Proximal Lower Leg Research Articles

Persistent retrograde venous-lymphatic reflux in side-to-end lymphaticovenous anastomosis in a lower extremity with lymphedema: a case report

End-to-end (ETE) and side-to-end (STE) anastomosis are two common configurations of lymphaticovenous anastomosis (LVA); however, it remains inconclusive which method is better. A 62-year-old man with lower extremity lymphedema underwent LVA with the STE method on the ankle. When the lymphatic vessel was cut for additional LVA at the proximal lower leg, blood drained out from the cut end of a lymphatic vessel, which suggested venous-lymphatic reflux at the STE anastomosis at the ankle. Because the reflux continued until 1 hour after the previous LVA at the ankle, the STE anastomosis at the ankle was re-explored and converted to ETE by ligation of the proximal lymphatic vessel. Reverse venous-lymphatic reflux was corrected, and a lymphovenous shunt was created immediately after the ligation. The current case suggests that STE anastomosis can be inferior to ETE anastomosis for creating a lymphovenous shunt when venous backflow exists.

Analysis of bone transport for ankle arthrodesis as a limb salvage procedure for the treatment of septic pilon fracture nonunion

Septic nonunion of the pilon region with ankle joint infection is challenging for orthopedic surgeons to treat and is associated with a high risk of limb loss. Therefore, the aim of this study was to evaluate the effectiveness of bone transport for ankle arthrodesis in salvaging the limp after septic ankle destruction of the pilon region. We conducted a single-center, retrospective study including 21 patients treated for septic pilon nonunion with accompanying septic ankle destruction via Ilizarov bone transport between 2004 and 2018. In all cases, the complete excision of the nonunion and the resection of the ankle joint were carried out, followed by treating the bone and joint defect with a bone transport into the ankle arthrodesis. In 12/21 patients an additional flap transfer was required due to an accompanying soft tissue lesion. The overall healing and failure rate, final alignment and complications were recorded by the patients’ medical files. The bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and a modified American Orthopedic Foot and Ankle Society (AOFAS) scale. After a mean follow-up of 30.9 ± 15.7 months (range 12–63 months), complete bone and soft tissue healing occurred in 18/21 patients (85.7%). The patients had excellent (5), good (7), fair (4), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 6 patients had excellent, 7 good, and 6 fair results. The modified AOFAS score reached 60.6 ± 18 points (range, 29–86). In total, 33 minor complications and 28 major complications occurred during the study period. In 2 cases, a proximal lower leg amputation was performed due to a persistent infection and free flap necrosis with a large soft tissue defect, whereas in one case, persistent nonunion on the docking side was treated with a carbon orthosis because the patient refused to undergo an additional surgery. Bone transport for ankle arthrodesis offers the possibility of limb salvage after septic ankle destruction of the pilon region, with acceptable bony and functional results. However, a high number of complications and surgical revisions are associated with the treatment of this severe complication after pilon fracture.

Clinical effects of retrograde anterolateral thigh perforator flaps assisted with computed tomography angiography in repairing skin and soft tissue defects around the knee or in proximal lower leg

