ObjectiveTo introduce the operative technique of pedicle evolution from isolated perforator to perforator-plus-adipofascial,and investigate its clinical results in venous drainage and safety in distallybased sural flaps.MethodsAfter identifying the proper viable perforators,the whole flap was designed in an eccentric propeller shape,with the perforating vessels corresponding to the pivot point.The proximal larger blade was a fasciocutaneous flap, while the distal smaller blade was a subdermal vascular plexus flap,preserving at least a quarter area of adipofascial tissue around the perforator.From January 2008 to December 2010,we performed distally perforator-adipofascial pedicled sural fasciocutaneous propeller flap in 12 patients,with 180 degrees rotation to cover foot and ankle defects.Postoperatively,flap swelling,survival and functional recovery were evaluated. Results There were 7 posterior tibial artery perforator flaps from the posteromedial and 5 peroneal artery perforator flaps from the posterolateral sural region. The proximal fasciocutaneous flap measured 4 cm × 8 cm-6 cm × 18cm, and the distal cutaneous flaps measured 2 cm × 2cm-4 cm × 4 cm.Flap swelling was noted under grade 2 in 9 cases,grade 3 in 2 cases,and grade 4 in 1case with some distal superficial skin necrosis,which occurred in the largest flap in our series.All flaps survived eventfully.After average 13 months follow up,the wound were cured successfully,and all patients recovered walking and shoe wearing function. ConclusionPedicle evolution by keeping some adipofascial tissue around the pivot perforator, can preserve more venous return routes and relieve flap swelling. This technique should be recommended in perforator pedicled propeller flaps,as it enhances flap safety,and without increasing the difficulty of 180 degrees rotation.

Objective To assay the clinical effect of proximal dorsal digital artery pedicled island flap in treatment and sensory reconstruction of adjacent finger soft-tissue defect.Methods The study enrolled 21 cases of soft-tissue defect in 21 fingers treated from January 2013 to January 2014.All the defects were covered with the proximal dorsal artery pedicled island flaps raised from the adjacent finger.Index finger was injured in 7 patients,middle finger in 9 patients,ring finger in 4 patients,and little finger in 4 patients.Defect and flap dimensions varied from 1.9 cm × 1.5 cm to 4.3 cm × 2.3 cm and from 2.0 cm × 1.7 cm to 4.5 cm × 2.5 cm respectively.Donor site was resurfaced with a fullthickness skin harvested from medial side of the upper arm.Postoperative flap appearance and two-point discrimination were evaluated.Total active motion (TAM) of the finger was evaluated after operation.Results All the flaps and skin grafts survived after operation.Duration of the follow-up was 6-18 months (mean,14.7 months).Through the final follow-up,appearance and function of the flap were satisfactory,donor site healed well,and two-point discrimination was 5-9 mm (mean,6.3 mm).TAM evaluation was excellent in 19 patients and good in 2 patients with the excellent-good rate of 100％.Conclusion The proximal dorsal artery pedicled island flap raised from the adjacent finger is an ideal choice in finger soft-tissue reconstruction,for the technique has advantages of high survival rate,satisfactory appearance and sensory function as well as few complications.

Objective:To evaluate the clinical outcome of all arthroscopic autogenous tendon suspended fixation for Myerson type III chronic noninsertional achilles tendon rupture in elderly patients.Methods:Data of 18 patients with Myerson type III chronic noninsertional Achilles tendon rupture who had performed all arthroscopic autogenous tendon suspended fixation from February 2016 to February 2019 in Department of Hand and Foot Microsurgery, Xuzhou Central Hospital were retrospectively analyzed. There were 12 males and 6 females (right side, 10 cases and left side, 8 cases) aged from 60 to 79 years with a median of 65.3 years. The mean injury-to-surgery time was 12 weeks (range, 6-32 weeks). All the patients were treated by all arthroscopic autogenous tendon suspended fixation. The function of the ankle and the foot was assessed using visual analogue scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) foot and ankle score and the achilles tendon total rupture score (ATRS), and the excellent and good rate was evaluated according to Arner-Lindholm score.Results:All patients healed at the first stage without any complications such as infection, sural nerve injury or tend re-rupture. The mean follow-up period was 18.6 months (range, 12-50 months). At the latest follow-up, all achilles tendons were healed with the VAS score reduced from 4 (1, 7) preoperatively to 0 (0, 1) postoperatively ( Z=2.334, P< 0.05); the AOFAS ankle and hindfoot score was improved from 60.3±9.7 (range, 40-83) preoperatively to 92.6±4.3 (range, 86-100) postoperatively ( t=34.541, P< 0.05); the ATRS score was improved from 55.7±10.6 (range, 42-80) preoperatively to 93.1±3.2 (range, 88-100) postoperatively ( t=64.773, P< 0.05); one patient was unable to stand on tiptoe of the single injured limb, because he could stand it, no further treatment was given; another patient complained of mild pain after a long time walking,which was alleviated by stretching the achilles tendon consistently. According to the score of Arner-Lindholm, 14 cases were excellent, 4 cases were good, and the excellent and good rate was 100% (18/18). Conclusion:All arthroscopic autogenous tendon suspended fixation for Myerson type III chronic noninsertional achilles tendon rupture in elderly patients is an effective method, which has the advantages of less trauma, faster recovery and fewer complications.

