Reconstr Microsurg Research Articles

Left cervical swelling due to lymphatic intraluminal obstruction.

A 42-year-old woman had presented to the outpatient clinic because of a swelling of the left cervical region. Her medical history was remarkable for multiyear episodes of recurrent cervical swelling with abdominal pain that always regressed spontaneously. The physical examination showed a soft nontender mass in the left supraclavicular fossa without pain or skin redness (A). Magnetic resonance lymphography (B) without contrast injection showed a marked dilation of the thoracic duct (arrowhead). We also visualized a dilation of the cervical lymphatic duct network (long arrow). The terminal part of the thoracic duct showed a segmental dilation ≤13 mm with visualization of lymphatic intraluminal obstruction (LIO; short arrows). Ultrasound examination (C) focused on this area confirmed the LIO of the terminal portion of the thoracic duct. No other lymphatic or vascular malformations were demonstrated by thoracoabdominal computed tomography or magnetic resonance imaging. One week later, the patient had recovered uneventfully with complete resorption of the cervical swelling. Because the cervical swelling had spontaneously resolved, surgery was not considered.1Veziant J. Sakka L. Galvaing G. Tardy M.M. Cassagnes L. Filaire M. Lymphovenous anastomosis for recurrent swelling syndrome and chylous effusion due to cervical thoracic duct cyst.J Vasc Surg. 2015; 62: 1068-1070Google Scholar A supraclavicular mass can arise from infectious disease, a branchial clef cyst, or a benign or malignant tumor. LIO of the thoracic duct is a rare condition that can cause recurrent swelling of the cervical region.2Kunze G. Staritz M. Lymph vessel thrombus detection in cervical lymphedema: a case series.J Ultrasound Med. 2017; 36: 1955-1960Google Scholar Magnetic resonance lymphography without contrast media injection allows for easy visualization of the lymphatic duct network and can directly demonstrate the LIO without the need to inject contrast media.3Cholet C. Delalandre C. Monnier-Cholley L. Le Pimpec-Barthes F. El Mouhadi S. Arrivé L. Nontraumatic chylothorax: nonenhanced MR lymphography.Radiographics. 2020; 40: 1554-1573Google Scholar,4Arrivé L. Derhy S. El Mouhadi S. Monnier-Cholley L. Menu Y. Becker C. Noncontrast magnetic resonance lymphography.J Reconstr Microsurg. 2016; 32: 80-86Google Scholar The patient gave her written informed consent for the report of her case details and imaging studies.

How Do We Raise the Bar in Autologous Breast Reconstruction? The Use of Progressive Tension Sutures for Donor Site Closure

BACKGROUND: The abdomen is the most common location from which tissue is harvested for autologous breast reconstruction.1 The evolution from musculocutaneous flaps to muscle-sparring perforators flaps has decreased donor site complications such as abdominal bulge and hernia; however, complications remain. The development of progressive tension suture placement for donor site closure has the potential to decrease complications and increase the esthetics of the abdomen after breast reconstruction.2 PURPOSE: To present our institutional experience using progressive tension sutures for a tensionless closure of the donor site to improve outcomes and optimize abdominal donor site esthetics. METHODS: A retrospective cohort study was conducted over a 2-year period. Sixty-six consecutive patients who underwent abdominally based autologous breast reconstruction were divided into an experimental group (36 patients), in which the donor site was closed using progressive tension sutures, and a control group (31 patients), in which the donor site was closed without the use of this technique. A comparison between both groups was conducted in terms of demographic characteristics, perioperative variables, and donor site–related postoperative complications. RESULTS: No significant differences were found between the 2 groups in terms of demographic characteristics including age, body mass index, smoking status, comorbidities, and previous abdominal surgery (P > 0.05). No significant differences were noted with respect to unilateral versus bilateral donor sites, operative times, and length of hospital stay (P > 0.05). With regard to donor site complications, the wound dehiscence rate was significantly higher for the control group (27.8% versus 6.5; P = 0.023). No differences were noted in terms of infection, seroma formation, hematoma formation, abdominal bulge, or abdominal hernia rates between the 2 groups. CONCLUSION: In the cohorts of patients analyzed, the use of a tensionless technique for the closure of the donor site after an abdominally based autologous breast reconstruction decreased the rates of donor site wound dehiscence. Seroma and hematoma formation rates remained the same across both groups. REFERENCES: 1. Agarwal J, Tatro E, Kwok A, et al. Immediate unilateral breast reconstruction using abdominally based flaps: analysis of 3,310 cases. J Reconstr Microsurg. 2018. 2. Lee BT, Agarwal JP, Ascherman JA, et al. Evidence-based clinical practice guideline: autologous breast reconstruction with DIEP or pedicled TRAM abdominal flaps. Plast Reconstr Surg. 2017;140:651e–664e.

