Reconstruction of extensive plantar forefoot defects with free anterolateral thigh flap

PURPOSE

The aim of the soft tissue reconstruction of plantar forefoot should yield weight-bearing function and aesthetic contour, which poses a significant challenge for reconstructive surgeons to provide an appropriate flap according to the "like for like" reconstructive principle. Local flaps and pedicled flaps have been described for the reconstruction of small- to medium-sized defects of plantar forefoot and achieved optimal results. However, reconstruction of extensive defects of plantar forefoot is rarely investigated. In this study, we present our experience using the free anterolateral thigh (ALT) flap in the reconstruction of extensive defects of plantar forefoot.

METHODS

Between November 2011 and April 2017, 9 patients were treated for extensive soft tissue defects in the plantar forefoot areas with ALT flaps. The mean age at the time of surgery was 39.3 years (range, 25-64 years).

RESULTS

The follow-up period ranged from 12 to 77 months, with a mean of 31 months. All flaps survived well, and the patients were satisfied with the aesthetic and functional results. The size of the flaps ranged from 63 to 455 cm, with a mean of 197.7 cm. Seven patients with no bony involvement began to gradually weight-bear at 3 weeks postoperatively. During the follow-up time, postoperative ulceration at the reconstructed weight-bearing areas was not encountered.

CONCLUSION

The ALT flap is a reliable option for treatment of extensive defects of plantar forefoot, resulting in an optimal functional and aesthetic outcome. Even when a total plantar loss exits, excellent results can be achieved.

Lisfranc injury: A review and simplified treatment algorithm

BACKGROUND

Lisfranc injuries encompass large spectrum of injuries varying from low energy to high energy complex fracture dislocations. Whilst multiple complex classification systems exist; these do little to aid and direct the clinical management of patients. Therefore, this study aims to provide a simplified treatment algorithm allowing clinicians to standardise care of Lisfranc injuries.

METHODS

A comprehensive literature search was performed, and abstracts were reviewed to identify relevant literature.

RESULTS

Delay in diagnosis has a negative impact on outcome. If a Lisfranc injury is suspected and plain radiographs are inconclusive; computed tomography and if necessary magnetic resonance imaging are indicated if there is still an index of suspicion. In the absence of joint dislocation/subluxation management will be determined by stability which can be best assessed by weightbearing radiographs. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks followed by a period of graduated weight bearing. Evidence is mounting that with regard to unstable purely ligamentous Lisfranc injuries primary arthrodesis (PA) has: better functional outcomes, increased cost effectiveness and reduced rates of return to theatre. With regard to bony unstable Lisfranc injuries more research is required before a single treatment modality - PA or open reduction internal fixation can be advocated, due to the lack of randomized control trials and limited patient follow-up periods in existing studies.

CONCLUSION

A simplified treatment algorithm excluding the requirement for complex classifications is suggested. This may help with the diagnosis and management of these injuries. It is our believe that this algorithm will aid health professionals to standardize care for these injuries. Further prospective research trials are required to assess outcomes of different modalities of operative management, particularly with regards to open reduction and internal fixation versus primary arthrodesis for bony Lisfranc injuries.

LEVEL OF EVIDENCE

Level 5.

[Traumatic Turf-Toe: challenging diagnosis and controversial treatment]

INTRODUCTION

Turf-Toe includes a wide variety of traumatic injuries of the metatarsophalangeal joint of the first toe (MTF1). It is a potentially severe injury and there is no consensus for surgical management. The objective of this case report was to describe a patient with traumatic Turf-Toe injury grade III with a sesamoid fracture treated surgically.

CLINICAL CASE

24-year-old male with motorcycle fall with hyperflexion of the MTF1 joint, presented pain, edema and functional limitation; the radiographs showed soft tissue edema, lateral displacement of lateral sesamoid with fracture. Traumatic Turf-Toe was established. The ultrasound of the MTF1 joint showed breakage of the plantar plate and collateral ligaments. Patient was surgically managed with sesamoid reduction and plantar plate repair; postoperative evolution was satisfactory. At 8 weeks the patient was assessed with the AOFAS forefoot scale, obtaining 82 points, SF-12 with 87% and VAS of two and returned to his daily activities.

