Tendon Exposure Research Articles

Surgical Technique: Repair of Forefoot Skin and Soft Tissue Defects Using a Lateral Tarsal Flap With a Reverse Dorsalis Pedis Artery Pedicle: A Retrospective Study of 11 Patients

Various authors have proposed flaps to reconstruct traumatic forefoot skin and soft tissue defects, especially with exposure of tendon and/or bone although which is best for particular circumstances is unclear. The indications for the technique were a forefoot defect area of no more than 8-cm × 8-cm and a well-preserved lateral tarsal (LT) donor site. The injured tendons were repaired using tendon grafts. The free dorsalis pedis flap was outlined by centering it on the cutaneous branch of the LT artery and tailoring it to the size of the wound, allowing 0.5-cm margins in length and width. The flap was rotated around the plantar perforating branch of the dorsalis pedis artery (DPA) to cover the forefoot defect. The lateral dorsalis pedis cutaneous nerve was anastomosed with the recipient plantar nerve stump. The donor site was covered with an inguinal, full-thickness skin graft. Traumatic forefoot skin and soft tissue defects with exposure of the tendon and/or bone involving 11 feet in 11 patients (mean age, 32 years) were covered using a LT flap with a reversed DPA pedicle. Three patients with forefoot defects underwent emergency repair within 8 hours of injury, whereas eight patients required delayed repair. All patients were followed up for at least 6 months (mean, 13 months; range, 6-24 months). All flaps survived uneventfully, except for two that had superficial marginal necrosis or severe venous insufficiency. All skin grafts covering the donor sites survived and all wounds healed. None of the patients had restricted standing or walking at followups. The two-point discrimination was 4 mm to 10 mm at 6 months postoperative. The mean hallux-metatarsophalangeal-interphalangeal scale score was 93 points (range, 87-98 points). Our observations suggest the LT flap with a reversed DPA pedicle is a reasonable option for repair of traumatic forefoot skin and soft tissue defects with exposure of tendon and/or bone but a well-preserved LT donor site and is associated with minimal morbidity.

Regenerative surgery of the complications with Morton's neuroma surgery: use of platelet rich plasma and hyaluronic acid

Morton's neuroma is an entrapment neuropathy of the plantar digital nerve. We treated five patients with wound dehiscence and tendon exposure, after Morton's neuroma surgery excision using a dorsal approach. In this article we describe our technique. From July 2010 to August 2011, at the Department of Plastic and Reconstructive Surgery, University of Rome 'Tor Vergata', five patients (four females and one male), with ages ranging between 35 and 52 years, were treated with a combination of PRP (platelet rich plasma) and HA (hyaluronic acid). Thirty days following surgery, all patients showed a complete healing of the wound. The use of this technique for the treatment of postoperative wound dehiscence and tendon exposure has proven as satisfactory.

Reconstruction of the thumb tip using palmar neurovascular flaps

Reconstruction of the tip of the thumb using a neurovascular flap. Transverse defects of the thumb's tip or large defects of the palmar pulp (max. 2.0-2.5cm) with exposure of bone and/or tendons. Extensive crush injury, heavy wound contamination, circulatory disorders, acute infection, very large defects (> 2.0-2.5cm finger length), circumferential soft tissue defects, and previous defects/operations (relative). Supine position, hand supinated, tourniquet, loupe magnification. Mid-lateral incisions along both sides of the finger running from the defect to the interphalangeal joint (small defect) or proceeding further proximally. Careful elevation of the flap including both neurovascular bundles leaving dorsal branches of the bundles (long fingers only) and the flexor tendon sheath intact. Suture of the flap in either flexion position (i.e., advancement flap) (Moberg) or by creating an island-flap through an additional transverse skin incision along the flap's base (O'Brien). Finally, closure of the defect at the flap's base using a full thickness skin graft, Z plasty, or V-Y plasty. Plaster cast (finger slightly flexed) for 2 weeks. Reliable method. Good functional results with good sensibility and only minor reduction in range of motion.

Versatility of Venous Flap for Coverage of Proximal and Middle Phalanges of Fingers

Owing to paucity of soft tissue in the fingers, the trauma to fingers can cause exposure of tendons, joints, and bone. Several flaps have been used to cover soft tissue defects of the fingers. From 2007 to 2010, we have operated on 18 male patients with skin defects of dorsal phalanges of fingers. We used reverse distally based venous flap with perivenous tissue to cover the defects. Their mean age was 30.6±8.6 (15 to 40). The etiology in all cases was severe trauma. Ten had defect in dorsal aspect of proximal phalanges and in 8 the defect was in the middle phalanges. One of our patients experienced superficial necrosis at the distal margin of the flap that was successfully treated with local wound care and dressing changes. There was 1 case of venous congestion that resolved itself. There were no postoperative wound infections. There were no serious complications. The venous flap with preservation of perivenous areolar network is a good option for coverage of soft tissue defects of proximal and middle phalanges of fingers.