Second Commentary on "Partial Wrist Denervation: The Evidence Behind a Small Fix for Big Problems".

Second Commentary on "Partial Wrist Denervation: The Evidence Behind a Small Fix for Big Problems".

Abstract: A Study on the Length of Flap in the Thigh for Abdominal Wall Reconstruction

INTRODUCTION: A pedicled or free tissue thigh flap has been used for large abdominal wall defect reconstruction.1, 2 Anterolateral thigh flaps, tensor fascia lata musculocutaneous flaps, and their combination are reliable and are often used.3, 4 Despite the reported efficacy, it is unclear how large an abdominal defect can be closed with a single thigh flap. The objective of this study was to compare the length of the abdomen and thigh, and to determine whether a thigh flap is suitable for all abdominal wall reconstruction procedures. METHODS: A total of 100 adult Japanese subjects (men: 50, women: 50) with no medical history of musculoskeletal disease or injury were recruited. The length from the xiphoid process to the pubic tubercle was defined as the length of the abdomen (AL). The length of the thigh (TL) was defined as the distance from the anterior superior iliac spine to the upper lateral edge of the ipsilateral patella. The height of each subject and the difference between the TL and AL (TL – AL) were recorded. Statistical analysis was performed. RESULTS: The average age was 42.6 years in men and 41.8 years in women. The average height and standard deviation was 172.65 ± 6.53 cm in men and 158.00 ± 5.14 cm in women. The averages and standard deviations of the TL, AL, and TL – AL were 45.26 ± 3.20 cm, 32.70 ± 2.78 cm, and 12.57 ± 3.73 cm in men, and 40..82 ± 1.68 cm, 32.69 ± 2.93 cm, and 7.91 ± 3.17 cm in women, respectively. The height showed no correlation with AL in female subjects. AL showed no correlation between the male and female subjects. A height of less than 170 cm in males showed a clear correlation with TL – AL. CONCLUSION: Since the TL was larger than the AL in all subjects, a thigh flap is suitable for abdominal wall reconstruction in most cases. AL was consistent according to height in female subjects. In female and male subjects less than 170 cm in height, the thigh flap may be too short for abdominal wall reconstruction. Reference Citations: 1. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg. 1999; 103: 1191–1197. 2. Williams JK, Carlson GW, Howell RL, Wagner JD. The tensor fascia lata free flap in abdominal-wall reconstruction. J Reconstr Microsurg. 1997; 13: 83–90. 3. Lv Y, Cao D, Guo F, Qian Y. Abdominal wall reconstruction using a combination of free tensor fasciae lata and anterolateral thigh myocutaneous flap: a prospective study in 16 patients. Am J Surg. 2015; 210: 365–373. 4. Sasaki K, Nozaki K, Nakazawa H, Kukuchi Y. Reconstruction of a large abdominal wall defect using combined free tensor fasciae lata musculocutaneous flap and anterolateral thigh flap. Plast Reconstr Surg. 1998; 102: 2244–2252.

