| Objective: For the past few years, with the fast development of industryagriculture and traffic transport, incidence of lower limb skin defect by traumagrows year by year, especially the skin defect of dorsum of foot. Because ofthe anatomical feature of the dorsum of foot, the skin is thin and it is short ofmuscle tissue to cover, when there is open injury, there is always skin defect orfracture and internal fixation reveal. If we can't cover the wound and eliminatethe wound in the early nonage, it is likely to lead to tendon necrosis andosteomyelitis, even have the risk to amputation. Therefore, to choose a pedicleskin flap which is less wound, more safety and with abundant blood supply tocure the skin defect of dorsum of foot is a question to study by traumaorthopedics doctors.After the1960s, with microsurgery technology appeared and developedquickly, it is possible to free transplantation every tissue of human body. Andit becomes one of the most important methods to repair tissue defect to plasticand reconstructive surgery doctors and hand surgery doctors. But, tissue freetransplantation operation by suture blood vessels has its defect and limitations,like high equipment requirement, skill complicated, need professional training,long operation time, high spend, and there is a risk that the blood vesselsanastomosis may be unsuccessful. Patients must be fixed to a compulsiveposition after the cross leg skin flap operation. Most patients can not accept it.Some main blood vessels must be sacrificed when we do the pedicle skin flapand free skin flap operations. The operation is hard. And it is even more hardto carry out it in a elementary hospital.The purpose of this experiment is to view the relationship of the vascularnet of ankle and the anterior tibial artery perforating branch give out in thelower part of the leg. Prove that when the anterior tibial artery perforating branch give out from the deep fascia, there is anastomosis between theperforating branch and the vascular net of ankle. If there is a stable perforatingbranch, which connected to the vascular net of ankle, give out between6cm to12cm above the ankle, we can design a antidromic pedicle island skin flap thatis big enough to cure the skin defect of dorsum of foot. Put this anatomicaldata in to clinic, and design the antidromic island skin flap based on anteriortibial artery perforating branch. According to this theory, we can develop anew method to cure the skin defect of dorsum of foot.The purpose of this study is to increase the theoretical foundation and theextent of clinical use. Make sure that there is a stable perforating branch fromthe anterior tibial artery6-12cm above the ankle, and make up the defect ofthe normal antidromic island skin flap based on anterior tibial arteryperforating branch that the skin flap is small and tissue loss is too much whileother skin flap can't treat a large area skin defect of dorsum of foot. We'vemade use of this operation to treat the large area skin defect of dorsum of footfor6patients. The flap is not fat and clumsy, the wound healing by1intention,no2intention operations to make it thin. This proved that the skin island ofthis type have reliable blood supply, and it developed a new repair method forclinic.Methods:1Anatomic studyThe study included16leg specimen of adult bodies treated by formalinsolution (10males,6females), and4fresh leg specimen of adult bodies (2male,2female). Cut open the skin subcutis and deep fascia2cm beside thetibia. Separate and cut off the tibialis anterior and the hallux longus, leave asmall piece of tunica muscularis to protect the artery and the perforatingbranch from injury. Turn open the skin from the deep side of the deep fascia,observe the location of the anterior tibial artery and the quantity locationdistribution position to give out and the anatomosis of the perforatingbranches.2Clinical study The study included7patients,5males and2females. The age range isfrom25to65years old. The reason of wound:3were wounded by someweight object falling from the high place,3were wounded by car crash and1were wounded by crushing of machine. The course of disease is from12to120days. Local condition:2were large area skin defect only,4were largearea skin defect with poly-fractures and tendon defect;1was large area skindefect with the fifth metatarsal bone fracture exposed. The condition afterdebridement: all of the seven patients has a expose of dorsum foot tendon,2were large area skin defect only,2were with tendon defect of the2ndand3rdtoes,2were with the expose of the1-3toes fracture and internal fixation andtendon defect,1was with the2-5toes fracture and internal fixation and tendondefect. The skin defect area range is between8cm×5cm to20cm×12cm. All ofthe7patients didn't have the fracture of the ankle joint and posterior tibialartery injury. The skin of the leg is integrity. After debridement, design theskin flap with the area and shape of the skin defect, we design it2cm largerthan the defect in the edge. Cut open the skin subcutis and deep fascia2cmbeside the tibia. Separate and find the inferior lateral peroneal artery, it exist inthe area6cm to12cm above the ankle. Leave a small piece of tunicamuscularis to protect the artery and the perforating branch from injury whenseparated to the gap between the extensor digitorum longusthe and the halluxlongus. Cut open the skin flap as the shape we designed before, carefully toprotect the tibial cutaneous branches and the anterior malleolus cutaneousbranches. Separate the arterial trunk and protect it in the proximal end of theflap. When the skin flap was separated completely, block up the arterial trunkand make sure that the blood supply of the skin flap is well. Cut off the arteryand ligate it. Cut open the skin and turn the flap to the the skin defect area.The turning point can be chosen at the according to the position and distancebetween the flap and the defect. To avoid footdrop after the operation andprepare for the operation of tendon transplantation, fix the tendon broken endsto the soft tissue, fix the ankle joint with the external fixation. After3to6months after the operation, we can do the tendon transplantation operation. Follow up3months to1year, observe the skin flap condition, made a criterionof the skin flap prognosis in long term.Results:According to the anatomical study of20leg specimen of adult bodies, thefrequency of inferior lateral peroneal artery is80%. The position to give out is(10.4±3.2)cm above the ankle joint, the anatomical position is stable.6ofthe7skin flaps were survived completely, the wound healing by1intention.There is a anatomic variation of the inferior lateral peroneal artery in onepatient. Because the tendon and the soft tissue were integrity existed, thegranulation tissue is fresh, we do the free skin graft operation. The woundhealing by1intention too.2patients have done the tendon transplantationoperation3to6months after the operation. The function of the foot regainwell, no footdrop, the color of the flap is nearly the same to the skin around.Follow up3months to1year, the skin flap didn't damaged, the texture is well,proved that the blood supply of the skin flap is well. The anatomic position ofinferior lateral peroneal artery is stable, and there is a great quantity ofanastomosis between the inferior lateral peroneal artery and the posterior tibialartery and the arterial rete of ankle. The reverse blood flow supplied the skinflap well.Conclusions:1The inferior lateral peroneal artery give out (10.4±3.2)cm above theankle, the frequency is80%. It gives out from the gap between the extensordigitorum longusthe and the hallux longus. When achieved the deep fascia, itdispersed to arterial rete, and there is a great quantity of of anastomosisbetween the inferior lateral peroneal artery and the posterior tibial artery andthe arterial rete of ankle.2The reverse island skin flap based on the far end of anterior tibial artery.The reverse blood flow supplied is enough for the skin island. That provided anew method to cure large area skin defect of dorsum foot. The skin of theforward leg is nearly the same to the skin of dorsum foot, so that it is notnecessary to do the operation to make the flap much thiner. 3The anterior tibial artery blood supply to foot is not the most importantto the patient with dorsal artery of foot injury, so that the effect of the footblood supply is fairly small when cut off the anterior tibial artery. |
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