Tissue defect repair and functional reconstruction of the limb with free flap by inverted-Y-shape microvascular anastomosis

Objective To discuss the clinic application and surgical technique of the free flap by inverted-Y-shape microvascular anastomosis in tissue defect repair and functional reconstruction of the limb.Methods Twenty-two flaps in 18 patients were involved in the study between June 2006 and September 2010 ( 12 cases for soft tissue defect repair with exposure of the tendons, bones or joints, and 6 cases for functional reconstruction; five cases were around the elbows and 13 cases were around the extremity of the lower limb). Before free flap graft, twelve cases with infective tissue defect were debrided extensively and covered with vacuum sealing drainage from 1 to 2 times and each time last 5 to 7 days until the granulation tissue growing well.Designed the free anterolateral thigh flaps with the transverse and descending branches of the lateral femoral circumflex vessels or free latissimus dorsi flaps with the subscapular and circumflex scapular vessels forming a inverted-Y-shape pedicle to repair the tissue defect or to reconstruct the limb function.The recipient artery was sectioned and the arterial tree of the flap was anastomosed to the recipient vessel by two end-to-end anastomoses.This inverted-Y-shape microvascular anastomosis could supply blood for both the free flap and the extremity of the limb.Not all of the veins of the recipient limb need to be cut off.Observed the circulation of the limb extremity, and evaluated the quality of flaps' survival. Results Complete flap survival was achieved in 21 flaps and without vaso-occlusive crisis; while partial flap loss in 1 case, which healed after changing dressings.The mean follow-up was 16.2 (6-36) months postoperatively,appearance of the flaps and the functions of limbs were satisfactory, and no obvious complication was found in the donor site. Conclusion The free flap by inverted-Y-shape microvascular anastomosis is a new choice for the tissue defect repair and functional reconstruction of the limb,especially for the wound around elbow or extremity of the lower limb with one major artery destroyed. Key words: Surgical flap ; Anastomosis ; Tissue transplantation ; Limb ; Functional reconstruction

Pedicled Flaps in Association With Distal Bypass for Lower-Limb Salvage

After distal bypass for limb salvage, persistence of large ischemic ulcers with exposure of tendons, joints, and bone and secondary graft exposure can lead to amputation, even though the bypass remains patent. Coverage of such defects using free flaps is too lengthy and complex for use in elderly patients. Although quick and simple, pedicled flaps are often considered to be contraindicated in patients with occlusive artery disease. The purpose of this study was to evaluate the outcome of pedicled flaps harvested after evaluation of revascularized territories on angiograms for coverage of tissue defects. From 1994 to 2000, a total of 23 pedicled flap procedures were performed in 22 patients with a mean age of 75 years (range, 54-91 years). The distal anastomosis of the bypass was located on a tibial or pedal artery in 19 cases and on the popliteal artery in 4. The indication for flap placement was chronic ulcer in 7 cases, secondary graft exposure in 15, and open fracture with acute ischemia in 1. To be considered as usable, the flap had to be vascularized by a pedicle fed by the bypassed artery and have a rotational axis sufficient to cover the defect. Muscle flaps were used in 11 cases, fasciocutaneous flaps in 10, and fascial flaps in 2. The flap procedures in this study led to primary healing in 17 cases, secondary healing in 4 cases, and failure due to necrosis in 2. Follow-up examination was carried out with Doppler ultrasonography at 1, 6, and 12 months and every 6 months thereafter. The mean follow-up period was 23 months (range, 3-5 years). Statistical analysis demonstrated bypass patency, limb salvage, and survival rates in agreement with those previously reported in the literature. Our results suggest that pedicle flaps are feasible after distal bypass in patients with lower-extremity occlusive artery disease. This technique expands the indication for limb salvage with low morbidity.