Author Reply

Since 1-stage phallic reconstruction using the radial forearm free flap was reported in 1984 by Chang and Hwang 1 Chang T.S. Hwang W.Y. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984; 74: 251-258 Crossref PubMed Scopus (323) Google Scholar and Kao et al, 2 Kao X.S. Kao J.H. Ho C.L. Yang Z.N. Shi H.R. One-stage reconstruction of the penis with free skin flap: report of three cases. J Reconstr Microsurg. 1984; 1: 149 Crossref PubMed Scopus (30) Google Scholar the radial forearm free flap has become the most frequently used flap in penile reconstruction. Massanyi et al reported positive results using this technique in patients with exstrophy. 3 Massanyi E.Z. Gupta A. Goel S. et al. Radial forearm free flap phalloplasty for penile inadequacy in patients with exstrophy. J Urol. 2013; 190: 1577-1582 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The technique of phallic reconstruction using radial forearm free flap is universally considered the standard technique for penile reconstruction. 4 Hage J.J. Bout C.A. Bloem J.J. Megens J.A. Phalloplasty in female-to-male transsexuals: what do our patients ask for?. Ann Plast Surg. 1993; 30: 323-326 Crossref PubMed Scopus (85) Google Scholar , 5 Fang R.H. Kao Y.S. Ma S. Lin J.T. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999; 52: 217-222 Abstract Full Text PDF PubMed Scopus (100) Google Scholar , 6 Monstrey S. Hoebeke P. Dhont M. et al. Radial forearm phalloplasty: a review of 81 cases. Eur J Plast Surg. 2005; 28: 206-212 Crossref Scopus (59) Google Scholar , 7 Monstrey S. Hoebeke P. Selvaggi G. et al. Penile reconstruction: is the radial forearm really the standard technique?. Plast Reconstr Surg. 2009; 124: 510-518 Crossref PubMed Scopus (191) Google Scholar

Abstract: Principles and Algorithm for the Microsurgical Treatment of Unstable Keloids on the Trunk after Burn Injury

INTRODUCTION: Unstable keloids are one of the most frustrating clinical problems in wound healing and the pathogeneses remains largely unknown.1 To date, little is known in the literature about the microsurgical management of unstable and middle-sized keloids on the trunk, and a clear consensus is lacking.2 Perforator flaps are thin and pliable, have a robust blood supply, potentially release the scar-site tension effectively and may provide an outcome with well-matched color, thickness, and texture.3,4 In this study, we provide a versatile algorithm by using various pedicled and free perforator flaps for the treatment of keloids on the trunk. MATERIALS AND METHODS: Patients with a history of multiple treatments of middle-sized keloids on various regions of the trunk were included. Color Doppler ultrasound (CDU) and multidetector-row computed tomographic angiography (MDCTA) were performed preoperatively. Depending on the location of the keloid, the following flaps were used: superficial circumflex iliac artery perforator (SCIP) flap, internal mammary artery perforator (IMAP) flap, superior epigastric artery perforator (SEAP) flap, anterior intercostal artery perforator (AICAP) flap, deep inferior epigastric artery perforator (DIEP) flap and anterolateral thigh (ALT) flap. RESULTS: Between June 2013 to June 2015, 29 patients (15 male and 14 females) with a mean age of 41 ± 15years were treated. Totally, we performed 5 free SCIP flaps, 2 pedicled SCIP flaps, 8 IMAP flaps, 6 SEAP flaps, 3 AICAP flaps, 4 DIEP flaps and 1 ALT flap. The mean flap size was 83 ± 36cm2 and the mean flap thickness was 14.8 ± 5mm. One partial distal necrosis occurred after a pedicled AICAP reconstruction, which healed conservatively. After a mean follow-up of 5 ± 3months, all surviving flaps showed excellent thickness, texture and color match. Importantly, there was no need for secondary debulking surgery. The donor site healed well after primary closure in all patients. CONCLUSION: We successfully applied various free and pedicled perforator flaps for the treatment of unstable keloids on the trunk. Based on our experience, we provide a useful and reliable algorithm in order to achieve the best possible outcome. No disclosures REFERENCES: 1. Ogawa R, Chin MS. Animal models of keloids and hypertrophic scars. J Burn Care Res 2008;29(6):1016–1017 2. Wang J, Min P, Grassetti L, et al. Preliminary Outcomes of Distal IMAP and SEAP Flaps for the Treatment of Unstable Keloids Subject to Recurrent Inflammation and Infections in the Lower Sternal and Upper Abdominal Areas. J Reconstr Microsurg 2015 3. Hong JP, Choi DH, Suh H, et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014;30(7):491–496 4. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42(6):645–648

