Ankle Skin Research Articles

Advancing the analytical toolkit in the investigation of vector mosquito host biting site selection.

High-resolution mass spectrometry and ion mobility spectrometry provide additional confidence in biological marker discovery and elucidation by adding additional peak capacity through physiochemical separation orthogonal to chromatography. Sophisticated analytical techniques have proved valuable in the identification of human skin surface chemicals used by vector mosquitoes to find their human host. Polydimethylsiloxane (PDMS) was used as a non-invasive passive wearable sampler to concentrate skin surface non-volatile and semi-volatile compounds prior to solvent desorption directly in an LC vial, thereby simplifying the link between extraction and analysis. Ultra-performance liquid chromatography with ion mobility spectrometry coupled with high-resolution mass spectrometry (UPLC-IMS-HRMS) was used for compound separation and detection. A comparison of the skin chemical profiles between the ankle and wrist skin surface region sampled over a 5-day period for a human volunteer was done. Twenty-three biomarkers were tentatively identified with the aid of a collision cross-section (CCS) prediction tool, seven associated with the ankle skin surface region and 16 closely associated with the wrist skin surface. Ten amino acids were detected and unequivocally identified on the human skin surface for the first time. Furthermore, 22 previously unreported skin surface compounds were tentatively identified on the human skin surface using accurate mass, CCS values and fragmentation patterns. Method limits of detection for the passive skin sampling method ranged from 8.7 (sulfadimethoxine) to 95 ng (taurine). This approach enabled the detection and identification of as-yet unknown human skin surface compounds and provided corresponding CCS values.

Effect of tibial transverse transport on chronic lower extremity angiopathy: a protocol for a systematic review and meta-analysis

IntroductionChronic lower extremity angiopathy is a peripheral vascular disease that can result in disability and death. The tibial transverse transport (TTT) technique has been used to treat this disease in...

Anterior Ankle Skin Surface Pressures in Lower Extremity Splints: Minimizing Insult after Injury

Category:Ankle; Trauma; OtherIntroduction/Purpose:Though ubiquitously utilized in orthopaedic trauma, lower extremity splints are not without their associated iatrogenic risk of morbidity. In fact, improper splinting not only necessitates replacement, but splint-related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. Improper splinting techniques include inadequate molding of plaster/fiberglass splints, inadequate padding over bony prominences, excessive compressive forces from elastic bandages applied too aggressively, and/or pressure areas created by applying padding and casting material in varying joint positions. While clinicians commonly pad bony prominences to minimize skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is understudied. The purpose of this study is to evaluate anterior ankle skin pressure secondary to joint position change during splinting.Methods:Following ethics approval by our institutional review board, various constructs of lower extremity, short-leg splints were applied to two healthy subjects (2 limbs total in this preliminary data set) with an underlying pressure transducer (Tekscan I- Scan system (Tekscan Inc, South Boston, MA, USA) on the skin surface centered on the anterior ankle on the tibialis anterior tendon. All subjects underwent anterior ankle surface pressure assessment when padding was applied in maximum plantar flexion and neutral position for conventional short leg splints application. Percent change from initial contact pressure centered on the tibialis anterior with either Webril (Covidien/Medtronic, Dublin, Ireland), or Specialist Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) were calculated. Neutral position of the foot/ankle will be confirmed with goniometer.Results:There were 2 limbs total that were analyzed for the presentation of pilot data for this study. The percent change in anterior ankle contact pressure when padding was applied in maximum plantarflexion (PF) and then placed in neutral was increased at least two-fold without the addition of plaster and subsequently with the addition of plaster in lower extremity short leg splints (Figure 1).Conclusion:In this pilot data, we report significant increases in anterior ankle contact pressures when splint padding is applied in plantar-flexion and re-positioned into neutral during splint application which may precipitate iatrogenic pressure ulcers in patients sustaining foot/ankle trauma. This data, though preliminary, underscores the importance in proper splinting techniques for all clinicians that manage lower extremity trauma (eg, orthopaedic surgery, emergency medicine, urgent care, etc).