The effect of dehydration and irrigation on tendon adhesion formation after tendon exposure

The aim of this study was to evaluate the effects of dehydration due to tendon exposure on adhesion formation on the tendon surface. Achilles tendons of 60 New Zealand white rabbits were surgically exposed and evaluated. In the control group (Group 1), the wound was closed immediately; and in the remaining two groups, Achilles tendons were exposed to air for 60 minutes without (Group 2) or with (Group 3) regular saline irrigation. After undergoing clinical examination, 50% of rabbits in each group were sacrificed 3 weeks postoperatively and 50% at the 6th postoperative week. All tendons exposed to air exhibited mild or moderate degrees of adhesion. Compared to the control group, the incidence of adhesion formation was significantly higher in the groups where tendons had been exposed to air for 60 minutes, whereas no significant difference was found between the irrigated and non-irrigated groups. No limitations or contractures were detected in the hind limbs of the animals at the clinical examination. Regardless of irrigation, tendons are not prone to form clinically apparent adhesions during operations under 60 minutes of duration.

Lateral Supramalleolar Flap for Coverage of Ankle and Foot Defects in Children

The lower part of the leg, the ankle and the foot, is a difficult region to cover especially with exposure of bones or tendons. There are many options for covering soft tissue defect in these areas. The supramalleolar flap is an interesting procedure. The lateral supramalleolar flap was used in 8 cases for the reconstruction of skin defects of the ankle, heel, and foot that compromised the Achilles tendon and the osteoarticular system. Of the 8 patients, 5 were males and 3 were females, with an average age of 6.4 (range 2 to 10) years. The skin defect was secondary to trauma in all cases. The mean follow-up period was 31 (range 19 to 47) months; at the last follow-up visit, the region had been successfully covered in all cases. No necrosis of the flap was reported. The donor site morbidity was minimal. The lateral supramalleolar flap is an interesting surgical technique to salvage the lower extremity in children because this flap has a large skin paddle and a wide rotation arc and is based on a secondary vascular axis.

Correction of Severe Postburn Claw Hand

Burn scar contractures are perhaps the most frequent and most frustrating sequelae of thermal injuries to the hand. Unfortunately, stiffness occurs in the burned hand quickly. A week of neglect in the burned hand can lead to digital malpositioning and distortion that may be difficult to correct. The dorsal contracture is the most common of all the complications of the burned hand. It is the result of damage to the thin dorsal skin and scant subcutaneous tissue, which offers little protection to the deeper structures. Consequently, these injuries are deep resulting in a spectrum of deformities that has remained the bane of reconstructive surgery. Flap coverage will be required in the event of exposure of joints and tendons with absent paratenons. Multiple different flap types are available to treat complex severe postburn hand contractures. In our center, which is the largest regional burn center in northwest Iran, we have considerable experience in the treatment of thermal hand injuries. Between 2005 and 2010, we treated 53 consecutive patients with 65 severe postburn hand deformities. There were 35 men and 18 women with a mean age of 35±3 years. Flame injury was the inciting traumatic event in each patient. The severity of original injury and inadequate early treatment resulted in all of the fingers developing a severe extension contracture with scarred and adherent extensor tendons and subluxed metacarpophalangeal joints. In 36 cases, the injury was in the patients' dominant hand. We first incised the dorsal aspect of the contracted hands where there was maximum tension, then tenolysed the extensor tendons and released the volar capsules, collateral ligaments, and volar plate in all cases. In 30 cases, we also tenolysed the flexor tendons. We reduced the subluxed metacarpophalangeal joints and fixed them with Kirschner wires in 70 to 90 degrees flexion. Then, we planned and performed axial groin flaps to reconstruct the defects in all of them. In all of these patients, there was availability of intact skin in the territory of groin flap. However, in case of burn scars in this region, we had other options such as posterior interosseous flap in mind. Six patients experienced superficial necrosis at the distal margin of the flap, which was successfully treated with local wound care and dressing changes. There were no other complications. Physical therapy was initiated after Kirschner wire removal.

The SNaP Wound Care System for Head and Neck Wound Closure

Objective: Vacuum-assisted closure of head and neck wounds has been previously described. Negative pressure wound therapy, although efficacious, has practical limitations in the outpatient setting. The purpose of this study is to describe a novel method of treating complex head and neck wounds using an ultraportable mechanical vacuum wound care system. Method: A cohort study at 2 tertiary care centers. All head and neck patients with complex, low to moderately exudative wounds were treated by the senior author using the SNaP Wound Care System. Patient comorbidities, wound etiology, site, length of treatment, outcomes, and ancillary procedures were recorded. Results: A variety of wounds was treated with this system and included mucocutaneous fistulas, a tracheocutaneous fistula, soft tissue defects of the head and neck, and tendon exposure of a radial forearm free flap donor site. Outpatient SNaP therapy was utilized in five patients with 6 small- to medium-sized wounds. This system was successful in obtaining wound closure in all patients. These patients were able to complete routine activities of daily living, participate in public social settings, and tolerate therapy without adverse events. One patient required an adjunctive procedure of split thickness skin grafting. Conclusion: This study demonstrates a novel use of the first FDA-approved ultraportable, mechanical negative pressure device in the treatment of several complex head and neck wounds. The device has utility in the outpatient setting for adjunctive closure of wounds with minimal disturbance to patients’ activities of daily living and lifestyle.

