissues defects on the anterior part of foot can not be repaired by skin graft,so it is usually repaired by flaps. The traditional pedicled flap, free flap as well as island flap, however ,are usually limited in reliability, size, reach, and arc-of-rotation,and are restrained in clinical applications. As we all know,soft tissue defects in the distal lower extremity present a formidable challenge due to the lack of reliable local flap options.Heretofore there is still no satisfaction appeared on this aspect. With the development of microsurgical anatomy, angiographic anatomical study on perforator distribution of anterior tibial artery, combining autopsy, DSA (digital subtraction angiography) technique ,we develop further improve the design of anterior tibial flap, put forward Pedicled compound anterior malleolar and anterior tibilis flap。The known vessels and intercommunication between them had already been clarified .But the perforator of source arteries and anastomosis branches have only become a hit resently. Therefore,the current study is focus on the major perforating branches between the anterior tibial artery and dorsalis pedis artery in the lower leg ,especially in the distal third of the lower leg.The arteries of the fresh cadaveric lower legs were perfused with methvlem blue to investigate the location and quantitaty of the the major perforating branches between the anterior tibial artery and dorsalis pedis artery. The above are in aim to provide the innovative pedicled compound anterior malleolar and anterior tibilal flap for skin defect of anterior foot,based on the research of the anatomical study and possible clinical application.Methods:1 Anatomical study: Anatomic dissections were performed on 10 fresh cadaver lower legs and location of the dominant perforator measured. The popliteal arteries of 10 fresh cadaveric legs were perfused with suspensions red gelatine.The location,origin, length, blood territories and anatomosis of the main perforating vessels,were recorded by dissection whith ruler.The bifurcation,outer diameter of the vessels were measured under surgery microscope.One normal case was accessed by digital subtraction angiography (DSA) from department of invasive technology,the third affiliated hospital of hebei medical university .1.1 Experimental:A large incision was made on the posterior intermuscular septum of the leg from the head of the fibula to the lateral malleolus.(Fig.1) Incise the skin,superficial and deep fascia,cut off the anterior intermuscular septum of leg,lift the flap along deep fascia forward inside to the marginal of tibia(Fig.2), and mobilize and retracting tibialis anterior muscle outward,expose cutaneous branch,intermuscular perforator and the muscle periosteal branch of the anterior tibial artery. (Fig.3)Finally insicise the extentor retinaculum,observe artery branches the anterior of malleolus department orgin.Expose anterior tibial artery perforator in the middle and distal third of the leg and branches of dorsalis pedis in the malleolus department.(Fig.5,Fig.6)1.2 One more fresh adault cadaveric leg was performed,whose anterior tibial arteries was perfused with methvlem blue firstly . A large incision was made on the anterior border of tibia in the middle and distal segment from the tibial tuberosity to the middle of the intermalleolar line. Incise the skin,superficial and deep fascia, lift the flap outwards, take care of protecting the important vessel and nerve.In the course of the anterior tibial artery. Perforators were located in discrete intermuscular septa. Those arising from the anterior tibial artery were predominantly encountered within three septa,try to find the perforators which are perfused with methvlem blue to investigatethe location distal and quantitaty of the the major perforating branches and anastomosis among them.Cut off the tenden of tibialis anterior , take care of protecting the important perforators and record carefully。And then make a incision on the anterior the intermalleolar line and intersect the line above at mid point. Incise the skin,superficial and deep fascia, mobilize and retracting along the course of the dorsalis pedis,expose the branches. Investigate the location and quantitaty of the the major perforating branches and anastomosis among them,especially in the layer deep fascia. (Fig.5,Fig.6) Mobilize and retracting under sugerical microscope,ruler,recording the cutaneous branch,location of deep fascia layer,diameter,length,blood territories,anastomosis among them. The location,origin, length, blood territories and anatomosis of the main perforating vessels,were recorded by dissection whith ruler.The bifurcation,outer diameter of the vessels were measured under surgery microscope.2 Clinical application2.1 Clinical case Patients who are all from department of hand surgery, the third affiliated hospital of hebei medical university,were performed combined anterior malleolus flap and anterior tibia flap to repair the skin defect of forefoot(5 cases). The skin defects of front foot range from 10cm×3cm to 14 