189 Anterior Ankle Surface Pressures in Lower Extremity Splints: Minimizing Insult After Injury

Though ubiquitously utilized in lower extremity orthopaedic trauma, lower extremity splints are not without their associated iatrogenic risk of morbidity. In fact, improper splinting not only necessitates replacement, but splint- related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. Pressure ulcers result from perpendicular forces that compress the soft tissues between body mass, bony prominences, and the support surfaces below. Within those soft tissues are vessels that run parallel to the surface of the site of skin collapse and may collapse easily from pressure loads. As such, prolonged pressure above the threshold for capillary tolerance results in occluded blood flow, interstitial fluid flow, ischemia, pain, necrosis, and sloughing of dead tissue. While clinicians commonly pad bony prominences to minimize the skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is real but has not been well studied or described. The purpose of this biomechanical study is to identify problems with anterior ankle skin pressure secondary to joint position change during splinting and ultimately to determine the optimal position of the ankle during application of the splint as well as the padding technique required over the anterior ankle to minimize iatrogenic skin pressure ulcers. Following ethics approval by our institutional review board, various constructs of lower extremity, short-leg splints were applied to two healthy subjects (two limbs total in this preliminary data set) with an underlying pressure transducer (Tekscan® I-Scan® system, (Tekscan Inc, South Boston, MA, USA) on the skin surface centered on the anterior ankle on the tibialis anterior tendon. All subjects underwent anterior ankle surface pressure assessment when padding was applied in maximum plantar flexion and neutral position for conventional short leg splints application. Percent change from initial contact pressure centered on the tibialis anterior with either Webril© (Covidien/Medtronic, Dublin, Ireland), or Specialist© Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) were calculated. Neutral position of the foot/ankle will be confirmed with a goniometer. There were two limbs total that were analyzed for presentation of pilot data for this study. The percent change in anterior ankle contact pressure when padding was applied in maximum plantar flexion (PF) and then placed in neutral was increased at least two-fold without the addition of plaster and subsequently with the addition of plaster in lower extremity short leg splints (Figure 1). In this pilot data, we report significant increases in anterior ankle contact pressures when splint padding is applied in plantar-flexion and re-positioned into neutral during splint application which may precipitate iatrogenic pressure ulcers. This data, though preliminary, underscores the importance of proper splinting techniques for all clinicians that manage lower extremity trauma (eg, orthopaedic surgery, emergency medicine, urgent care, etc).

More than meets the naked eye: an unusual psoriatic arthritis mimicry and the important role of dermoscopic examination

BackgroundPsoriatic arthritis (PsA) can manifest in various forms. This includes mimicry of other diseases. We describe an unusual mimicry of PsA.Case presentationWe report a case of a middle-aged lady who presented with severe pain and morning stiffness over the small joints of the left hand for 3 months and painless deformity of the affected joints 1 year before. She was under treatment for pruritic rash over her ankles and knees for the past 1 year as well. Physical examination revealed a fixed flexion deformity, swelling and tenderness of the left ring and little fingers’ distal interphalangeal (DIP) joints. Left hand radiograph showed sclerotic joint margin, narrowed joint space and marginal osteophytes of the affected DIP joints. Dermoscopic examination showed red- violaceous, flat-topped papules and plaques with minimal scales on both ankles; hyperpigmented scaly plaques over both knees and vertical fingernail ridges. Serum autoimmune screening and inflammatory markers were unremarkable. Left ankle skin biopsy showed features consistent of psoriasis. PsA was diagnosed. Weekly titrated oral methotrexate and topical steroid were started. The patient showed significant improvement after 1 month of treatment.ConclusionPsA is a great mimicker. Dermoscopy is an accessible and valuable tool to assess skin lesions in greater detail. Clinicians should be aware of coexisting diseases or misdiagnosis when patients do not respond to treatment.