CONCLUSION

We describe a patient with traumatic Turf Toe grade III injury, not related to sports practice; first report in the literature of the use of ultrasound in the evaluation of patients with lesion of the metatarso-phalangic joint of the first toe.

Staged surgical treatment of open Lisfranc fracture dislocations using an adjustable bilateral external fixator: A retrospective review of 21 patients

OBJECTIVE

The aim of this study was to assess the early operative results of a staged progressive reduction technique using a bilateral external fixator in the treatment of patients with open Lisfranc fracture dislocations.

METHODS

In this retrospective study, 21 patients (5 women and 16 men; mean age=44.4 years; age range=24 to 69 years) with open Lisfranc fracture dislocations were included. All the patients were treated in a staged manner from 2012 to 2015. The mean follow-up was 15.4 months (range=12 to 24 months). A two-stage surgical protocol was performed for each patient. At the first stage, a bilateral spanning external fixator was applied across the injured Lisfranc joint, and the length of the disrupted columns was restored by distraction process. Vacuum-assisted closure was used if required. At the second stage, the external fixator was removed, and open reduction and internal fixation were carried out. The time interval between the first and second stages and postoperative complications were documented. To assess the functional status of the patients, the visual analog scale (VAS) and the American Orthopaedic Foot - Ankle Society (AOFAS) midfoot scale were measured at the final follow-up. Radiographic parameters indicating the alignment of the midfoot after the second operation were examined.

RESULTS

Deep infection in one patient and superficial infection in 2 patients were observed. Venous thrombosis was detected in 3 patients. The mean interval between the first and second stages was 18.6 days (range=8 to 48 days). The first metatarso-cuneiform step-off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) significantly improved at the final follow-up. The mean VAS score was 2.4 (range=0-5), and the mean AOFAS score was 76.3 (range=63 to 97). Primary arthrodesis was performed in seven patients, and six of the remaining 14 patients developed post-traumatic arthritis.

CONCLUSION

With a low risk of complications, the staged progressive reduction protocol using an adjustable bilateral external fixator can be an effective treatment to achieve and maintain anatomic reduction for patients with open Lisfranc fracture dislocations in a short-time follow-up.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Metatarsal Transfer Associated with Microsurgical Flap in Exposed Foot Fracture: A Case Report and 10-Year Follow-up

CASE

A 35-year-old female patient presented with an exposed forefoot fracture with bone and dermal loss after a vehicular accident. There was a bone defect at the level of the second toe and the third metatarsal. She was treated by second toe resection and second metatarsal transfer to augment the third metatarsal diaphysis ray (nonvascularized, without any soft-tissue envelope) and a microsurgical forearm flap.

CONCLUSION

As one option among the reconstruction techniques available for a metatarsal segmental defect, metatarsal transfer associated with a fasciocutaneous radial forearm flap proved to be effective in this patient.

Rare Mucor circinelloides and Fusarium infection in latissimus free flap reconstruction after devastating foot injury in non-neutropenic patient

Nowadays, free flap reconstruction in devastating lower limb trauma is a standard procedure in reconstructive surgery. The greatest factor directly affecting limb salvage is still the risk of infectious complications, whether local or systemic. Fungal wound infections are not among the most common infection complications in surgery, but their low incidence is compensated for by their fulminant and serious course, as well as severe local tissue destruction and strong angio-invasive potential together with the possibility of dissemination. In this case study, we present an example of a devastating lower leg injury, solved using latissimus free flap reconstruction, with subsequent difficult and prolonged healing, due to an invasive filamentous fungi infection. In the final part of the article, we focus briefly on the occurrence of similar cases in the literature.

"Locked-Lateral" Calcaneal Fracture-Dislocation Treated with Primary Subtalar Fusion: A Case Report

CASE REPORT

A 65-year-old man presented with pain in his left ankle. After a delay, he presented to the orthopaedic clinic where computed tomography scan revealed an intra-articular, locked-lateral calcaneal fracture with dislocation of the peroneal tendons.

CONCLUSIONS

This combination of injuries can produce subtle signs, such as an atypical double-density sign and varus talar tilt, on plain radiographs; however, the consequences of delayed treatment can be catastrophic. Early recognition and treatment are essential to avoid chronic pain and limited function.