Abstract: The Neighboring Flap Theory: A New Idea for Defect Closure Achieving Both Reducing the Defect and Confirmed Primary Donor Closure

INTRODUCTION: Covering a large defect with minimal donor site morbidity is a challenging task in reconstructive surgery. Recent advances in perforator flaps provides further alternatives. The research for angiosome or perforasome distinguishes the maximum size of each flap.1 The maximum size with direct donor site closure is determined by its position and has individual variation. The size of flap is, of course, measured from the size of the defect. The flap size tends to be slightly larger than the defect to avoid tension on the flap after suture. MATERIALS AND METHODS: Our new idea, flap elevation from adjacent area, enables making the defect smaller and simple in calculating the largest size of flaps. Preoperatively the perforators for flap around the defect should be detected. The pedicle of the flap should be inside the defect. The ligation test is done on the edge of the defect in the direction of the pedicle, and the maximum distance of these ligation points is the flap breadth. The length is decided as needed. RESULTS: From April 2012 to February 2016, 8 malignant tumor excision cases were treated with this method. Among them, 3 cases were anterolateral thigh flaps (ALT) or tensor fasciae latae musculocutaneous flap for inguinal to lateral buttocks. 3 cases were anterior chest wall reconstructions by vertical rectus abdominis musculocutaneous (VRAM) flaps or thoracoacromial perforator flap. 2 cases were latissimus dorsi musculocutaneous flaps (LD) for back. In one of VRAM cases, the 35x15cm size skin paddle was divided into 2 pieces to cover 25x21cm defect. None of the flaps failed. All the donor sites were closed directly. CONCLUSION: There are many studies about reduction in the donor site morbidity.2,3 Especially for large flaps, reducing the width by dividing the skin paddle or combined flap enables direct closure of the donor sites.4,5 To reduce the defect, partial direct closure is useful, but results in big dog ear. Our method enables two advantages by taking the flap from the neighboring area intentionally, because the dog ear is used as flap. If the breadth is less than the defect size, dividing the flap into some pieces is useful especially for LD, VRAM, and ALT. REFERENCES: 1. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998;102(3):599–616. 2. Arnez ZM, Khan U, Pogorelec D, Planinsek F. Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br J Plast Surg. 1999;52(5):351–4. 3. Hekner DD, Abbink JH, Van es RJ, Rosenberg A, Koole R, Van cann EM. Donor-site morbidity of the radial forearm free flap versus the ulnar forearm free flap. Plast Reconstr Surg. 2013;132(2):387–93. 4. Sawaizumi M, Maruyama Y, Kawaguchi N. Vertical double flap design for repair of wide defects of the lower limb, using combined ascending scapular and latissimus dorsi flaps. J Reconstr Microsurg. 1995;11(6):407–14. 5. Sawaizumi M, Maruyama Y. Sliding shape-designed latissimus dorsi flap. Ann Plast Surg. 1997;38(1):41–5.

Abstract: Intermittent Irrigation of the Microvascular Anastomosis Site During the Critical First 72 Hours

