The Anatomy And Clinical Preliminary Experience Study Of The Distally Based Posterior Tibial Artery Perforator Flap For Reconstruction Of Skin Defects Overlying The Achilles Tendon

OBJECTIVE:To provide anatomical data for the distally based posterior tibial artery perforator flap for reconstruction of skin defects overlying the Achilles tendon, and use this flap in clinical to explore its clinical effects.METHODS:To dissect specimens of 30 sides of adult cadaver calves, observing the number of muscular space perforating branches of the posterior tibial artery and its traveling,length, diameter and the distribution of piercing points and the branches of the muscular space perforating branches of the posterior tibial artery and its distribution, anastomsis and the distribution and travelingof longitudinal vascular network,and simulated surgery to cut the distally based posterior tibial artery perforator flap to repair the skin defects overlying the Achilles tendon. From October 2008 to November 2009, we use the the distally based posterior tibial artery perforator flap to repair 12 cases of the skin defects overlying the Achilles tendon,observing its clinical effects.RESULTS:Anatomical:(1), The posterior tibial artery in the medial calf issue 2～7 muscular space perforating branches, of which 4-5 branchs mostly, accounting for 67.13%. (2), The posterior tibial artery in the lower medial calf issue 2～3 muscular space perforating branches, an average of 2.33, which the arterial diameter is (1.24±0.50) mm and the length is (2.50±1.00) cm, where the farthest space of muscular space perforating branches issued at the medial malleolus tip of about 2.2～5 cm,arterial diameter is; The posterior tibial artery in the middle of calf issued 1～2 muscular space perforating branches, an average of 1.23, which the arterial diameter is (0.98±0.30) mm and length is (1.48±0.70) cm;In the upper of the calf, there is a constant perforating branches artery issued from the posterior tibial artery perforating at the distance of 21～25cm from the ankle angle, which distribute at the medial upper calf's superficial fascia and the skin after piercing the deep fascia.its arterial diameter is (0.56±0.30) mm and length is (0.62±0.10) cm.₃,The muscular space perforating branches of the posterior tibial artery separate the ascending branch and down branch afer issuing from the posterior tibial artery.The ascending and descending branches of the adjacent perforator arteries forming the anastomosis Chain, distributing in the medial calf fascia skin. (4), Range of about 4cm at the above and down medial malleolus tip, the posterior tibial artery issue two fascia perforating branches, which arterial diameter is (1.18±0.30) mm and (0.78±0.30) mm and length is (0.64 ±0.40) cm and (0.42±0.20) cm. Its ascending branch form the anastomosis with the descending branch of the muscular space perforating branches at the lower calf. (5), The posterior tibial artery issue more muscular space perforating branches than other regions at a distance of 10cm within the medial malleolus, accounting for 47.55%. The perforating branches of the surface projection axis is approximately from after the medial tibial condyle to the midpoint between the medial malleolus and the Achilles tendon.Clinical aspects:Applicating in 12 patients, Flap of case 4 and Case 10 which appear darker and hypertonia at the second day after the surgery, we have adopted a combination of Chinese and Western medicine method:On the one hand, we have continued to antispasmodic, anticoagulant, promoting blood circulation drugs such as papaverine, dextran and so on; On the other hand, we use Bu Yang Huan Wu Tang based on TCM. After treatment of 5 days, flap of case 4 which color change from cyanosis to ruddy and moderate tension,final survival; Flap of case 10 which distal part of the necrosis,and the necrotic part of the flap entirely post-treatment survival after debridement and dressings. The remaining cases flap survived completely with no adverse event occurred. All patients who we followe up for more than six months can be a normal gait and the flap wear.CONCLUSION:In the medial calf, the muscular space perforating branches of the posterior tibial artery form the longitudinal vascular Chain, and the posterior tibial artery issue more muscular space perforating branches than other regions in the medial calf. Based on this conclusion, we confirmed the distally based posterior tibial artery perforator flap feasibility and design the distally based posterior tibial artery perforator flap to repair the skin defects overlying the Achilles tendon. Because of such flaps have the advantage of near transfer,little injury, does not hurt cutaneous nerve, texture near the Achilles tendon area, the reliable blood supply,operation simple, flexible design and so on,therefore this flap is one of the better choices to Repair the skin defect overlying Achilles tendon.