Objective: To investigate the clinical effects of retrograde anterolateral thigh perforator flaps assisted with computed tomography angiography (CTA) in repairing skin and soft tissue defects around the knee or in proximal lower leg. Methods: A retrospective cohort study was conducted. From May 2015 to October 2019, 17 patients with skin and soft tissue defects around the knee or in proximal lower leg were admitted to the Department of Orthopedics of Jizhong Energy Xingtai Mig General Hospital, including 12 males and 5 females, aged 16-65 years, with an average age of 35 years. The areas of skin and soft tissue defects after debridement ranged from 6.0 cm×3.0 cm to 15.0 cm×9.0 cm. The retrograde anterolateral thigh perforator flaps were designed according to the origin and distribution of the perforating branches in flaps and the length of the vascular pedicle examined with CTA and the condition of the wound to repair the wounds. The areas of resected flaps ranged from 6.5 cm×3.5 cm to 15.5 cm×9.5 cm. The wounds in donor sites of flaps were sutured directly or covered with medium-thickness skin grafts from healthy upper leg. The sources of the perforating branches in flaps were recorded. The lateral circumflex femoral artery, its branches, and the relative length of the vascular pedicle were compared between preoperative CTA detection and intraoperative observation. The survivals of the flaps were observed. At the last follow-up, the effects of flaps in repairing wounds were evaluated according to evaluation standard of efficacy satisfaction; the motion ranges of flexion and extension of the knee joint were measured, and the knee joint function was evaluated according to the Hohl knee joint function evaluation standard; the sensory function in the flap area was evaluated according to the sensory function evaluation standard formulated by the British Medical Research Council; the wound healing and the occurrence of complication affecting motor function of limb of flap donor sites was observed. Data were statistically analyzed with paired sample t test. Results: The perforating branches in flaps originated from descending branches, oblique branches, and rectus femoris branches of lateral circumflex femoral artery in 7, 6, and 4 patients, respectively. The flaps with blood supply from descending branches, oblique branches, and rectus femoris branches of lateral circumflex femoral artery were type 1, 2, and 3 retrograde anterolateral thigh perforator flaps, respectively. The preoperative CTA examination of lateral circumflex femoral artery and its branches were consistent with those observed during operation. The relative lengths of vascular pedicles of type 1, 2, and 3 retrograde anterolateral thigh perforator flaps calculated after CTA examination were 0.32±0.13, 0.56±0.07, and 0.56±0.15, which were close to 0.35±0.12, 0.52±0.10, and 0.53±0.12 measured and calculated during operation, respectively (t=0.45, 0.80, 0.31, P>0.05). All flaps survived in 17 cases without vascular crisis. At the last follow-up, 16 patients were satisfied with effects of flaps in wound repair, with 1 patient feeling average about the effect; the flexion range of knee joint was 100-120°, and the extension range of knee joint was -2-0°; knee joint function was evaluated as excellent in 9 cases, good in 7 cases, and poor in 1 case; the sensory function of the flap area reached S4 level in 2 cases, S3 level in 8 cases, and S2 level in 7 cases; the wounds in flap donor sites healed well; there was no adverse effect in motor function of limbs. Conclusions: Retrograde anterolateral thigh perforator flap is an effective method for repairing skin and soft tissue defects around the knee or in proximal lower leg. Preoperative CTA examination can fully show the anatomical characteristics of the branches of the lateral circumflex femoral artery and the perforating vessels of each branch, which can guide preoperative flap design and operation, thus shortening operation time and improving flap survival rate, with good clinical effects.

The Versatility of the Pedicled Medial Sural Artery Perforator Flap: From Simple to Its Chimeric Pattern and Clinical Experience with 37 Cases.

Defects in the knee area, popliteal fossa region, and upper third of the lower extremity can pose a challenge for reconstructive plastic surgeons. The purpose of this article is to report the authors' experience with the use of the pedicled medial sural artery perforator flap in its simple and chimeric form for reconstruction of defects in three different regions: knee, popliteal fossa, and proximal lower leg. From April of 2018 to April of 2019, 37 patients (29 men and eight women) with a mean age of 51 years (range, 18 to 78 years) underwent reconstruction with 37 pedicled medial sural artery perforator flaps. All flaps were harvested as pedicled perforator flaps in conventional or chimeric fashion and were based on one or two perforators. The defect locations included the knee (18 cases), popliteal fossa (seven cases), and proximal lower leg (12 cases). The cause of reconstruction was trauma in 22 patients (59 percent), tumor in 10 patients (27 percent), and donor-site closure of free medial sural artery perforator in five patients (14 percent). The flap sizes varied from 3.5 × 5 cm to 5 × 10 cm. All but one flap, which showed distal tip necrosis, survived completely after surgery. The donor sites were all closed primarily. Minor complications included flap dehiscence (two cases) and minor wound infection delaying the healing process (four cases). All complications were treated conservatively. Follow-up observations were conducted for 3 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results. The pedicled medial sural artery perforator flap can be considered an optimal method of reconstruction for covering defects not only in the knee area but also in the popliteal fossa and upper lower leg. Therapeutic, IV.