Microvascular reconstructive techniques in orthopaedic traumatology

Great evolution has taken place in Orthopaedic Traumatology, regarding techniques, surgical means and equipment. However, we still encounter complicated cases of limb trauma that necessitate microvascular reconstruction. Through three different illustrative cases (one emergency foot revascularization by a free flap, covering an ankle arthrodesis and bridging the anterior tibial artery, one cure of a complex infected tibial non-union with extensive skeletal defect by double barrel fibular transfer and one osteo-chondral reconstruction of the scaphoid proximal pole using a vascularized graft harvested from the femoral medial condyle), the authors remind the Orthopaedic community about the benefits of microsurgery, especially if used in proper indication and timing. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology.

Reconstructive surgery for foot and ankle defects in pediatric patients: Comparison between anterolateral thigh perforator flaps and deep inferior epigastric perforator flaps

BACKGROUNDS

Due to the delicate tissue, small blood vessels and incomplete development of interarticular ligaments, skin and soft-tissue defects of the foot and ankle in pediatric patients remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap are the most commonly used flaps for the repair of lower-extremity soft-tissue defects. The literature contains a shortage of evidence involving the differences between ALTP and DIEP flaps in the reconstruction of young patients with complex foot and ankle defects. This study was designed to determine which type of flap is better for foot and ankle repair in pediatric patients.

METHODS

From January 2004 to January 2018, 79 children younger than 14 years treated with DIEP flap (41 cases) or ALTP flap (38 cases) for composite defects of the feet and ankles were retrospectively investigated. The two groups were homogeneous in terms of age, the location of the defect, etiology, and flap area. Complications, scarring, cosmetic appearance, flap sensory recovery, and functional outcome were analyzed, and statistical analysis was performed.

RESULTS

The ALTP group had shorter operation time (155.0 ± 12.0 min vs 212.2 ± 23.9 min), flap harvested time (39.6 ± 5.1 min vs 57.2 ± 10.4 min), and operative blood loss (143.4 ± 23.7 ml vs 170.7 ± 44.7 ml) than the DIEP group (P <  0.05). In short-term follow-up, ALTP group showed a lower flap necrosis rate (5.3% vs 24.4%) and vascular insufficiency rate (2.6% vs 19.5%) than DIEP group (P <  0.05). In long-term follow-up, ALTP group showed a lower late complication rate and better cosmetic, functional, scar outcomes than DIEP group (P <  0.05).

CONCLUSIONS

The study showed that an ALTP flap may brings better results than a DIEP flap in terms of short- and long-term complications, scarring, and morpho-functional outcomes for pediatric patients undergoing reconstruction of foot and ankle defects.

Closed Distal Dislocation of the Intermediate Cuneiform in a Complex Lisfranc Fracture-Dislocation: A Case Report

CASE

A 21-year-old, active duty male sustained an irreducible, complex Lisfranc fracture-dislocation with distal extrusion of his intermediate cuneiform. He was treated in a staged manner with external fixator placement, followed by an extended midfoot fusion with autograft bone. At 19 months, he could perform all activities of daily living independently with minimal pain using an Intrepid Dynamic Exoskeletal Orthosis.

CONCLUSIONS

Complex Lisfranc injuries are severe and often result in chronic pain and disability after operative management. To our knowledge, this is the only case report describing a Lisfranc fracture-dislocation with a distally extruded intermediate cuneiform treated with a fusion.