Objective To investigate the application of a narrow pedicle cross-finger flap in the treatment of fingertip degloving injuries.Methods Between June 2011and May 2013,23 patients (23 fingers) suffered from fingertip degloving injuries were treated with a narrow pedicle cross-finger flap.There were 15 males (15 fingers) and 8 females (8 fingers).Defects were caused by machine crush injury in 11 cases,girdle crush injury in 7 cases and punch press injury in 5 cases.The defects were located on the index finger in 10 cases,long finger in 2 cases,ring finger in 7 cases,and little finger in 4 cases.The flaps sized 2.6 cm × 1.9 cm to 6.5 cm × 2.2 cm.After six months,according to Zhang's curative effect satisfaction score method,the efficacy of the treatment was evaluated by five aspects of skin flap healing:flap fleeing,skin flap,flap outline,flap temperature and donor site scar.Results The island flaps were survived completely in 23 patients.After followed-up for 6 to 18 months (one case was lost to follow-up).The color and texture of the flap were the same to the surrounding normal skin,and the finger shape was satisfactory.There was no pigmentation and contraction relapse ofthe injured finger.The mean values of static 2-point discrimination were (6.1 ± 1.3) mm (range,5-8 mm) of the flap.Conclusions The narrow pedicle cross-finger flap can be used to repair the fingertip degloving injuries with the flexible flap design and reliable blood supplement.The flap survives well and the repair area is good.Therefore,it is a good method and strongly recommended for fingertip degloving injuries repair in clinics.

OBJECTIVETo investigate the clinical outcomes of the use of the perforator propeller flaps based on the end dorsal branch of digital proper artery in the same finger in repair of finger pulp defects and sensory reconstruction in children.

METHODSTwenty-three children (31 fingers) with index, middle, ring or little finger pulp defects were hospitalized from September 2012 to December 2013. The area of finger pulp defects ranged from 1.2 cm × 1.0 cm to 2.0 cm × 1.5 cm. The perforator propeller flaps based on the end dorsal branch of digital proper artery in the same finger were used to repair the defects, with the flap size ranging from 1.3 cm × 1.2 cm to 2.2 cm × 1.6 cm. The dorsal branch of the digital proper nerve of the flap was conducted end-to-end anastomosis with the broken end of the nerve of the wound to reconstruct sensation. The donor sites were covered with autologous full-thickness skin obtained from inner aspect of the thigh.

RESULTSPrimary healing of the wounds and donor sites were achieved in all 23 children. All the flaps and skin grafts of donor sites survived. All the patients were followed up for 6 to 20 months, with mean time of 14 months. At the last follow-up, the flaps and donor sites were in good appearance, the finger pulps were mellow and plump, with no obvious pigmentation or cicatricial contracture. The sensation of finger pulps reached S3(+), and the distance of two-point discrimination ranged from 4.5 to 6.0 mm, with mean distance of 5.1 mm. Twenty-one parents of the patients were strongly satisfied with the appearance of the repaired fingers, and the other 2 parents also expressed satisfaction.

CONCLUSIONSTransplantation of the perforator propeller flap based on the end dorsal branch of digital proper artery in the same finger is a safe and reliable method for the repair of index, middle, ring, and little finger pulp defects and sensory reconstruction of children. The flaps are with good blood supply, appearance and sensory function after operation.

Arteries ; innervation ; Child ; Contracture ; Finger Injuries ; surgery ; Fingers ; blood supply ; innervation ; surgery ; Humans ; Perforator Flap ; Reconstructive Surgical Procedures ; methods ; Skin ; Skin Transplantation ; methods ; Soft Tissue Injuries ; surgery ; Surgical Flaps ; blood supply ; Treatment Outcome ; Wound Healing