Multiple Firm Livid Nodules on the Proximal Lower Leg: A Quiz

Multiple Firm Livid Nodules on the Proximal Lower Leg: A Quiz

Better wearing comfort of knee-length elastic compression stockings with an interface pressure of 18-21 mmHg compared to 23-32 mmHg in elderly people after a one day trial - Influence on foot deformities, rheumatism and arthritis.

Although the efficacy of compression therapy through knee-length compression stockings with an interface pressure of 18-21 mmHg for leg oedemas has been confirmed by many studies, 91% of patients are still treated with a higher interface pressure. In this prospective open randomised monocentric study 19 patients (age ≥65, movement restrictions and symptomatic leg oedema) received knee-length compression stockings with an interface pressure of 18-21 mmHg (stocking type 1) and 23-32 mmHg (stocking type 2). On two consecutive days each of the two compression stocking types were worn for at least 8 hours. After this test period, both stocking types were assessed subjectively and skin changes were recorded. A significantly (p-value <0.001) subjective improvement of the symptoms and complaints based on leg oedema was reported with the knee-length compression stockings. The Stocking type 1 recorded a significantly (p = 0,045) better wearing comfort. In addition, the Stocking type 2 was significantly too large amongst women in the front foot area (p = 0.044). The most common side effects were constrictions on the proximal lower leg (stocking type 1 = 73,7% (14/19); stocking type 2 = 78,9% (15/19)). Subjects with arthritis (p = 0.006), hallux valgus (p = 0.034) and/or digitus flexus (p = 0.021) found the socking type 1 significantly more comfortable. In order to achieve optimal patient compliance it is recommended to prescribe knee-length compression stockings with an interface pressure of 18-21 mmHg if the following criteria are met: age ≥65 years, female sex, arthritis, digitus flexus (claw toe) or hallux valgus.

Peroneal nerve location at the fibular head: an anatomic study using 3D imaging.

Injuries to the peroneal nerve are a common complication in operative treatment of proximal tibial or fibular fractures. To minimize the risk of iatrogenic injury to the nerve, detailed knowledge of the anatomy of the peroneal nerve is essential. Aim of this study was to present a detailed description of the position and branching of the peroneal nerve based on 3D-images to assist preparation for surgical approaches to the fibular head and the tibial plateau. The common peroneal nerve, the deep and the superficial peroneal nerve were marked with a radiopaque thread in 18 formalin-embalmed specimens. Three-dimensional X-ray scans were then acquired from the knee and the proximal lower leg in full extension of the knee. In 3D-reconstructions ofthese scans, distances of the common peroneal nerve and its branches to clearly defined osseous landmarks were measured digitally. Furthermore, the height of the branching of the common peroneal nerve was measured in relation to the landmarks. The mean distance of the common peroneal nerve at the level of the tibial plateau to its posterior osseous limitation was 7.92 ± 2.42mm, and 1.31 ± 2.63mm to the lateral osseous limitation of the tibia. In a transversal plane, distance of the common peroneal nerve branching was 27.56 ± 3.98mm relative to the level of the most proximal osseous extension of fibula and 11.77 ± 6.1mm relative to the proximal extension of the tibial tuberosity. The deep peroneal nerve crossed the midline of the fibular shaft at a distance of 22.14mm ± 4.35 distally to the most proximal extension of the fibula, the superficial peroneal nerve at a distance of 33.56mm ± 6.68. As the course of the peroneal nerve is highly variable in between individuals, surgical dissection for operative treatment of proximal posterolateral tibial or fibular fractures has to be done carefully. We defined an area were the peroneal nerve and its branches are unlikely to be found. However, specific safe zones should not be utilized due to the individual anatomic variation.