cm×5cm. All cases were followed up from 1 to 6 month by clinic examination and qustionnaire survey. (Fig.8~Fig.17)2.2 The designing and spliting,the flap recoveringof the flap.2.3 Texture, shape of the flap.Results:1There are 11 branches arising from the anterior tibial artery and the dorsalis pedis, which run stickily along periosteum to skin,and give out ascending branches,descending branches and horizontal branches.Those branches give out many times bifurcated branches as a vessel tree. They communicate with each other. Branches arising from the anterior tibial artery from proximalis to distal end were found : The distance between the start site of first branch and mid-point of the intermalleolar line:17.8±1.4cm,in deep fascia :18.0±1.8cm,the length of the artery:1.1±0.3cm,external diameter:0.5±0.1mm;The distance between the start site of second branch and mid-point of the intermalleolar line: 13.7±2.0cm, in deep fascia :14.0±2.0cm, external diameter:0.4±0.1mm; The distance between the start site of third branch and mid-point of the intermalleolar line:9.7±2.5cm,in deep fascia : 10.0±7.3cm, the length of the artery:0.5±0.2cm,external diameter:0.5±0.1mm; The distance between the start site of fourth branch and mid-point of the intermalleolar line :4.3±3.3cm, in deep fascia :6.0±4.5cm, the length of the artery:0.4±0.2cm, external diameter:0.5±0.1mm; The distance between the start site of fifth branch and mid-point of the intermalleolar line 1.6±2.6cm, in deep fascia : 3.4±2.4cm,the length of the artery:1.6±0.6cm, external diameter:1.1±0.2mm; The distance between the start site of sixth branch and mid-point of the intermalleolar line 2.2±2.1cm.In deep fascia :3.0±2.0cm,the length of the artery :0.9±0.2cm, external diameter:0.7±0.1mm; The distance between the start site of seventh branch and mid-point of the intermalleolar line :3.0cm,in deep fascia :3.0cm,the length of the artery :1.2±0.2cm, external diameter:1.2±0.1mm; The distance between the start site of eighth branch and mid-point of the intermalleolar line:1.2±0.1cm,in deep fascia :1.0cm,the length of the artery :1.1±0.1cm, external diameter:1.5mm; The distance between the start site of ninth branch and mid-point of the intermalleolar line0cm,in deep fascia :0.5±2.0cm,the length of the artery :0.9±0.2cm, external diameter:0.7±0.1mm; The distance between the start site of tenth branch and mid-point of the intermalleolar line1.5±0.6cm,in deep fascia :1. 3±0.6cm,the length of the artery :1.4cm, external diameter:0.2±0.7mm; The distance between the start site of 11th branch and mid-point of the intermalleolar line:3.3±1.1cm:in deep fascia :3.5±0.6cm,the length of the artery:1.2cm, external diameter:0.13±0.04mm.The 9th to 11th branches are the supply vessels of the anterior malleolus flap.They give out from the anterior border,middle point(the crotch on Y like ligament)and inferior border of the inferior extensor retinaculm seperately.The 6th,7th,8th branch of anterior tibia artery are near the branch the vessel of the anterior malleolus.The 6th branch extend to the skin from the space 1 which is between the anterior tibial muscle and tibia.The 7th,8th branch extend from the space between m.extensor hallucis and digitorum longus.They running stickily along periosteum to skin and they are communicated with anterior mallelus branch of anterior tibial artery by anatomy in specimen and in operation. (Fig.5, 6)All flaps(5 cases) completely survived.1 cases had partial necrosis due to venous reflux disturbance. 1 patient for second suture which was too swelling and affected vein reflux after operation. And the flap detumescenced when we dismantled partial stitches. Donor-site morbidity was minimal in all cases. Both functional and esthetical results were satisfactory. Because of thin and pliable features, this flap is suitable for repair of defects in the front foot.Postoperation follow-up between 2 months and 6 months, averaged 3months, the flaps had good shape, texture and color with no abrasion. And the donar aera heeled well with no obvious dysfunction.Conclusion:1 In the middle and inferior segment of the lower leg as well as ankle,anterior tibial artery give out many osteocutaneous branches which communicate with each other and nourish periosteum and anterior tibial skin. In fascia, the vessel nets of anterior tibial and ankle turn out as chains which have big diameter and communicate with each other.2 The flap could be used to repair big area of anterior foot skin defect because of its large size.3 Combined anterior malleolus flap and anterior tibia flap which uses anterior malleolus cutaneous branches and osteocutaneous branches of tibia has the advantages of clear anatomic landmark, long blood vessel pedicle, big diameter and few anatomy variations. But we always have to sacrifice anterior foot artery and dorsal artery of foot before we repair. 4 The flap enlarged cutting area and could be used to repair anterior foot skin defect of any location and area because of its good blood supply. |
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