Vacuum‐assisted closure improves the incorporation of artificial dermis in soft tissue defects: Terudermis® and Pelnac®

As a dermal scaffold, artificial dermal substitutes allow the body to accomplish its own tissue regeneration through infiltration of cells and neovascularisation. However, they show not only rather lower take rates compared to autologous skin grafts alone, but they also require more time for sufficient vascular ingrowth to overlay the skin graft. To accelerate this overlaying, we applied vacuum-assisted closure negative-pressure settings over the artificial dermis: Terudermis(®) and Pelnac(®) grafts. Fourteen patients with complex tissue defects were treated, including bone exposure in two cases, tendon exposure in seven cases and soft tissue defects in five cases. Nine cases had combined wound infections. The time interval between the first artificial dermis graft and the second split-thickness skin graft over it was 7·64 days on average. Dermal substitutes took place completely in all cases and there were no graft failures.

Evaluation for Flexural-load Capacity of Prestressed Concrete Girders with Broken Tendons

The use of low-grade material sheath grouting for PC girders has resulted in some PC girders initially constructed in the 1950s having insufficiently filled sheaths. The exposure of PC tendons in the sheath generates corrosion and rupture of the PC tendons, reducing the load-bearing capacity of PC girders. This research focused on the interface bond between PC tendons and grout in the sheath through loading tests in order to explain the loading capacity of deteriorated PC girders.

Trephination and Subatmospheric Pressure Therapy in the Management of Extremity Exposed Bone

Distal lower and upper extremity wounds with bone and tendon exposure present unique challenges to reconstructive surgeons. The limitations of the local anatomy usually make simpler reconstructive modalities such as primary closure and skin grafting difficult. As a result, wounds in this area, especially ones with bone or tendon exposures, are classically treated with free tissue transfer. Limb preservation using the combination of bone trephination and subatmospheric pressure therapy is described. Six cases with preserved extremities are presented. Three cases illustrate extremity wound with bone and tendon exposure healing through pregrafting wound optimization (bone trephination) with the use of subatmospheric pressure therapy. This treatment may offer an alternative method of limb salvage, in cases where flaps or free tissue transfer are not possible or optimal.

Management of severe hand wounds with integra® dermal regeneration template

We report our experience with the use of Integra® for the management of severe traumatic wounds of the hand. Fifteen patients were treated with follow-up ranging from 10 to 37 months. Wounds were associated with an osseous and/or joint and/or tendon exposure. Following Integra® placement, patients were managed with dressings and subsequent split-thickness skin grafting an average of 26 days later. Integra® was successful in achieving durable, functional and aesthetic definitive coverage in 13 of 15 applications while allowing a satisfying pollicidigital prehension. Regarding our clinical experience, Integra® is an effective technique to deal with severe wounds of the hand with exposed tendon and/or bone and/or joint, even in the absence of paratenon or periosteum. This can potentially lessen the need for local rotational or free flap coverage and should be taken into consideration as a viable alternative in traumatic reconstruction of the hand.

Lymphedematous Arm as Donor Site for Radial Forearm Free Flap in Thoracic Reconstruction