INTRODUCTION: Although up to 99 percent of free tissue transfers are eventually successful, the rate of reexploration necessary to achieve this is still high despite advances in technique and monitoring.1 We explore the benefits of intermittent postoperative irrigation of the microvascular anastomosis site with lidocaine. PURPOSE: To share our experience with a simple, safe and effective technique that can be easily adopted at minimal cost. RATIONALE: Blood, vascular manipulation, stretching, hypothermia, vasopressors, increased catecholamine states are some of the local and systemic factors that can lead to vasospasm of both artery and vein. While up to 94 percent of plastic surgeons use an intraoperative vasodilator to counteract this, little has been reported on postoperative use of vasodilators.2,3,4 The vasospasm-inducing noxious stimuli may persist in this period and lead to a cascade of events culminating in flap compromise. Studies have shown that the first 72 hours are the critical period during which overwhelming majority of compromised flaps are recognized.5 TECHNIQUE: The cut end of an intravenous catheter tube is placed in close proximity to the anastomosis avoiding direct contact. The other end of the tube is brought out through the wound edge, fixed to the skin with non-absorbable suture and connected to a 10-milliliter syringe filled with one percent lidocaine. The nurse infuses slowly one milliliter every hour amounting to a total of 240 mg of lidocaine per day. The catheter is removed after 72 hours. RESULTS: The senior author has used this technique in 3698 cases (50 percent of which involved lower extremity reconstruction) over the past 25 years. The 6.6 percent rate of re-exploration corroborates with published literature. None of the cases requiring reexploration demonstrated any evidence of vasospasm. Decreased pain and opioid requirements was an expected favorable outcome. However, an unexpected benefit noted early in the series was the cleansing effect of the gentle irrigation, removing small collections of blood, exudate or saliva from the vicinity of the anastomosis site. No inadvertent disruption of the anastomosis, increased bleeding or systemic sign of lidocaine toxicity was identified. CONCLUSION: A simple intraoperative measure can not only minimize the risk of a potentially disastrous vasospasm, but also provide the additional benefits of better pain control and clean microvascular anastomosis site. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119:2092–100. 2. Yu JT, Patel AJ, Malata CM. The use of topical vasodilators in microvascular surgery. J Plast Reconstr Aesthet Surg. 2011;64:226–8. 3. Yokoyama T, Tosa Y, Kadomatsu K, Sato K, Hosaka Y. A novel approach for preventing the development of persistent vasospasms after microsurgery for the extremities: intermittent topical lidocaine application. J Reconstr Microsurg. 2010;26:79–85. 4. Gu YD, Yuan W, Gong XY.Value of irrigation with a lidocaine solution in tissue transplantation. Zhonghua Wai Ke Za Zhi. 1987;25:215–7, 253. Chinese. 5. Chen KT, Mardini S, Chuang DC, Lin CH, Cheng MH, Lin YT, Huang WC, Tsao CK, Wei FC. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg. 2007;120:187–95.

Erratum to: Anesthesia Duration as an Independent Risk Factor for Postoperative Complications in Free Flap Surgery: A Review of 1,305 Surgical Cases. J Reconstr Microsurg 2014;30(4):217–226

Erratum to: Anesthesia Duration as an Independent Risk Factor for Postoperative Complications in Free Flap Surgery: A Review of 1,305 Surgical Cases. J Reconstr Microsurg 2014;30(4):217–226

Erratum to: Acquired Traumatic Arteriovenous Fistula of the Long Finger. J Reconstr Microsurg 2014 (epub ahead of print)

Erratum to: Acquired Traumatic Arteriovenous Fistula of the Long Finger. J Reconstr Microsurg 2014 (epub ahead of print)

On “Perioperative Antibiotics in the Setting of Microvascular Free Tissue Transfer: Current Practices” (J Reconstr Microsurg 2010;26(6):401–407)

On “Perioperative Antibiotics in the Setting of Microvascular Free Tissue Transfer: Current Practices” (J Reconstr Microsurg 2010;26(6):401–407)

Invited commentary

This article presents an important conclusion as a guideline for the reconstruction of circumferential pharyngeal defects. The healing between skin and mucosa is slower than that between mucosa and mucosa (or skin–skin). The functional results of swallowing are also better with intestinal flaps. However, when a plastic surgeon is facing a large defect of pharyngo-oesophagus, he probably chooses skin flaps which are more familiar to him. As pointed out by the authors, the rates of leakage and fistula as well as later stricture are much higher in the groups of skin flaps (pectoralis major (PM) and anterolateral thigh (ALT)). Currently, PM and ALT flaps are acceptable methods for reconstruction of these defects. However, the authors point out that the jejunal flap is a better choice, which is correct but is not used by many surgeons. After this article, more plastic surgeons would be encouraged to select the jejunal flap, which is of course better for the patients. 1 Yu P. Lewin J.S. Reese G.P. et al. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh flap versus the jejunal flap. Plast Reconstr Surg. 2006; 117: 968-974 Crossref PubMed Scopus (118) Google Scholar , 2 Nakatsuka T. Harii K. Asato H. et al. Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection. J Reconstr Microsurg. 2003; 19: 364-368 Crossref Google Scholar