Ostrvasti miokutani medijalni gastroknemijus režanj u rekonstrukciji kolena i proksimalnog dela potkolenice

Ostrvasti miokutani medijalni gastroknemijus režanj u rekonstrukciji kolena i proksimalnog dela potkolenice

Medial opening wedge high tibial osteotomy

Reduction of the load to the medial compartment in patients with medial knee osteoarthritis and varus malalignment. Unloading of the posterolateral complex in varus deformity with complex ligamentous laxity. Medial knee osteoarthritis and varus malalignment with largely intact lateral and patellofemoral joint aspect. Complex ligament insufficiency combined with varus deformity. Substantially impaired range of motion. Medial skin incision on the proximal lower leg. Preparation of the pes anserinus. Marking of the osteotomy from the deepest point of the medial metaphysis laterally ascending. Biplane osteotomy, carefully protecting the posterior neurovascular structures, with ventral completion proximal or distal to the tibial tuberosity, depending on concomitant pathologies. Angular-stable plate fixation. In general, early weight bearing is possible when angular-stable plate fixation is used. Often concomitant pathologies such as accompanying cartilage regenerative therapy necessitate longer unloading. Range of motion does not need to be restricted following stand-alone osteotomy. Orthoses are recommended regularly. Under the correct indication, the medial opening wedge high tibial osteotomy (OW-HTO) technique can achieve good results with high patient satisfaction, despite arelatively high statistical complication rate, provided that a standardized surgical technique is used. There is a tendency for a poorer outcome in patients with a body mass index above 30 and higher stages of osteoarthritis.

Pseudoaneurysm of the anterior tibial artery after interlocking tibial nailing: an unexpected complication.

Anterior tibial pseudoaneurysm is a rare complication after interlocking screw insertion in tibial nailing. We present the case of a 28-year-old male patient with this complication with a 6-week delay after tibial nailing of a right tibial fracture type 42-A1 of the Association for the Study of Internal Fixation (AO/ASIF) classification. On presentation to our emergency department, the patient’s complaints were solemnly intermittent pain and occasional swelling of his proximal lower leg. Deep vein thrombosis, compartment syndrome, and implant dislocation were ruled out, and the patient was discharged after his symptoms improved without further intervention. Four weeks later, the patient was readmitted for similar symptoms. A computed tomography (CT) angiography then revealed a pseudoaneurysm of the anterior tibial artery at the level of the proximal interlocking screw insertion. Aneurysmal sac excision with vessel repair was performed while reconstructing the additional dislocated proximal fibular fracture using standard AO/ASIF plating. Postoperatively, sufficient flow through the repaired vessel was documented using Doppler ultrasound and CT angiography. However, the patient sustained a temporal damage to the peroneal nerve after surgery. This case highlights the risk of a pseudoaneurysm of the anterior tibial artery after interlocking screw insertion as a rare but major complication of a routine surgical procedure. Early ultrasound diagnostics, CT angiography, or magnetic resonance (MR) angiogram should be performed to prevent the delay in diagnosis and treatment of such complications.

Cuff Algometry for Estimation of Hyperalgesia and Pain Summation.