Stentoplasty of calcaneal fractures: Surgical technique and early outcomes

Calcaneus is the most common site of hindfoot fracture, frequently caused by fall from height or high energy trauma. The therapeutic strategy ranged from non-operative to ORIF (Open Reduction Internal Fixation). Indications for percutaneous fixation include soft tissue damage or relative contraindications to open surgery. Minimally invasive percutaneous calcaneoplasty should be an alternative to ORIF aiming to reach a stable reduction, early functional recovery and short hospital stay. The aim of our study was to evaluate the clinical and radiographic outcomes of calcaneus fractures treated with balloon calcaneoplasty (BCP) by using a new generation vertebral augmentation system, VBS™-Vertebral Body Stent-DePuy Synthes. A total of 10 patients treated with VBS™ system were recruited for the study. Nine fractures were caused by a fall from height and one case by traffic accident. The mean follow-up was 8.9 months (range 2.6-23.1). The fractures were categorized according to Sanders and Essex-Lopresti classifications (5: type II, 3: type III and 2: type IV; 9: "joint depression" type and 1 case "tongue" type). Radiographic measurement (Böhler's and Gissane's angles) were evaluated at both pre-operative and immediate postoperative time. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score as well as a subjective evaluation (Visual Analog Scale, VAS) were used for the clinical assessment at the last follow-up. Mean preoperative Böhler's angle was 12.3 ± 8.41° (95% CI 6.3-18.3°), whereas mean preoperative Gissane's angle was 123.66 ± 20.47° (95% CI 109.0-138.3°). At postoperative follow-up mean Böhler's angle increased to 21.51 ± 4.17° (95% CI 18.5-24.5°; p < 0.01), and mean postoperative Gissane's angle was 121.74°±6.82° (95% CI 116.8°-126.6°). Mean AOFAS at the last follow-up was 70.4 ± 17.44 (95% CI 57.9-82.8). Our study demonstrates that percutaneous calcaneoplasty using VBS™ is an effective treatment for calcaneus fracture and capable to implement correction manoeuvre with clinical and radiographic outcomes comparable with other percutaneous stentoplasty.

Retrograde dorsalis pedis angiosomal flow compromised by small puncture wound leading to transmetatarsal amputation

Pedal puncture wounds can precipitate a variety of complications, often resulting from a delay in treatment. Although the risk of infection predominates, direct vascular insult and subsequent ischemia is a lesser reported complication of these injuries. Consequently, this may have morbid results, especially on a background of pre-existing peripheral vascular disease. A case involving a small, plantar forefoot puncture wound, ultimately resulting in transmetatarsal amputation due to ischemic dry gangrene in an uncontrolled, but sensate, diabetic with profound vasculopathy is presented. This presentation highlights the importance of considering the potential for macrovascular damage via pedal puncture, and the potentially magnified complications in patients with dependent retrograde angiosomal flow and compromised collateral circulation. Based on a thorough analysis of the literature and the findings in this clinical example, a detailed investigation of angiosomal blood supply through direct and indirect vessel flow in patients with peripheral arterial disease incurring puncture wounds is advocated. In these patients, lack of compensatory avenues of the pedal circulation may portend significant tissue loss in an otherwise inoffensive situation. Knowledge of this complication, although rare, may prompt the clinician to assess for its potential, and emphasize a preference for direct revascularization in those with critical limb ischemia. Level of Clinical Evidence: 4.

Fractures and dislocations of the lisfranc tarso-metatarsal articulation: outcome related to timing and choice of treatment

A Lisfranc injury is when one or more of the metatarsals are displaced from the tarsus. The term is more commonly used to describe an injury to the midfoot, centred on the 2nd tarso-metatarsal joint. These fractures are sometimes easily overlooked, especially if they are part of a polytrauma. They are often difficult to diagnose and treat, but if they go undetected and are not properly treated, they can cause long-term or chronic disability. Our team reviewed a group of 71 patients with a Lisfranc fracture dislocation. The lesions were classified according to Meyerson classification. All the patients were re-evaluated 3 years after their surgeries by clinical examination, Ankle-Hindfoot Scale AOFAS questionnaire, X-rays and baropodometric analysis. This review outlines the treatment outcome of this injury, taking into consideration the timing of diagnosis.

High-Energy Midfoot Fracture-Dislocations: Staged Treatment With an External Fixator

The purpose of this study was to analyze the clinical outcomes of patients treated for high-energy midfoot (Lisfranc) injuries with initial temporization of an external fixator before definitive fixation. A retrospective chart review at two level 1 trauma centers was completed. Clinical parameters including demographics and comorbidities were evaluated in addition to hospital and clinical data. Time to full weight bearing took an average of 4.4 months, and with the numbers available no significant difference (p < .05) was found between the open reduction and internal fixation (ORIF) group and the arthrodesis group in regard to length of stay, days from initial reduction with an external fixator to definitive fixation, time to full weight bearing, or return to work. Staged treatment of high-energy Lisfranc injuries with external fixation demonstrated minimal soft tissue complications similar to other series reported in the literature. Definitive stabilization with either ORIF or arthrodesis produced similar results in staged treatment of these injuries. (Journal of Surgical Orthopaedic Advances 28(1):24-30, 2019).

