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Background: There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using supra-inguinal inflow for revascularization of infra-inguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infra-femoral targets., Methods: The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB from the aortoiliac arteries to the popliteal and tibial arteries. Patients were stratified into 3 cohorts based on outflow targets (above-knee [AK] popliteal, below-knee [BK] popliteal, and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival (AFS), and major adverse limb events (MALEs) were compared. A Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes., Results: Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, while the remaining used the aorta or common iliac artery as inflow. In terms of the distal target, the AK popliteal was used in 116 (28.8%), the BK popliteal in 151 (27.5%), and tibial vessels in 136 (43.7%) cases. BK popliteal and tibial bypasses, compared to AK popliteal bypasses, were more commonly performed in patients with chronic limb-threatening ischemia (69.5% and 69.9% vs. 48.3%; P < 0.001). Vein conduit was more often used for tibial bypass than for AK and BK popliteal bypasses (46.3% vs. 21.9% and 16.3%; P < 0.001). In the perioperative period, BK popliteal and tibial bypass patients had higher reoperation rates (16.9% and 13.2% vs. 5.2%; P = 0.02) and lower primary patency (89.4% and 89% vs. 95.7%; P = 0.04) than AK bypass patients. At 1 year, compared with AK popliteal bypasses, BK and tibial bypasses demonstrated lower primary patency (81.9% vs. 56.7% vs. 52.4%, P < 0.001) and freedom from MALE (77.6% vs. 70.2% vs. 63.1%, P = 0.04), although AFS was not significantly different (89.7% vs. 90.6% vs. 83.8%, P = 0.19).On multivariable analysis, compared with AK popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio 1.9, 95% confidence interval, 1.03-3.51, P = 0.04). Subanalysis of patients with chronic limb-threatening ischemia demonstrated significantly higher primary patency in the AK popliteal cohort at discharge and 1 year, but no difference in AFS or freedom from MALE between the cohorts at follow-up., Conclusions: LEB with supra-inguinal inflow appear to have acceptable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency but not with MALE or AFS., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Retrograde tibio-pedal access represents a feasible method for endovascular revascularization when antegrade methods fail. The article offers an extensive review of retrograde tibio-pedal access, emphasizing the technique and documented outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI., Methods: A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300 mm (1 point), and poor pedal runoff score (1 point). Patients were then divided into 3 groups: low risk (0 or 1 points), moderate risk (2 points), and high risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis [>70%], or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-oriented outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention: new bypass graft, jump/interposition graft revision) were evaluated., Results: 1,607 patients (55% male, average age 60 years, 3,846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic origin. Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day major amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate risk and high risk exceeded the goal threshold. For the OPG, freedom from MALE was 60 ± 5%, 46 ± 5%, and 22 ± 9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.008). Overall AFS was 55 ± 5%, 37 ± 6%, and 18 ± 7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.003)., Conclusions: Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short- and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Autologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, a vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below-knee popliteal and tibial bypasses compared to prosthetic bypass alone., Methods: A retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjuncts were compared. Inclusion criteria included age ≥18 years, and bypass to below-knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below-knee popliteal and tibial subgroups., Results: A cohort of 3,939 patients underwent bypass to the below-knee popliteal artery, with 287 (7.3%) receiving vein adjuncts. More patients were male (68.8 vs. 57.8%, P < 0.001) and had higher rates of congestive heart failure (21.1 vs. 16.0%, P = 0.040) within the below-knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs. 17.1%, P = 0.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjuncts. Within the tibial group, patients were similar in age, body mass index, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, P = 0.005) and amputation (20.5 vs. 15.9%, P = 0.048) rates at 2 years were worse for patients who did not receive a distal vein adjunct to tibial arteries., Conclusions: Distal vein adjuncts are associated with improved freedom from occlusion, amputation, major adverse limb events, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the Vascular Quality Initiative. A vein adjunct was not associated with improved freedom from occlusion in below-knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To investigate the clinical effect of posterior perforator tibial artery flaps on repairing soft tissue defects of limbs., Methods: From June 2012 to June 2021, 14 cases of soft tissue defects of limbs were repaired with pedicled or free flaps of posterior perforator