Application effects of self-made simple vacuum sealing drainage device in postoperative treatment of sural neurocutaneous flap transplantation in the foot and ankle

Objective: To investigate the application effects of self-made simple vacuum sealing drainage (VSD) device in the postoperative treatment of sural neurocutaneous flap transplantation in the foot and ankle. Methods: From January 2017 to January 2019, 36 patients with foot and ankle skin defects and bone exposure admitted to People's Hospital of Xinjiang Uygur Autonomous Region met the inclusion criteria, and a retrospective cohort study was conducted. According to the bandaging method of the operative area, simple negative pressure group and antibacterial dressing group were both allocated with 18 patients, with 12 males and 6 females in the former group, 14 males and 4 females in the latter group, aged (41.6±2.8) and (42.3±2.6) years, respectively. Patients in the two groups all received sural neurocutaneous flap transplantation. Patients in antibacterial dressing group received nano silver antibacterial dressing change in the operative area, and the dressing was changed once every 3 days. In simple negative pressure group, the operative area was sealed with a simple VSD device made of gauze, silicone sputum suction tube with holes cut out, and biological permeable membrane, etc., which was connected with the wall central negative pressure suction system for continuous VSD treatment of -40.0 to -16.6 kPa. The negative pressure material was changed once every 5 days. The number of dressing change, the pain score evaluated by Numeric Rating Scale during each dressing change, the cost of dressing change, and the degree of flap swelling evaluated on the 3rd and 5th day after surgery were recorded, and the flap survival was observed. Data were statistically analyzed with independent sample t test, Wilcoxon rank sum test, and chi-square test. Results: The number of dressing change of patients in simple negative pressure group was (3.4±0.5) times, which was significantly less than (7.0±0.8) times in antibacterial dressing group (t=15.338, P<0.01). The pain score during dressing change of patients in simple negative pressure group was (4.3±0.8) points, which was significantly lower than (6.8±0.7) points in antibacterial dressing group (t=10.168, P<0.01). The cost of dressing change of patients was similar between the two groups. On the 3rd and 5th day after surgery, the degrees of flap swelling of patients in simple negative pressure group were significantly superior to those in antibacterial dressing group (Z=4.448, 2.395, P<0.05 or P<0.01). The flap survival of patients in simple negative pressure group was significantly superior to that in antibacterial dressing group (χ(2)=4.500, P<0.05). Conclusions: Compared with the traditional dressing bandage, the self-made simple VSD device used after sural neurocutaneous flap transplantation can reduce the frequency of dressing change, relieve the pain of dressing change and the swelling of flap, and promote the flap survival, which is worth popularizing and applying in clinic.

Chemical profiling of the human skin surface for malaria vector control via a non-invasive sorptive sampler with GC×GC-TOFMS.

Volatile organic compounds (VOCs) and semi-VOCs detected on the human skin surface are of great interest to researchers in the fields of metabolomics, diagnostics, and skin microbiota and in the study of anthropophilic vector mosquitoes. Mosquitoes use chemical cues to find their host, and humans can be ranked for attractiveness to mosquitoes based on their skin chemical profile. Additionally, mosquitoes show a preference to bite certain regions on the human host. In this study, the chemical differences in the skin surface profiles of 20 human volunteers were compared based on inter-human attractiveness to mosquitoes, as well as inter- and intra-human mosquito biting site preference. A passive, non-invasive approach was followed to sample the wrist and ankle skin surface region. An in-house developed polydimethylsiloxane (PDMS) passive sampler was used to concentrate skin VOCs and semi-VOCs prior to thermal desorption directly in the GC inlet with comprehensive gas chromatography coupled to time-of-flight mass spectrometry (GC×GC-TOFMS). Compounds from a broad range of chemical classes were detected and identified as contributing to the differences in the surface skin chemical profiles. 5-Ethyl-1,2,3,4-tetrahydronaphthalene, 1,1'-oxybisoctane, 2-(dodecyloxy)ethanol, α,α-dimethylbenzene methanol, methyl salicylate, 2,6,10,14-tetramethylhexadecane, 1,2-benzenedicarboxylic acid, bis(2-methylpropyl) ester, 4-methylbenzaldehyde, 2,6-diisopropylnaphthalene, n-hexadecanoic acid, and γ-oxobenzenebutanoic acid ethyl ester were closely associated with individuals who perceived themselves as attractive for mosquitoes. Additionally, biological lead compounds as potential attractants or repellants in vector control strategies were tentatively identified. Results augment current knowledge on human skin chemical profiles and show the potential of using a non-invasive sampling approach to investigate anthropophilic mosquito-host interactions. Graphical abstract.