Foot reconstruction with the superficial circumflex iliac artery perforator flap under local anesthesia: Two case reports

RATIONALE

The superficial circumflex iliac artery perforator (SCIP) free flap is a popular method used in foot reconstruction. Although the SCIP flap has a relatively short pedicle and does not require intramuscular dissection, general anesthesia is largely preferred for SCIP flap reconstruction. We report 2 cases with the free SCIP flap for skin and soft tissue reconstruction of the foot under local anesthesia.

PATIENT CONCERNS

Case 1 was a 34-year-old man sustained a crush injury to the dorsal foot, resulting in a soft tissue defect with bone and tendon exposure. Case 2 was a 41-year-old man with type 2 diabetes was referred to our division for an intractable ankle wound after surgery for a calcaneal bone fracture.

DIAGNOSIS

The diagnosis was intractable wounds on feet caused by trauma and surgery. Patients were unable to receive general anesthesia because of asthma or elevated liver enzymes.

INTERVENTIONS

Two patients with tissue defects on their feet were treated with SCIP flaps under local anesthesia. Fifteen milliliter of 0.5% bupivacaine was injected for ankle block. SCIP flaps were harvested after injecting 10 to 15 mL of 1% lidocaine combined with epinephrine around the flap incisions.

OUTCOMES

No complications related to the use of local anesthesia developed during the operation or postoperatively. Two flaps survived and fully took without complications.

LESSONS

With proper local anesthesia, successful foot reconstruction with a free SCIP flap was possible. This method can be considered a sufficient option for foot reconstruction for patients unable to receive general anesthesia.

Operative treatment algorithm for intra-articular calcaneal fractures

Displaced calcaneus fracture often results in severe permanent sequelae and considerably limits the activities of daily living. In this prospective cohort study we present the outcomes of surgical treatment of 137 displaced intra-articular calcaneal fractures, over 8y period. Follow-up data were obtained up to 3 years post-operatively. Post-operative function was assessed by scoring systems - Creighton-Nebraska Health Foundation Assessment Scale (C-N score) and Ankle-Hindfoot Scale AOFAS (A-H score) and radiographic assessment revealed the accuracy of the position. According to our experience we could advocate percutaneous reduction and screw fixation as the method of choice for Sanders type IIC tongue- type fractures and modified Palmer approach with screw alone, C-nail, K-wires or alternatively an open plate osteosynthesis in Sanders type IIAB depression fractures. For Sanders Type III fractures, we find ORIF with a plate as the most suitable method and an external fixation supplemented with K-wires for Sanders Type IV.

Fasciocutaneous flap with perforating branches of peroneal artery repairing soft tissue loss in anterior and middle parts of children's feet: A STROBE-compliant article

Repairing soft tissue loss in feet's anterior and middle parts has become a problem, especially for children. We observed the feasibility and clinical effects of superficial peroneal fasciocutaneous flap pedicled with terminal perforating branches of peroneal artery for repairing children's feet.Between January 2015 and December 2016, soft tissue loss in anterior and middle regions of feet were repaired using superficial peroneal fasciocutaneous flap pedicled with terminal perforating branches of peroneal artery in 8 children with a median age of 6.5 [4-9, interquartile range (IQR) = 3] years. The skin of lower leg was intact, and the soft tissue loss area was located in the anterior and middle regions of feet with a size of 5 cm × 4 cm to 11 cm × 7 cm combined with the exposure of tendons and joints in all the 8 children. On the basis of the conditions above, there were no indications of free skin grafting. Foot wounds were repaired all with the superficial peroneal fasciocutaneous flap pedicled with terminal perforating branches of peroneal artery (6 cm × 5 cm to 12 cm × 8 cm), and then the donor area was sutured to narrow the donor area followed by intermediate split thickness skin graft. The perforating branch trunk of peroneal artery was used as a rotation point (4 cm above the lateral malleolus) in 5 children and descending branch of perforating branch of peroneal artery as a rotation point (2 cm under the lateral malleolus) in 3 children.All flaps survived with primary healing in the 8 children. Postoperative median 7.5-month (3-12, IQR = 4.5) follow-up indicated that flap color and texture were fine, the appearances of donor and recipient areas were satisfactory, wearing shoes was not affected, and walking function and foot blood circulation were normal.For intractable soft tissue loss in the anterior and middle regions of children's feet, superficial peroneal fasciocutaneous flap pedicled with terminal perforating branches of peroneal artery can improve recipient area appearance and walking function because it has the characteristics of reliable blood supply and convenient rotation. It is worth using this method widely in clinics.