tibial artery. Among them, there were 9 cases of pedicled flaps and 5 cases of free flaps. The donor sites were closed directly or covered with skin grafting. The defects area varied from 3 × 5 cm to 7 × 16 cm. All cases were followed up for 1 year to 2 years., Results: All flaps survived completely except 3 cases with distal end necrosis and the 3 cases healed after dressing change. There were not any other complications at both donor and recipient sites. Appearance of the recipient sites was close to the surrounding skin. All patients were satisfied with the results., Conclusion: Posterior perforator tibial artery flaps have the advantages of relatively simple technique, few damage, few complications and satisfying appearance. It is a good choice for soft tissue defects of limbs., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

During tibial plateau leveling osteotomy (TPLO), the laceration of the cranial tibial artery (LCTA) may occur, and the ligation of the cranial tibial artery might lead to impaired blood supply to the osteotomy site. The present case-control study aimed to evaluate the effect of LCTA on TPLO healing and the occurrence of perioperative complications. The incidence and predisposing factors to LCTA were also investigated. Fourteen cases experiencing LCTA were retrospectively enrolled from medical records of two veterinary teaching hospitals (LCTA group), whereas 28 randomly selected TPLOs that did not experience LCTA were included in the control group. Signalment data, proximal tibial epiphysis conformation, osteotomy features, perioperative complications, and bone healing were compared between the two groups. Bone healing was evaluated using the modified radiographic union scale for tibial fracture and the visual analog scale. The mean incidence was 9.6%. Bodyweight was significantly higher in the LCTA group compared to the control group (P = 0.009). Dogs belonging to the LCTA groups were significantly younger (P = 0.01). Intraoperative hypotension was significantly overreported in the LCTA group (P = 0.0001). None of the other variables differed significantly between the two groups. Dogs' size seems to be a predisposing factor, with dogs weighing >15 kg having 22 times more chance of experiencing LCTA. Due to the well-developed collateral blood supply of the canine hindlimb, LCTA and the closure of the cranial tibial artery did not appear to delay the radiographic bone healing or affect the incidence of perioperative complications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Disclosures None.

Importance Free tissue transfer for reconstruction of the head and neck requires complicated repair of complex anatomy. The posterior tibial flap is a free tissue flap that has viability and versatility to be used for complex reconstructions that is not offered by other free flaps., Objective: The posterior tibial artery flap is a perforator flap which is found between the flexor digitorum longus and the soleus. It has been described as both a pedicled flap for lower extremity reconstruction as well as a free flap, including for head and neck reconstruction. Limited data exists on the subject in the English literature. The objective of this study is to present our experience with the flap in the head and neck., Design: Retrospective review of cases from a single institution between October 2019 and May 2023. Primary indications included patients whose defects were felt to be larger than a conventional radial forearm free flap that were not well served by the anterolateral thigh flap, either because of body habitus or room for the associated muscle., Setting: Tertiary academic hospital system performing free tissue transfer reconstruction of within the head and neck., Results: Fifteen patients underwent posterior tibial artery free flap during the study period. Indications for flap reconstruction included oral cavity, tongue, oropharynx and skin of the scalp and forehead. Flap size ranged from 24cm 2 to 143cm 2 . Only one flap failure was observed. Flap harvest time was universally under forty-six minutes, and as little as thirty-two., Conclusion: The posterior tibial artery flap is a useful option in head and neck reconstruction. It provides an intermediary in size and bulk between the radial forearm and the anterolateral thigh flap. Additionally, it provides a straightforward harvest with minimal donor site morbidity., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma., Methods: A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3)., Results: Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < 0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = 0.59). T3 received greater blood transfusion volume (P = 0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P = 0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = 0.16), and amputation was not significantly predicted by arterial ligation in T1 (P = 0.08) or T2 (P = 0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P = 0.02), but other limb complication rates were similar., Conclusions: In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Reconstruction of large soft tissue foot defects were considered a difficult issue due to weight-bearing function of the foot. The reconstruction becomes more difficult when both plantar and dorsal soft tissues are involved. The options for the reconstruction were variable, in 2016 Hao Wu et al. presented a combined flap for coverage of combined fore-foot plantar and dorsal soft tissue defects. We used combined flaps in two cases and present our experience in this article.