(194) Epidermal Axon Changes in Patients with Prediabetes: The PACMAN Study

Pain is a tremendous health care burden associated with prediabetes and diabetes. However, not everyone with prediabetes or diabetes develops pain and the factors that increase susceptibility to painful neuropathy remain elusive. The epidermis is innervated by both peptidergic and nonpeptidergic axons and our studies in mice reveal that mechanical allodynia induced by consuming a high fat diet increases peptidergic epidermal axons. We hypothesize that patients with prediabetes and painful neuropathy have an abnormal proportion of epidermal peptidergic axons. We are carrying out an ongoing clinical study in which patients are recruited into 3 groups based on their metabolic status: 1) normal (n=6), 2) prediabetes (n=7), or 3) prediabetes with neuropathic symptoms (n=5). Metabolic status (healthy vs. prediabetic) is determined using the 2016 American Diabetes Association (ADA) Guidelines associated with A1c (5.7-6.4%), fasting glucose (100-125 mg/dl), or oral glucose tolerance (140-199 mg/dl). Data (vitals, demographic, social/lifestyle, medical history) is collected, and fasting patients undergo a blood draw (insulin, lipid panel, hematocrit, hemoglobin, and HBA1c) and a glucose tolerance test and to identify their metabolic status. In a second visit, patients undergo a clinical evaluation of their sensory status (Brief Pain Inventory for Diabetic Neuropathy (BPI-DPN), Michigan Neuropathy Screening Instrument, Utah Early Neuropathy Scale) and an ankle skin biopsy is obtained to quantify intraepidermal nerve fiber density (IENFD). PGP 9.5 is used to identify all axons, and TrkA+ fibers are used to identify peptidergic axons. Our primary analysis will compare differences in peptidergic fiber measures to neuropathy symptoms among the 3 groups. Our goal is to identify risk factors that modify peripheral innervation and increase the risk of pain associated with neuropathy. The status of this ongoing clinical study will be presented at the meeting and include discussions of the translational approaches driving this clinical study.

Colocalization of pain and reduced intraepidermal nerve fiber density in individuals with HIV-associated sensory neuropathy.

There is poor correlation between decreases in intraepidermal nerve fiber density (IENFD) and the presence of pain in HIV-associated sensory neuropathy (HIV-SN) and other painful distal symmetrical polyneuropathies. We investigated whether in individuals with HIV-SN, having pain at the ankle skin biopsy site was associated with lower IENFD compared to when there was no pain at the ankle biopsy site. We recruited 15 individuals with symptomatic HIV-SN. Nine had pain at the site where the ankle biopsy was taken, whereas 6 did not. Skin punch biopsies for IENFD quantification were taken from the ankle and the thigh. Contrasts between the 2 groups were made using the overlap of confidence interval (CI) method. Intraepidermal nerve fiber density was substantially lower in the group that had pain at the site of the ankle biopsy compared with the other group (6.6 [CI: 5.3-7.2] vs 3.3 [CI: 10.0-15.0] fibers/mm). However, there was no group differences at the thigh biopsy site (15.6 [CI: 15.0-15.9] vs 16.2 [CI: 14.5-17.8] fibers/mm). When taking the ratio of ankle IENFD:thigh IENFD, the point estimate for the pain at the ankle group (0.43 [CI: 0.36-0.48]) was about half that of the other group (0.81 [CI: 0.68-0.87]). Thus, colocalization of pain to the ankle is associated with meaningful decreases in ankle IENFD.

Electroacupuncture Alleviates Pain Responses and Inflammation in a Rat Model of Acute Gout Arthritis.