Cuff algometry is useful to assess pain sensitivity mechanisms, but effects of cuff position and stimulation pattern are not clear. In 20 healthy volunteers, cuff pain detection threshold (PDT) and pain tolerance (PTT) were recorded with cuffs accommodating two individual chambers at four locations (eight positions) along the leg, using ramp inflation (1 kPa/s) until subjects indicated PDT and PTT. Repeated stimulations (1-s stimulation, 4-s break) with a staircase increase in stimulus intensity (5 kPa/step) were used to assess PDT and PTT on a single location. Spatial pain summation was calculated as the ratio between PTTs recorded with one chamber or simultaneously with two neighbor chambers. Temporal pain summation was assessed by repeated cuff stimulations (1-s stimulation, 1-s break) and the pain intensity was recorded on a visual analog scale (VAS); the PTT from ramp and staircase assessments were used as stimulus intensity. For the most distal cuff position, the PTT was higher compared with other leg positions except when in proximity to the knee ( P < 0.01). The PDT was higher for the distal part compared with the mid-portions of the lower and upper leg ( P < 0.01). Compared with other leg locations, the spatial summation ratio was highest at the proximal lower leg ( P < 0.02). The staircase versus ramp pattern revealed higher PDT and PTT (P < 0.01), as well as pronounced temporal pain summation ( P < 0.01). The mid-portion of the lower leg is recommended for cuff placement, and the staircase paradigm provides relevant stimulus intensity for assessment of temporal pain summation.

Rapport de 2 cas de couverture du genou par lambeau de face externe de cuisse en ilôt rétrograde

The coverage of soft-tissue defects concerning the front of the knee and the proximal lower leg is a complex procedure. The reverse flow anterolateral thigh flap represents a good solution for this defects, especially when the coverage surface is large-sized and a free flap is not appropriate regarding the difficulty of the process. Flap retrograde vascularization is based on the anastomosis between the descending branch of the circumflex femoral artery and lateral superior genicular artery. It is an easy solution with low morbidity. The authors have chosen this flap to cover soft-tissue defect of anterior knee from two patients with total knee prothesis.

Electromagnetic fields do not affect bone micro-architecture in osteoporotic rats.

ObjectivesElectromagnetic fields (EMF) are widely used in musculoskeletal disorders. There are indications that EMF might also be effective in the treatment of osteoporosis. To justify clinical follow-up experiments, we examined the effects of EMF on bone micro-architectural changes in osteoporotic and healthy rats. Moreover, we tested the effects of EMF on fracture healing.MethodsEMF (20 Gauss) was examined in rats (aged 20 weeks), which underwent an ovariectomy (OVX; n = 8) or sham-ovariectomy (sham-OVX; n = 8). As a putative positive control, all rats received bilateral fibular osteotomies to examine the effects on fracture healing. Treatment was applied to one proximal lower leg (three hours a day, five days a week); the lower leg was not treated and served as a control. Bone architectural changes of the proximal tibia and bone formation around the osteotomy were evaluated using in vivo microCT scans at start of treatment and after three and six weeks.ResultsIn both OVX and sham-OVX groups, EMF did not result in cancellous or cortical bone changes during follow-up. Moreover, EMF did not affect the amount of mineralised callus volume around the fibular osteotomy.ConclusionsIn this study we were unable to reproduce the strong beneficial findings reported by others. This might indicate that EMF treatment is very sensitive to the specific set-up, which would be a serious hindrance for clinical use. No evidence was found that EMF treatment can influence bone mass for the benefit of osteoporotic patients.Cite this article: Bone Joint Res 2014;3:230–5.

Proximal-Based Saphenous Neurocutaneous Flaps: A Novel Tool for Reconstructive Surgery in the Proximal Lower Leg and Knee

Soft tissue defects around the knee region are usually complex and require adequate reconstruction with flaps. In this article, we present our experience using the proximal-based saphenous neurocutaneous flap for the reconstruction of soft tissue defects around the knee and the proximal lower leg. Between 2008 and 2010, 17 patients with soft tissue defects around the knee and the proximal lower leg were treated with proximal-based saphenous neurocutaneous flaps. The age of patients ranged from 19 to 61 years (mean 35.6 years). Defect sizes ranged from 3 cm × 4 cm to 9 cm × 18 cm and the flaps were designed with sizes ranging from 3 cm × 5 cm to 11 cm × 20 cm. The mean follow-up was 16 months (range 8 to 26 months). Sixteen flaps survived completely, and one flap developed partial necrosis. Mild swelling was observed within a few days postoperatively, and no severe venous congestion occurred. The skin grafts in the donor sites survived completely. All of the 17 flaps gained a good sensory recovery, and only 2 patients complained of numbness on the grafted donor-site during extended follow-up. Our experience has demonstrated that the proximal-based saphenous neurocutaneous flap is a safe and reliable tool for reconstruction of the defects around the proximal lower leg and knee.