Sir: Recently, an article by Chang and Kim was published describing a large study of the incidence of lymphedema after mastectomy and radiotherapy, and after breast reconstruction with autologous flaps.1 This problem is a concern for every breast surgeon and remains controversial in the field of reconstructive surgery.2 Obviously, the real issue is for patients, who often avoid reconstruction to avoid risks related to surgery or further demolitions.3 In this way, we suggest an alternative free flap. We found that fasciocutaneous flaps could represent a valid alternative to muscular free flaps4—which represents one of the best alternatives—with an easy surgical technique and less morbidity, particularly when the patient refuses a contralateral latissimus dorsi free flap as in our case. We submitted four mastectomized patients suffering from radionecrosis and lymphedema to thoracic reconstruction with a radial forearm free flap taken from lymphedematous arm, to preserve the healthy arm (Fig. 1, above). We used the traditional procedure. Despite the lymphedematous tissues, dissection and harvesting of the flap was carried out with no difficulty (Fig. 1, below). The radial forearm free flap was successful in all cases. Flaps demonstrated long-term survival with easier surgical technique and less morbidity, particularly when harvested using a lymphedematous arm, and no worsening of the lymphedema was verified after surgery (Fig. 2, above). Despite initial scepticism, no disadvantages that we expected occurred, including an unsightly donor-site scar and skin graft breakdown with tendon exposure. The quality of our results seems to be stable, because actually no recidivism was verified and all the patients could return to their daily activities (Fig. 2, below).Fig. 1.: (Above) Preoperative view of radiodermitic wound in the thoracoaxillary region, with area of severe cutaneous distress and fistula in the right lateral district, associated with arm lymphedema. (Below) One year after surgery, improvement of surrounding tissues is observed because of trophism caused by the flap.Fig. 2.: (Above) Intraoperative view of flap sculpting from right lymphedematous limb, subsequently transferred and micro-anastomosed by means of two end-to-side anastomoses to the ipsilateral brachial vein and artery. (Below) Donor site 12 months after surgical treatment.We have proved that the radial forearm free flaps performed on lymphedematous upper limbs represented an adequate therapeutic choice, ascertaining the following: Upper limb lymphedema should not to be considered an absolute contraindication to perform microvascular radial forearm free flap surgery. The donor site shows normal healing without pathologic scars. Skin grafts taken at the donor site were successful, and no complications arose, despite the presence of lymphedema. In all patients, a great improvement was obtained, characterized by pain release and reduction of thoracic constriction. The lymphedematous swelling of the flap provided expanded and reliable tissue,5 which demonstrates that lymphedema does not represent a contraindication, making this the most conservative surgical procedure. In addition, lymphedema is not worsened after surgery and seems to be reduced in the long term. In our opinion, the radial forearm free flap offers several potential advantages over other fasciocutaneous flaps and muscle flaps for mastectomized patients and patients affected by radionecrosis undergoing thoracic reconstruction: it provides a large amount of well-vascularized, thin, pliable soft tissue; it is easy to harvest; and it has large consistent vessels and a long pedicle, particularly when, performing it, a lymphedematous donor site is used, which provides expanded tissue. Luca Vaienti, M.D. Laura Masetto, M.D. Giovanni Palitta, M.D. Plastic Surgery Department Università degli Studi di Milano Policlinico San Donato San Donato Milanese Milan, Italy Michel Merle, M.D. Institut Européen de la Main Hôpital Kirchberg Luxembourg

Friction Burn Injuries to the Dorsum of the Hand After Car and Industrial Accidents: Classification, Management, and Functional Recovery

A total of 65 cases of friction burn injuries to the dorsum of the hand after car and industrial accidents were reviewed. The mean age of the study population was 31 years (range 18-68 years). The injury sustained from friction was graded into four grades: grade I (n = 6), isolated second-degree skin burn, grade II (n = 6), full-thickness skin burn without extensor tendon exposure, grade III (n = 45) the friction injury affected and exposed the extensor tendons, and grade IV (n = 8) the friction injury extended to bones and joints. Management was by dressing, split skin grafting, local/pedicle flap, and free muscle flap in grades I to IV, respectively. Functional recovery of the hand in terms of percentage normal range of motion and grip strength was best in grade I and worst in grade IV injury. Complications of reverse-pedicled forearm flaps were higher than free muscle flaps. However, the aesthetic appearance of grafted free muscle flaps on the dorsum of the hand was inferior to fasciocutaneous flaps.

Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects

Even a small defect in the lower leg and foot with exposure of bones or tendons can result in an intractable wound, which may require a microsurgical tissue transfer. With the concept of the perforator flap, a pedicled peroneal artery perforator flap can be used for coverage of this difficult region. Between August 2001 and August 2008, 18 pedicled peroneal artery perforator flaps were performed in 18 patients. The fasciocutaneous flaps were employed to cover defects in the pretibial area (n=6), Achilles' tendon and/or hindfoot (n=7) and lateral malleolar area (n=5). The pedicled peroneal artery perforator flaps are classified into five types: propeller flap (n=11), peninsular flap (n=4), advancement flap (n=2), proximally based island flap (n=1) and distally based island flap (n=0). The size of the flaps ranged from 7.5×3 cm(2) to 20×8 cm(2). The selected perforator depended on the defect location, ranging from 4.5 to 18 cm above the tip of the lateral malleolus. Postoperative venous congestion was encountered in four propeller flaps and one proximally based island flap. Venous congestion subsided within days without complications, except one which needed further reconstruction with skin grafts. In conclusion, the peroneal artery perforators are predictable and reliable for the design of a perforated-based flap. Elevation of the flap can be performed easily in the supine or prone position, depending on the defect location. Different designs of this perforator-based flap can repair a variety of leg and foot defects.