Acute gout arthritis is one of the most painful inflammatory conditions. Treatments for gout pain are limited to colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids, which oftentimes result in severe adverse effects. Electroacupuncture (EA) has been proved to be effective in relieving many inflammatory pain conditions with few side effects. Here, we aim to investigate the therapeutic potentials of EA on pain and inflammation of a rat model of acute gout arthritis and underlying mechanisms. We found that 2/100 Hz EA produced the most robust analgesic effect on mechanical hyperalgesia of acute gout arthritis rat model compared with 2 and 100 Hz. EA produced similar analgesic effect compared with indomethacin. 2/100 Hz EA also significantly alleviates the ongoing pain behavior, thermal hyperalgesia, and ankle edema. Locally applied μ and κ-opioid receptor antagonists but not adenosine A1 receptor antagonist significantly abolished the analgesic effect of EA. Locally applied μ and κ-opioid receptor agonists produced significant antiallodynia on acute gout arthritis rats, mimicking EA. Furthermore, 2/100 Hz EA upregulated β-endorphin expression in inflamed ankle skin tissue. Our results demonstrated, for the first time, that EA can be used for relieving acute gout arthritis with effect dependent on peripheral opioid system and comparable with the one obtained with indomethacin.

Effectiveness of Various Cryotherapy Systems at Decreasing Ankle Skin Temperatures and Applying Compression

A variety of cryotherapy systems may be used to cool tissues immediately after an injury. The purpose our study was to examine the effect of a 30-min application of various cryotherapy devices on skin temperatures and compression. A crossover-designed study performed in a university research laboratory was conducted. Each treatment condition was applied to the lateral ankle for 30 min on different days. HyperIce’s colder temperatures over the lateral ankle (p &lt; .0001) would make it the treatment choice for immediate care of ankle lateral ligament injuries, but is limited due its size for larger injuries.

Ankle Skin Temperature Changes Following Ice Bag Application With Compression at Varying Levels of Elevation

Ankle Skin Temperature Changes Following Ice Bag Application With Compression at Varying Levels of Elevation

In-vivo reflectance confocal microscopy of Meissner's corpuscles in diabetic distal symmetric polyneuropathy

ObjectiveTo evaluate in-vivo reflectance confocal microscopy (RCM) of Meissner's corpuscles (MC) in diabetic distal symmetric polyneuropathy (DSP). MethodsForty-three adults with diabetes and 21 control subjects underwent RCM of MC density at the fingertip of digit V, thenar eminence (TE), and arch of the foot, ankle skin biopsy for epidermal nerve fiber density (ENFD), electrophysiological studies, monofilament threshold testing, and timed vibration at the toe. Subjects with diabetes were subdivided into groups with and without clinical DSP using the American Academy of Neurology (AAN) case definition and neuropathy outcomes were compared across groups. ResultsBoth diabetic groups (with and without AAN clinical DSP criteria) had objective evidence of peripheral sensory involvement using conventional sensory measures, although those with clinical DSP criteria had greater abnormalities. MC densities were lower in the entire diabetic group at the TE and digit V relative to controls. MC densities at all imaging sites were associated with corresponding conventional sensory measures. MC densities were reduced in subjects without AAN clinical DSP criteria at the TE and digit V compared to controls whereas conventional upper limb sensory measures did not differ between these groups. ConclusionsIn-vivo RCM of MC density at digit V is a non-invasive, painless, objective marker in diabetes that offers a window into early large fiber sensory nerve terminal loss. Further studies are needed to determine whether RCM of MCs can identify quantitative changes in DSP associated with disease progression or treatment.