Importance of assistant intra-operative medial distraction technique for intraarticular calcaneus fractures

To report the clinical efficacy of open reduction and internal fixation (ORIF) assisted by medial distraction for intra-articular calcaneus fractures. From September 2010 to November 2013, 151 patients with intra-articular calcaneus fractures were treated at our department by ORIF. They were 95 men and 56 women, 18 to 69 years of age. According to the Sanders classification, there were 24 cases of type II, 76 ones of type III and 51 ones of type IV. Medial distraction was used in 27 cases but not in 124 ones. The 2 groups were compatible, without significant differences in preoperative general data (p > 0.05). The two groups were compared in intraoperative indexes and follow-up radiological data. The mean duration of surgery in the distraction group (71.6 ± 18.3 minutes) was significantly shorter than that in the non-distraction group (80.4±20.7 minutes), and the varus angle in the distraction group (5.3° ± 4.4°) was significantly smaller than that in the non-distraction group (10.6° ± 6.5°) (p < 0.05). There were no significant differences between the 2 groups in intraoperative bleeding, postoperative drainage, hospital stay, bone union time, follow-up duration, American Orthopaedic Foot & Ankle Society score, Böhler angle, Gissane angle, calcaneal axis, calcaneal horizontal length, tuberosity height, hillock calcaneal height, calcaneal width, or talar inclination angle (p > 0.05). ORIF assisted by medial distraction technique is effective for intra-articular calcaneal fractures, especially in correcting the calcaneal axis.

Pitch Ointment: Applications in Scar and Wound Management

There is a high incidence of household knife-related injuries requiring emergency department treatment in the U.S. The Pitch Ointment, a named formula developed by a compounding pharmacist, was used separately by two patients who suffered a knife injury in a finger and a foot. This formula combines Pinene (L-Alpha) 0.5% and Canada Balsam 5% in PracaSil-Plus, special ingredients with applications in scar and wound healing. The patients' level of satisfaction with the Pitch Ointment was very high since all 4 treatment satisfaction domains by the Treatment Satisfaction Questionnaire for Medication (effectiveness, side effects, convenience, global satisfaction) were rated over 85. These results are consistent with the clinical improvements observed in the before and after treatment photographs. The success of these case reports is evidence to suggest that the Pitch Ointment may be recommended by compounding pharmacists as a viable treatment option in scar and wound management.

Outcomes of using a modified anteromedial thigh perforator flap for repairing the anterolateral thigh free flap donor site: A retrospective clinical review

The anterolateral thigh (ALT) flap plays an essential part in plastic and reconstructive surgery. However, repair of the anterolateral donor site has not been the focus of the clinicians.To assess the clinical value and feasibility of using a modified anteromedial thigh (AMT) perforator flap for repairing the ALT free flap donor site.In this retrospective study, 16 ALT flaps were transferred to resurface large soft-tissue defects (ranged from 7 × 5 to 13 × 8 cm) in the foot or hand from June 2012 to March 2013. The donor sites were repaired with an advancement flap pedicled with an AMT perforator. Sensation within the advancement flap, return-to-work (RTW) time, the aesthetic appearance of the donor sites, and functional recovery were measured.All 15 flaps survived completely without necrosis. One flap developed partial necrosis in the tip but healed with dressing changes after 1 week. The medain follow-up period was 3.5 months (range, 3-6 months). The average median time was 9.5 weeks (range 8-13 weeks). There was no numbness of the advancement flap. Additionally, there was no specific complication at both the recipient and donor sites. Thigh quadriceps muscle strength and activities of the knee were normal. All patients were satisfied with the aesthetic outcome postoperatively at the 3-month to 6-month follow-up.The modified advancement flap pedicled with an AMT perforator is an ideal option for repairing the anterolateral donor site.

