The Clinical And Imaging Study Of Chimeric Sural Artery Perforator Of Free Fibula Flap In Reconstruction Of The Defects Of First Metatarsal

Objective:To probe the distribution of vascular perforating branch of peroneal artery by preoperative CT Angiography( CTA), and then to know it,s practicality and reliability in the design of peroneal artery perforator flap, precise pinpointing of the optimal pedicled with perforating vessels for transplanting. Providing a reliable theoretical basis of image analysis and visualization for using of the flap bleed by peroneal artery perforator. According to the basic experimental study, exploring the practicability that repair of composite tissue defects of first metatarsa with the dissociating vascularized fibula chimeric peroneal artery perforator flap in stage I, and hen analyze the curative effect and clinical significance.Methods:This study consists of two parts, the first part is the study of imaging. Collect the data that application of ectocnemial of the peroneal artery perforator flap transplantation in 30 patients from March 2013 to August 2014. According to whether the CTA is applied into the design of perforating branches artery preoperative design group(n=15) and control group(n=15). Observing and analyzing the distribution, location and running of its perforating branches of peroneal artery vascular. In the same time, measuring and statistic the exit points, diameter, occurrence rate of the perforator branch of peroneal artery. According to the measured data, select the optimum perforating vessels in the limbs positioned on the vertical axis and the coronal axis. According to preoperative design, Comparison of positioning, availability of perforating veins, postoperative complications and reoperation rate and other indicators, and postoperative follow-up. The second part is study on the clinical practice, collected from May 2010 to September 2014 were 9 patients with lateral tibial defects of first metatarsal of the foot. Viewing peroneal artery and its perforating branches by CT vascular imaging in preoperative. All of them are using free fibula flap chimeric sural artery perforator flap repair of composite tissue defects of first metatarsal. According to the length of the first metatarsal in the healthy side, to determine the dissociating fibular of the contralateral side reconstruct the first metatarsal, while cutting with peroneal artery perforator pedicled flap to repair soft tissue defects. In this group the length of fibular is range from 5.0cm~9.0cm, about 7.0cm on average, the area of flap in the range of 6.0cm×4.0cm~9.0cm×6.0cm. Three cases of flap donor site sutured, thickness skin graft of inguinal in 6 cases. Postoperative follow-up, check the flap and bone graft healing, direct the rehabilitation exercises.Results:By means of imaging tools, and locate the optimum perforating branches of peroneal artery can be designed. We also can know there are four relatively constant sites in the middle of fibula that the perforating branches of peroneal artery appear from further measurements and statistical analysis. The vascular inner diameter is approximately 1mm, suitable for anastomosis, vascular pedicle length is about 5cm, is long enough as a vascular pedicle for the skin flap. The discussions above provide strong theoretical basis for further research of chimeric fibular flap and then to design the best position. After statistics processing the measured data, were compared with surgical results of Fisher exact test between the two groups. There was significant difference of complication of transplantation between the two sets of data after operative. There were 30 patients in this group, the flap survival rate was 96.7%(29/30). Results of clinical practice: In 9 cases of postoperative skin flap survival of all, 1 case occur with vascular crisis after the surgery, the skin flap survival after probing again for vascular anastomosis, the incision in the recipient and donor area both healing of phase I. Postoperative follow-up of 5~18 months, the flap have good shape, without bloated feeling, the quality of wear-resistant, two-point discrimination in 3~5 mm. For good function and stability of the ankle joint, bone healing of tibia and fibula transplantation, walking and is of medium weight, and satisfactory results. According to the PFCS foot functional evaluation standards: Excellent 6 cases, 3 cases of benign. On the fibula graft outcome, based on an international rescue the body symposium of "Radiologic Evaluation Method of the same and vascular graft" evaluate the results, including the healing speed of transplanted bone, the absorption, translocation of fracture and changes in diameter of the bone grafts.Conclusions : 1. Depend on three-dimensional CT can directly pinpoint perforating arteries, clearly shows that the distribution of vascular perforating branch of the peroneal artery and its location, rate, running and flap perfusion range, CTA has good application value in the donor evaluation and selection, design and so on before operation. It is a worth implementing method nowadays to study the anatomy of the skin flap. 2. CTA can provide personalized, intuitive, and stereo three dimensional imaging graphic, also can precise measure series anatomy data such as vascular pedicle length and diameter. This can positioning the peroneal artery before the operation, avoid artificial errors relatively, highlight individual special heterosexual. That can improve the accuracy and security during the operation, reduce the occurrence of complications after operation. Therefore, the application of CTA in perforator flap transplantation is feasible. 3. Preoperative assessment of the CTA, the periosteal and cutaneous branches of the peroneal artery to the axis is relative constant, sural artery perforator chain connection throughout the flap. In order to ensure the blood supply, you can expand the scope of the flap when cutting. Combined with the nutrient artery of the peroneal artery, the distribution of the arcuate arteries, along with the location of the link between the flap and periosteal branches, we select free vascularized fibula flap chimeric peroneal artery perforator flap to repair of defects of metatarsal and composite tissue defects in the same time. The use of combined flap for repairing the first metatarsal bone defect of tibia and fibula, reducing the frequency of operation, shortened the course, smaller surgical trauma, method of work, the effect of reliable, good looks and functions, achieving the purpose of repair and reconstruction of cosmetic. It is an effective method that rebuilding the weight- bearing area and soft-tissue defect around the foot.