REPAIR OF ANKLE SKIN AND SOFT TISSUE DEFECT WITH FREE SUPERFICIAL ILIAC CIRCUMFLEX ARTERY PERFORATOR FLAP

To investigate the effectiveness of free superficial iliac circumflex artery perforator flap for repair of foot skin and soft tissue defect. Between January 2010 and December 2015, 16 patients with ankle skin and soft tissue defect were treated. There were 13 males and 3 females with an average age of 32 years (range, 5-56 years). The causes included traffic accident injury in 8 cases, machinery injury in 3 cases, falling injury in 3 cases, and electrically injury in 2 cases. The time from injury to hospital was 1 to 6 hours (mean, 3.5 hours). The wound sites included foot dorsum skin defect in 6 cases, ankle skin defect in 5 cases, the back foot and ankle skin defect in 5 cases. The skin defect size ranged 5 cm×4 cm to 16 cm×7 cm. All patients had tendon exposure, and 8 patients had fracture. An emergency repair was performed in 6 cases, and selective surgery in 10 cases. The free iliac circumflex artery perforators flap was used to repair defect; the flap size was 6 cm×5 cm to 17 cm×8 cm, and the flap thickness was 0.4 to 1.1 cm (mean, 0.8 cm). The flaps survived in the other 15 patients with primary healing of wounds except 1 patient because the iliac circumflex artery was too small to provide good blood supply, who underwent repair with local skin flap. Incision at donor site healed by first intention. The 15 cases were followed up 6-24 months (mean, 13 months). The appearance of the foot was satisfactory, and the flap had good texture without bulky flaps. Free iliac circumflex artery perforators flap is one of ideal flaps in repair of skin defect of the foot and ankle because of hidden donor site, reliable blood supply, less injury to donor site, and full use of the flap.

Cutaneous afferent feedback from the posterior ankle contributes to proprioception

Cutaneous mechanoreceptors in skin surrounding joints can respond to the skin strain generated by movement, and thus provide proprioceptive cues. The objective of this experiment was to determine the contribution of skin feedback from the posterior ankle to position sense during passive movements. In 28 healthy adults (12 male), a topical anesthetized (n=14) or placebo cream (n=14) was applied to an area of skin on the posterior ankle that undergoes stretch and compression during ankle dorsi- and plantar-flexion. Position sense was assessed before and after anesthetization using a passive joint matching task (target angles: 6°, 12°, and 18° dorsiflexion and plantar flexion). Results showed that reducing skin feedback caused the perception that the ankles were aligned when the anesthetized ankle was relatively more dorsiflexed, suggesting that posterior ankle skin primarily signals the magnitude of skin stretch. Larger movement into dorsiflexion was likely necessary to provide enough stretch of muscle and surrounding intact skin to compensate for reduced signals from the anesthetized skin region. Reducing skin feedback also increased matching variability during larger movements. These findings suggest that skin feedback from the posterior ankle has a significant contribution to position sense during passive movement. Therefore, the sensitivity of skin surrounding the ankle could be important to consider in populations with reduced peripheral skin sensitivity as a result of ageing or neurological disorders.

Clinical research of vacuum sealing drainage combined with artificial dermis for the treatment of ankle and foot soft tissue defects

To investigate the effect of vacuum sealing drainage (VSD) combined with artificial dermis for treatment of the ankle and foot soft tissue defects. A total of 15 patients with skin and soft tissue defect of ankle and foot were treated from January 2011 to December 2013, including 10 males and 5 females, with an average age of 32.5 years old ranging from 3 to 55 years old, involving 8 cases by traffic accident, 2 cases by machine accident, 5 cases by crush injury;8 cases with soft tissue exposure, 2 cases with tendor exposure, 5 cases with bone exposure. VSD was used to cover the wounds and continuous negative pressure drainage after debridement, the wounds covered with artificial dermis after the second granulation tissue grew well, again VSD was used to cover the wounds and negative pressure suction was applied, after 7 to 14 days negative pressure closed drainage was removed, free skin graft was transplanted above the artificial dermis, sterile gauze was used to compression bandage. All cases were followed up for 3 to 14 months with an average of 6.5 months. Skin graft of 15 of patients survived after transplantation, artificial dermis graft interval was 7 to 14 days with an average of 9.5 days. There was no obvious scar hyperplasia and contracture, no obvious pigmentation, appearance and functional recovery. After the implantation of artificial dermis and traditional skin graft method need for 2 to 3 weeks, vacuum sealing drainage technique combined with artificial dermis in treatment of soft tissue defect of foot and ankle skin has advantages of simple operation, significantly shorten the time of the second phase of the skin, without flap to repair, little injury to donor skin area, wound healing quality high, clinical effect of satisfaction.

Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon and Posterior Heel Wound Complications

Category: Ankle Introduction/Purpose: Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here we describe coverage of a series of posterior heel and achilles wounds via simple, local tissue transfer, a bipedicle fasciocutaneous flap. This surgical technique can be performed by an orthopaedic foot and ankle surgeon without resources of tertiary/specialized care or microvascular support. Methods: Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with wound breakdown following midsubstance Achilles tendon repair. Case 2 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 3 was a heel venous stasis ulcer with calcaneal exposure in a diabetic vasculopath. All three cases were treated with the following technique: an incision was immediately posterior to the lateral malleolus. The length of the incision was approximately 25% greater than the proximal to distal measurement of the wound. The dissection was carried to the flexor retinaculum and carried posteriorly to create a fasciocutaneous flap attached proximally and distally. This flap was then mobilized posteriorly to close the desired defect, leaving an ellipsoid shaped skin defect laterally. A split thickness skin graft was used to cover the defect created by the flap transposition. Results: All three patients demonstrated initial complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site following surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear. Conclusion: The bipedicled fasciocutaneous flap described offers a simple, predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap allows for relatively short operative times and can be customized to facilitate defect coverage. Ultimately, the flap is sufficiently durable to withstand the local tissue stresses required for ambulation at an early stage. This provides a reasonable alternative to complicated and time consuming microvascular reconstruction, but does require careful follow-up to manage the patient’s underlying comorbid conditions that may complicate wound healing.

"Logsplitter" injury in clinical treatment and prognosis evaluation in ankle fractures

Objective Logsplitter injury as a kind of unique ankle fracture with the inferior tibiofibular syndesmosis separation caused by varieties of violence does not catch the attention of domestic orthopedic surgeons enough in the past years. This passage is to discuss the damage mechanism, clinical treatment and prognosis evaluation of this kind of injury through the analysis of the case of injury. Methods Retrospective analysis 23 patients of Logsplitter injury from December 2006 to December 2014, male in 17 cases, female in 6 cases, average age (43.68±12.67) years (21-60 years). Hurt injury in 9 cases, sports injury in 1 case, falling injury in 2 cases, traffic injuries in 10 cases, crushing injury in 1 case. Open injures in 10 cases, of which the Gustilo Ⅱtype in 7 cases, Gustilo ⅢA type or above in 3 cases, closed injuries in 13 cases. According to the AO/OTA fracture classification, 44c type in 19 cases, 44b type in 3 cases, 44a type in 1 case. Fibula fractures in 22 cases, 19 cases of medial malleolus fracture. Results 23 patients received follow-up, with an average period was (0.91±0.26) years (0.4-2.37 years). 21 cases underwent open reduction internal fixation (ORIF), 2 cases underwent closed reduction external fixation and K-wire fixation.17 cases were fixed with the syndesmosis screws, among them,1 screw was used to fix 14 cases, two screws were used to fix 3 cases;the utilization rate of 3.5 mm screws is higher, at 94.1%, and all screws were entered through 3 layers of cortical; Combined with medial malleolus fracture cases were fixed with cannulated screws/K-wire internal fixation. Average healing time of the skin surrounding the ankle skin was (2.26±1.91) weeks; average healing time of fracture was (15.34±5.13) weeks; Joint pain ocurred combined with joint space narrowing after loading in 18 cases, at 78.3%; Postoperative infection, 2 cases, the proportion was 8.7%; Fracture delayed union 1 case. Functional examination of the ankle joint (angle measurement method): Dorsiflexion average angle (23.9±2.21) degrees, Plantar flexion average angle (32.1±4.13) degrees. Average angle of introversion was (23.91±2.24) degrees. Hallux valgus average angle (27.6±3.81) degrees. 75 points and over were got in AOFAS in 21 cases, the ratio of excellent was 91.3%. Conclusion Logsplitter injury represents a kind of important and unique ankle fracture, dislocation and the inferior tibiofibular syndesmosis separation caused by varieties of violence, accompany with potentially soft tissue injury and platford injury, according to existing treatment principle and treatment strategy summarizied by us,the clinical therapeutic effect of this damage is ideal, functional recovery is relatively satisfactory prognosis. Key words: Ankle injuries; Fractures, bone; Fracture fixation, internal