Lesser Metatarsophalangeal Joint Instability: Advancements in Plantar Plate Reconstruction

The plantar plate and associated collateral ligaments are the main stabilizers of each of the lesser metatarsophalangeal joints. Although clinical examination and plain radiographs are usually sufficient to establish the diagnosis of a plantar plate tear, MRI or fluoroscopic arthrograms may help in specific cases. Recent results with a dorsal approach to plantar plate repair are promising with respect to pain relief and patient satisfaction.

Peroneus brevis tendon in proximal 5th metatarsal fractures: Anatomical considerations for safe hook plate placement

INTRODUCTION

The peroneus brevis tendon (PBT) inserts into the proximal aspect of the 5th metatarsal. Metatarsal bone fractures are encountered to be the most common fractures in the foot with predominantly fractures at the base of the fifth metatarsal bone. Mechanism of injury and treatment of the proximal 5th metatarsal fractures vary due to the complex anatomy and diverse biomechanical properties. The purpose of this study was to analyze the footprint of the PBT with regards to the proximal 5th metatarsal fractures and to define a "safe zone" for hook plate placement.

MATERIALS AND METHODS

Forty-one (41) fixed human lower leg specimens were dissected to expose the PBT insertion. The following footprint characteristics were evaluated: area of insertion (AOI) (mm²), length (mm), width (mm), shape and insertional variations. The position of the main PBT footprint was localized according to the Lawrence and Botte classification for the proximal 5th metatarsal fractures (Zone I-III). A "safe zone" was defined for the fracture-specific hook plate placement.

RESULTS

In 25 (61%) feet the PBT footprint was situated in Zone I and in 16 feet (39%) in Zone I&II. The mean AOI, length and width measured 54.5 mm² (SD 16.5), 16.0 mm (SD 5.1) and 4.7 mm (SD 1.4), respectively. Analysis of the footprint shapes revealed four different shape types: kidney (29.3%), diamond (22.0%), crescent (31.7%) and oval (17.0%). A "safe zone" for hook plate placement without or minimal interference of the PBT at its insertion could be defined at the lateral aspect of the 5th metatarsal.

CONCLUSION

The majority of the PBT footprints were found in Zone I. Hook plate placement demonstrated to be safe when placed strictly laterally at the proximal aspect of the 5th metatarsal. Precise knowledge of the peroneus brevis anatomy may help to better understand the biomechanical aspects of the proximal 5th metatarsal fractures.

Laparoscopy-assisted Chimeric Peritoneal-deep Inferior Epigastric Perforator Flap for Reconstruction of Hand and Foot

Management of hand and foot defects with exposed tendons is a big challenge for plastic surgeons. Thin vascularized tissue offers an ideal surface for tendon excursion.

OBJECTIVE

This study examines the reconstructive benefits of a laparoscopy-assisted chimeric peritoneal-deep inferior epigastric artery perforator (DIEP) flap in the treatment of hand and foot injury defects.

MATERIALS AND METHODS

A retrospective review was performed on 8 patients (6 men, 2 women) that received hand or foot reconstruction with laparoscopy-assisted chimeric peritoneal-DIEP flap. Soft tissue defects of the hand or foot ranged from 16 cm x 10 cm to 22 cm x 14 cm. The peritoneum supplied by the peritoneal branches of the deep inferior epigastric artery was retrieved by laparoscopy to cover exposed extensor tendons, while the DIEP flap consisted of the cutaneous component part of this chimeric flap.

RESULTS

The flaps survived in 7 of 8 patients. Partial necrosis of the chimeric flap was observed in 1 patient due to venous thrombosis. A split-thickness skin graft then was performed to achieve wound closure on that patient. Motor and sensory functions of these 8 patients improved gradually within the first-year follow-up.

CONCLUSIONS

The laparoscopy-assisted chimeric peritoneal-DIEP flap is useful for reconstructing defects of the hand and foot with exposed tendons.