The Anatomy And Clinical Application Of Perforator Flap With The Injury Anterior Tibial Artery For Repairing Soft Tissue Defect Of Dorsal Foot

Objective: At present,our country is a rapid development in the developing countries,which industry,agriculture and transportation industry are in rapid development.With the resulting injury accident increasing,trauma caused by the lower limb tissue defect incidence has increased significantly,while the lower extremity trauma in soft tissue defect of dorsal foot is the most common.However,the skin of dorsal foot is thin and the subcutaneous tissue of dorsal foot is very little,only with the extensor tendon tissue covering the bone,lacking of muscle and soft tissue coverage.Such anatomical features determine that it is ofen accompanied by defect of skin and bone,tendons,nerves,blood vessels and internal fixation exposing,when after avulsion injury or crush injury has happened and the clinical treatment is very difficult.Therefore,the choice of small trauma,safe,reliable and blood supply rich flap to repair the skin defect of dorsal foot has been one of the orthopedic trauma research topic.In order to avoid further damage to foot blood supply in the process of repairing dorsal foot defects,while we achieve good effect of repair and reconstruction on the skin defect of dorsal foot wound.According to the anatomic basis of the ankle vascular network is interlinked with the tibial anterior artery between the calf in the lower third of the intermuscular branch of anastomosis,and anterior tibial artery musculocutaneous perforator in penetrating the deep fascia is interlinked with ankle vascular network.Utilizing the ”lost” anterior tibial artery,we design and apply perforator flap with the injury anterior tibial artery to repair soft tissue defect of dorsal foot,which does not increase for vascular trauma cases and with the minimum cost exchanges for the biggest function recovery.Methods: The case group totally have 10 patients,which 7 cases of male,3 cases of female;age 28~ 62 years;the site of the injury: 5 cases for right dorsal foot,3 cases for the left dorsal foot,1 case right before dorsal foot,1 case in the left before dorsal foot;the factors of injury: wringer injury in 4 cases,traffic accident in 5 cases,high fall injury in 1 case,the course of 40~120 days.The skin defect area: 8cm x 15 cm to 15 cm x 20 cm.Not associated with ankle fracture and posterior tibial artery injury,lateral calf skin integrity exists.After debridement,according to the size of the soft tissue defect,flap should be bigger than it about 10%.Connecting ankle's medial and ankle attachment midpoint with tubercle of tibia and fibula midpoint,taking the walking direction of the anterior tibial artery as axis,according to the skin defect shape design and cut flap over the front of the lower leg lateral.The area of the flap is from carina nodules and fibula attachment(upper bound)to the line between internal malleolus and external malleolus(lower bound),and from lateral tibial crest(medial border)to posterior midline of leg(lateral border).In front of the flap,along the lateral border of tibial crest,we make a longitudinal incision of the skin,subcutaneous tissue until deep fascia.Between the deep fascia and muscle membrane,we find and separate the anterior tibial artery perforator,which is about in the anterior tibial artery trunk direction,7cm and 14 cm on the ankle.When it separated to anterior tibial muscle,extensor hallucis longu and xtensor digitorum longus gap,in order to avoid loss of perforator,we can retain the intermuscular fascia about 1 ~ 2 cm around the vascular pedicle to protect cutaneous perforator,paying attention to the protection of the common peroneal nerve.Cutting the flap with upper,lower and trailing edge,we separate to the vascular pedicle muscle clearance under the deep fascia.After blockading of the anterior tibial arteriovenous proximal and observing the blood supply of the flap and distal foot end,we cut off the anterior tibial artery and suture the broken end,while we should get done with flap edge and basal hemostasis.Inciding the anterior ankle skin and rotating 180 degrees to the affected area with open tunnel or subcutaneous tunnel,in order to prevent vascular pedicle into an acute angle,compression or torsion,according to the skin defect position and the flap of the transferring distance,the rotation point of the pedicle can be selected in the ankle joint,ankle and tarsal artery,artery and anterior level.In order to improve the flap venous reflux,we can coincide appropriately 1 ~ 2 superficial vein of the flap with the proximal subcutaneous superficial vein.In order to prevent postoperative plantar flexion to distract flap,when we repair dorsal foot wound we can place a Kirschner wire both in the tibia and 1~5 metatarsus.Between the two kirschners wires with rubber strips are suffering from foot traction in function,whith forms "a simple external fixator".The donor area is sutured directly without tension and the tension cut covers with thick skin grafting.It is necessarily we should make some drainage strips in the flap,meanwhile exposing the flap and blinding up it.After a follow~up of 3 months to 9 months,we can observe the flap survival,skin texture and abrasion or not,which determines the long~term prognosis of flap.Results: All 10 flaps survived totally.No congestion,necrosis and blisters occurs.All of them take out stitches 14 days after operation.Flaps are followed up for 3~9 months.In addition to a slight swelling of skin flap,flap without ulceration occurs.The appearance of the flaps are good and the activity of ankle joint is good.All of the skin grafts survive.Conclusions:1 Dorsal foot wounds with the with the injury of dorsal artery,rely on the anterior tibial artery,artery of the fibula and posterior tibial artery coincided on the ankle.We design perforator flap with the injury anterior tibial artery to repair soft tissue defect of dorsal foot,which provides a new repair method for clinical.2 The flap has a lot of advantages,such as constant perforator blood vessels,reliable blood supply,adjacent to cut,convenient transfer,higher survival rate and non fat flap,which is first choice for repairing the large area soft tissue defects in clinical.3 For the patients with the injury of dorsal artery,the main blood vessel of the foot is derived from the posterior tibial artery,rather than the anterior tibial artery,so the retrograde island flap of the anterior trunk of the tibial artery has little effect on the blood circulation of the foot.