Clinical application of free super-thin anterolateral femoral perforator lobulated skin flap with nerve for repair of tissue defect of the foot and ankle

Objective To explore the clinical outcome of free super-thin anterolateral femoral perforator lobulated skin flap with nerve for repairing the tissue defect of the foot and ankle. Methods Free super-thin anterolateral femoral perforator lob-ulated skin flap with nerve was transferred to repair soft tissue defects of the foot and ankle in 32 cases. There were 20 males and 12 females with an average age of 35.5 years(range, 21-50 years). The wounds located in dorsal and plantar ankle skin with ten-don, bone and/or internal fixation exposed. The defect area was from 12 cm×10 cm to 20 cm×15 cm. At first the site of perforator vessels were determined by Doppler, according to the wound shape and size, the flaps were designed and harvested with the site as center; the femoral lateral cutaneous nerve was carried and most tensor fascia was reserved. During flap harvesting trimming of the flap was carried out, the flap was freed and only connected with its vascular pedicle. A step-wise defatting was done from the periphery of the flap towards the vascular pedicle with 1.0 to 2.0 cm tissue around the perforator preserved. Flap circulation was carefully observed to prevent damage to the perforators. The vascular pedicle was disconnected and formed a split leaf skin flap, and then the flap was transferred to the foot and ankle to cover the defect. Results All the 32 flaps were survived. No vascular crisis happened and all skin grafts were survived in donor sites. Necrosis of 1.5 cm×1.0 cm of the distal flap occurred in 1 case five days after surgery and it was healed by dress changing. All the 32 cases were followed-up for 6 to 24 months(average, 13 months). The flaps were supple and elastic with near normal color. There was no bulkiness. Sensory function was recovered well and two point discrimination(2-PD)was about 3.0-5.0 mm. The function and appearance of the foot and ankle were good. According to the Chinese Medical Association of hand surgery upper limb function evaluation of upper limb, the results were excellent in 22 cases, good in 9, fair in 1, with 97%(31/32)overall excellent and good rate. Conclusion The free super-thin anterolateral femoral perforator lobulated skin flap with nerve is an improvement of the traditional anterolateral thigh flap. The survived flaps are ideal in terms of covering foot and ankle defects and restore function. Key words: Foot; Ankle; Surgical flaps; Soft tissue injuries; Microsurgery

Effect of cryotherapy on the ankle temperature in athletes: ice pack and cold water immersion

Introduction Cryotherapy is often used for rehabilitation of injured athletes. Objective To compare the effectiveness of ice pack (IP) and cold water immersion (CWI) on lowering the ankle skin surface temperature in athletes. Materials and methods Thirteen athletes (seven women and six men), age 19.53 (± 2.9) years. IP and CWI were applied on the anterior talofibular ligament (ATFL) of the dominant leg for 30 minutes. The skin surface temperature was measured with an infrared digital thermometer prior to the application and during cryotherapy (10, 15, 20, 25 and 30 minutes) and up to two hours of rewarming. During rewarming, the athletes remained at rest and the temperature was measured every 1 minute until 10 minutes, every 5 minutes for up to an hour and every 15 minutes until 2 hours. Results The two types of cold application were effective in lowering the skin surface temperature after the 30-minute procedure. Significant differences were observed among the following temperatures: pre-application (IP = 29.8 ± 2.4 °C and CWI = 27.5 ± 3 °C – P &lt; 0.05); after 30 minutes (IP = 5 ± 2.4 °C and CWI = 7.8 ± 3 °C – P &lt; 0.01). For rewarming, after 25 minutes (IP = 20.8 ± 3.3 °C and CWI = 18.2 ± 2.7 °C – P &lt; 0.04); after 45 minutes (IP = 24.5 ± 2.3 °C and IP = 22.1 ± 3.5 °C – P &lt; 0.05); after 75 minutes (IP = 26.4 ± 2.2 °C and CWI = 24 ± 2.7 °C – P &lt; 0.02). Conclusion After the 30-minute application, both IP and CWI produced the appropriate temperature; however the application of CWI produced the lowest temperature during rewarming.