Clinical experience with a reverse-flow anterolateral thigh perforator flap for the reconstruction of soft-tissue defects of the knee and proximal lower leg

Soft-tissue defects in the knee region are usually complex and require adequate reconstruction with flaps. The aim of this article is to present the authors' experience using the reverse-flow anterolateral thigh perforator flap for the reconstruction of a variety of soft-tissue defects around the knee including the upper third of the leg. A total of 17 reverse-flow anterolateral thigh perforator flaps were used for reconstruction of soft-tissue defects around the knee and the upper third of the leg between December 2006 and December 2010. The ages of patients ranged from 26 to 82 years (mean, 64.3). Defect sizes ranged from 6×8 to 10×14 cm. The application of the reverse-flow anterolateral thigh perforator flaps in relation to the variable arterial anatomy was described. The dimensions of the largest flap used for reconstruction were 10×16 cm. The perforators were musculocutaneous in 14 patients and septocutaneous in three patients. The maximal pedicle length was 28 cm. All of the flaps survived. Only two flaps developed partial skin necrosis at the distal end. Good aesthetic and functional results with adequate range of motion were achieved in all cases. Despite a variable vascular anatomy that can be challenging for the surgeon, reverse-flow anterolateral thigh perforator flap is a safe and reliable method for reconstruction of the defects around the knee and even the upper third of the leg.

Myositis proliferans: diagnosis and therapy of a pseudosarcomatous soft tissue lesion

Myositis proliferans is a soft tissue neoplasia with rare incidence. In the most cases, it is localized in the region of the neck, shoulder, pelvis and thigh. Due to its rapid growth and histological picture, the tumour may appear as a malignant neoplasia. We report the case of a 29-year-old woman suffering from an increasing painful swelling of the left proximal lower leg. Performed biopsies and histological examinations provided the diagnosis of myositis proliferans adjacent to the fibula, which responded to local resection and did not recur after 2years. We show the importance of adequate diagnostic and therapeutic approach to avoid unnecessary and probably radical overtherapy of the patient.

Biologische Rekonstruktionsmöglichkeiten nach Tumorresektion

The resection of musculoskeletal tumours often makes reconstruction of the resected bone structure necessary. There are both autologous and allogenous options as well as prosthetic bone substitutes for reconstruction of the created bone defect. In cases with sufficient residual stability a boney reconstruction may not be necessary and a temporary modification of load-bearing or immobilisation will give satisfactory results. Spongey bone, tricortical bone chips, or vascular pedicled bone grafts (clavicle, fibula) can be used as autogenous grafts. Callus distraction by means of segment transport is suitable as a secondary reconstruction option for hollow bones. The use of allogenous grafts is accompanied by a high rate of complications and is rarely employed. The reversal plasty according to Borggreve offers a further option for reconstruction in cases of tumours of the femur or, respectively, the proximal lower leg. Bones that are merely temporarily weakened can be stabilised with the help of a temporary osteosynthesis.

Effects of low-intensity KAATSU resistance training on skeletal muscle size/strength and endurance capacity in patients with ischemic heart disease