Free Anterolateral Thigh Flap for Reconstruction of Car Tire Injuries of Children's Feet

Grade IV and V car tire injuries occurring in children cause extensive soft tissue defects with exposure or loss of tendons and bone on the dorsum of the foot. Free tissue transfer is indicated for reconstruction of these defects because of the limited local tissue available. We describe our management of high-grade car tire foot injuries in children with free anterolateral thigh flap (ALT). Five pre-school children with car tire injuries (one grade IV and four grade V) were treated with free ALT flap in the last 4 years. The mean age was 4.8 years. In four patients, immediate flap coverage after initial debridement was performed and delayed reconstruction was used as a secondary procedure in one patient. One of the flaps was re-explored for hematoma evacuation and salvaged. All of the flaps survived completely and there were no donor site complications. None of the flaps required a debulking procedure and custom shoe wear has not been necessary in any of the patients. Minor gait abnormalities were detected in two of the patients. With minimal donor site morbidity, long vascular pedicle allowing anastomosis outside of the trauma zone, we believe free ALT flap provides the ideal soft tissue reconstruction for high grade car tire injuries of foot in children. ALT flap can be further thinned to adapt to the defect, contracts less than muscle flaps and contains a vascularized fascia which can be used for extensor tendon reconstruction.

The Use of a Dermal Substitute (Integra) to Preserve Maximal Foot Length in a Diabetic Foot Wound With Bone and Tendon Exposure Following Urgent Surgical Debridement for an Acute Infection

In this report, the authors present the case of a 62-year-old female patient who was admitted to our hospital with an acute deep foot infection. The patient was taken immediately to the operating room where she underwent surgical debridement to completely remove all infected tissues; at the end of this first surgical step, all 5 metatarsal bones remained exposed dorsally. Once eradication of infection was completed, we had to decide whether to perform a transmetatarsal amputation at proximal levels, which would have allowed healing by first intention but would have left the patient with a smaller foot stump, or amputation at more distal levels followed by coverage of healthy tendon and bone tissues with a dermal regeneration template (Integra, Integra Life Sciences Corporation, Plainsboro, NJ), which would have preserved the foot stump length and allowed better walking. We opted for the second choice, and the use of a dermal template actually enabled our patient to maintain a considerable foot stump length, much longer than would have resulted from an amputation with immediate primary closure.

Bypass Flap Reconstruction, A Novel Technique for Distal Revascularization: Outcome of First 10 Clinical Cases

Combined distal venous bypass grafting and free flap transfer can achieve successful treatment of soft tissue defects due to advanced leg ischemia. However, this combined approach is a complex technique involving multiple anastomoses on the same arterial axis with an increased risk of thrombosis. To reduce this risk, we have proposed a new bypass-flap (BF) reconstruction technique using an arterial graft and a free flap supplied by a collateral branch of the graft. The purpose of this report is to document the outcome in the first 10 patients treated using the BF reconstruction technique. From 2002 to 2004, a total of 10 patients with a mean age of 67 years (range 55-78) were treated using a BF. All patients presented critical ischemia with soft tissue defects resulting in exposure of tendons and muscles on the foot or ankle. Distal anastomosis was made between the distal branch of the BF and the pedal artery in five cases, the posterior tibial artery or plantar artery in four cases, and the peroneal artery in one case. In six cases proximal anastomosis was performed between the leg artery and arterial autograft. In the remaining four cases proximal anastomosis required extension of the bypass using a venous graft. The mean duration of hospitalization was 25 days. During the postoperative period, one patient died due to stercoral peritonitis and one patient required major amputation due to unrelenting sepsis. Bypass occlusion was not observed. Mean follow-up was 24 months (range 14-36). No patient was lost to follow-up and no patient died after the first 30 postoperative days. Follow-up examinations including clinical assessment and Doppler ultrasound imaging were performed at 3 months and every 6 months thereafter. Findings demonstrated bypass patency and healing of the covered defect in all cases. Outcome in this initial series demonstrates the clinical feasibility of the new BF reconstruction technique, which allows revascularization and coverage of tissue defects using a one-piece anatomic unit.