On “Successful Management of Foot Drop by Nerve Transfers to the Deep Peroneal Nerve” (J Reconstr Microsurg 2008;24:419–428)

We read with great interest the original paper by Nath et al entitled “Successful Management of Foot Drop by Nerve Transfers to the Deep Peroneal Nerve.” The authors describe the transfer of nerve fascicles of either the superficial peroneal nerve or the tibial nerve to reinnervate deep peroneal nerve innervated muscle groups in patients with peroneal nerve injuries.

Ectopic scalp replantation: A case report

Temporary ectopic implantation with secondary replantation at the anatomic site is useful in salvage of extremities or organs [Godina M, Bajec J, Baraga A. Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 1986;78: 295-99; Chernofsky MA, Sauer PF. Temporary ectopic implantation. J Hand Surg [Am] 1990;15:910-14; Matloub HS, Yousif NJ, Sanger JR. Temporary ectopic implantation of an amputated penis. Plast Reconstr Surg 1994;93:408-12; Hallock GG. Transient single-digit ectopic implantation. J Reconstr Microsurg 1992;8:309-11; Graf P, Groner R, Horrl W. Temporary ectopic implantation for salvage of amputated digits. Br J Plast Surg 1996;47:174-77; Yousif NJ, Dzwierzynski WW, Anderson RC, et al. Complications and salvage of an ectopically replanted thumb. Plast Reconstr Surg 1996;97:637-40; Wang J-N, Tong Z-H, Zhang T-H, et al. Salvage of amputated upper extremities with temporary ectopic implantation followed by replantation at a second stage. J Reconstr Microsurg 2006;22:15-20]. Temporary ectopic implantation is usually considered due to poor conditions for replantation at the anatomic site. We report a case of near-total scalp avulsion treated by temporary implantation to the lower abdomen with secondary replantation.

On “Maximizing the Reliability and Safety of the Distally Based Sural Artery Flap (J Reconstr Microsurg 2008;24:589–594)”

On “Maximizing the Reliability and Safety of the Distally Based Sural Artery Flap (J Reconstr Microsurg 2008;24:589–594)”

On “Analysis of Flow Changes to the Foot after Sacrifice of One of the Major Arteries (J Reconstr Microsurg 2009;25:35–39)”

On “Analysis of Flow Changes to the Foot after Sacrifice of One of the Major Arteries (J Reconstr Microsurg 2009;25:35–39)”

Response to Letter to the Editor Regarding “Patency of Radial Arteries Reconstructed after Radial Forearm Flap Harvest (J Reconstr Microsurg 2007;23:347–350)”

We appreciate the opportunity to respond to the correspondence of Drs. Knobloch and Vogt regarding our article.[1]

On “Patency of Radial Arteries Reconstructed after Radial Forearm Flap Harvest (J Reconstr Microsurg 2007;23:347–350)”

We read with great interest the recent article by Dr. Kiehn and coworkers[1] reporting their patency rates following reconstructed radial arteries after radial forearm flap harvesting. We would appreciate a comment on some questions raised by their research.

Response to Letter to the Editor Regarding “Noninvasive Tissue Oximetry for Flap Monitoring: An Initial Study (J Reconstr Microsurg 2007;23:189–197)”

Response to Letter to the Editor Regarding “Noninvasive Tissue Oximetry for Flap Monitoring: An Initial Study (J Reconstr Microsurg 2007;23:189–197)”

Car tire injuries: a review of 35 patients

During the period from October 2001 to March 2007 (66 months), 35 patients, all pedestrians, were treated at the King Khalid Civil Hospital, Tabuk, Saudi Arabia for injury to the foot and ankle due to road traffic accidents. The injuries share common features and are grouped in a distinct entity known as "car tire injuries". The victim is always a pedestrian, usually a child, who while trying to escape from the car, gets his foot caught undl der the car tire when the driver is trying to stop the car. The resultant injuries are usually severe due to a combination of friction burns, crushing, shearing, and degloving. Language: en