KAATSU training induces muscle hypertrophy and strengthens muscle in athletes and healthy subjects through short-term and low-intensity exercise. However, it remains uninvestigated whether lowintensity KAATSU resistance training (LIKRT) induces muscle strength and hypertrophy in patients with cardiovascular diseases. We examined the effects of LIKRT on skeletal muscle size/strength and endurance capacity in patients with ischemic heart disease (IHD). Seven male patients with stable IHD performed three kinds of resistance exercises (leg press, leg curl and leg extension) with their femoral muscle blood flow restricted by KAATSU belt two times/week for three months. We measured one RM (1-RM) in each resistance exercises, and evaluated muscle cross-sectional areas (CSA) by MRI before training and after the training. We used cardiopulmonary examinations to measure endurance capacity (Peak VO2 (VO2peak), VO2 at anaerobic threshold (VO2AT)). We performed blood sampling to measure resting plasma level of insulin growth factor-1 (IGF-1) and serum high-sensitive C-reactive protein (hsCRP). LIKRT significantly increased leg press (15%), leg curl (18%) and leg extension (17%) 1-RM strength. Increases of muscle CSA in quadriceps femoris at the proximal lower leg (30%), the mid-thigh (50%), and the proximal lower leg (70%) were 5.1%, 4.6% and 10.4%, respectively. Similarly, hamstring and adductor CSA were also increased by LIKRT. LIKRT significantly increased VO2peak and VO2AT by 10.7% and 10.9%, respectively. IGF-1 and hsCRP were not altered before or after the training. These results suggest that LIKRT increases muscle strength/mass and endurance capacity in patients with IHD. LIKRT appears to be a promising and effective resistance method in cardiac rehabilitation.

Epithelioid hemangioendothelioma after radiotherapy for congenital hemangioma: a case report

A rare case of post-radiation epithelioid hemangioendothelioma arising in a congenital hemangioma of the lower leg 18 years after radiotherapy is reported. At 7 years of age, the patient underwent partial resection of a subcutaneous congenital hemangioma with intramuscular extension of the left lower leg, and at 10 years of age, the patient was given radiotherapy with a total dose of 30 Gy for recurrence. At 28 years of age, the patient noticed a large tumor mass with intractable pain at the antero-lateral aspect of the proximal lower leg, and she presented to our hospital. Since microscopic examination of a biopsy specimen showed epithelioid hemangioendothelioma, disarticulation at the knee joint was performed. Although malignant change in a benign vascular tumor is extremely rare, irradiation can induce malignant transformation of a hemangioma.

Der modifizierte erweiterte distal gestielte sapheno-fasziokutane Suralislappen: Klinische Ergebnisse

Summary An anatomical study was performed to develop a modified technique for an extended saphenofasciocutaneous sural flap for coverage of large combined soft tissue lesions at the lower leg and foot. Then a prospective clinical study was performed to investigate the clinical applicability of the new technique. From August 1999 to August 2002, 7 patients with 10 large combined soft tissue lesions with exposed tendon, bone and joint or compound infected wounds, with loss of bone and osteitis, were prospectively examined after an operative treatment using the extended saphenofasciocutaneous sural flap. All patients had a variety of additional risk factors or severe co-morbidity (traumatic ipsilateral vascular lesion of the major nutrient artery of the lower leg, ipsilateral deep vein thrombosis, diabetic polyneuro-pathy with arteriosclerotic vessels and severe occlusive vascular disease). The size of defect of the ten combined soft tissue lesions ranged from 80 to 180 cm2. The defects were located in the mid and hind foot and also the lower leg. A complete coverage of all defects was achieved in a single-stage procedure with a distally based modified saphenofasciocutaneous sural flap from the proximal lower leg. All flaps survived completely withhot any partial necrosis of the flap. The flap donor site was directly closed in 7 cases and a simultaneous skin graft was applied in 3 cases. All patients were repeatedly clinical examined and the mean duration of followup was 22 months. All flaps had complete success. Any secondary donor site morbidity was not registered. We did not observe formations of neuromas of the sural nerve. There was no need for secondary de-bulking. Venous congestion nor long lasting edema were not seen. All patients were satisfied with the functional and aesthetic results. The new flap provides many advantages. The flap is reliable for covering large defects even in a selection of patients with sub-stancial risk factors by preservation of the major arteries of the lower leg. The technique represents safe surgery, which can be performed at a single stage without microsurgery with an easy and quick dissection and with minimal morbidity of donor site.