Objectives: The objective of this study was to define the danger zone at which the anterior tibial artery (ATA) is at risk during anterolateral plating of the distal tibia using a novel 3D computed tomography angiography (CTA) modeling technique., Methods: 116 patients (232 lower extremities) who underwent lower extremity CTAs between April 2020 and April 2022 were identified. Those with lower extremity trauma, evidence of a previously healed tibial fracture, or poor visualization of the ATA were excluded. The remaining 150 lower extremities (92 patients) were modeled with an anterolateral distal tibia plate using Sectra IDS7 software. The distance of the ATA from bony landmarks was measured perpendicular to the level at which the vessel intersected the plate., Results: The ATA intersected the plate proximally at a mean distance of 10.5 cm (95% confidence intervals, 10.2-10.9) and at a mean distance of 4.6 cm (95% confidence intervals, 4.4-4.9) distally from the central tibial plafond. The ATA intersected with the plate as far distal as hole number 1 and as proximal as hole 14 of the plate. The greatest injury risk was associated with plate holes 3-8. In this region, the artery was at risk in 46-99 percent of specimens., Conclusions: The ATA is at risk when screws are placed percutaneously in an anterolateral distal tibia plate. The artery can be as close as 4.4 cm and as far as 10.9 cm proximal to the tibial plafond when crossing the plate, correlating to a risk of injury to the ATA at plate holes 1 through 14., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To investigate the architecture of the cutaneous branch-chained blood vessels in the medial lower leg and provide the anatomical basis for design and clinical application of the cutaneous branch-chained flap from this region. Methods: The experimental research method was used. From March to May 2023, the anatomical study was conducted on the 5 voluntarily donated fresh adult (aged 50 to 70 years, all male) cadaveric specimens from Hangzhou Normal University School of Basic Medical Sciences. The fine anatomy under microscope was performed on each lower leg specimens of 5 corpses (1 lower leg specimen was conducted with digital radiography (DR) scan before fine anatomy), to observe, measure, and record the course of posterior tibial artery, quantity of perforator, the distance between the perforating point of each perforator and the medial condyle of tibia, the external diameter of posterior tibial artery perforator, the length of perforator pedicle, the horizontal distance between the posterior tibial artery perforator and the saphenous nerve, and the course of each perforator within superficial fascia after crossing the deep fascia and the distribution of the cutaneous branch-chains. The DR scan under the perfusion of barium sulfate was conducted in one lower leg specimen to observe the distribution of cutaneous branch-chained vascular network (hereinafter referred to as vascular chain) between perforators. Transparent skin specimen was made from one leg specimen after anatomy to observe the distribution of perforators and vascular chains between perforators. Results: In 5 lower leg specimens, the upper part of posterior tibial artery was located deep in soleus muscle, and the lower part was located between the medial edge of gastrocnemius muscle and flexor digitorum longus muscle. A total of 28 posterior tibial artery perforators were identified, with an average of 5.6 branches in each lower leg. The distance between the perforating point of perforator and the medial condyle of tibia ranged from 6.5 to 36.0 cm, mainly distributed at 22.0 (15.1, 28.1) cm from the medial condyle of tibia, in zones 3 to 6. The external diameters of perforators of posterior tibial arteries were 0.7-1.1 mm. The length of perforator pedicle was 1.0-4.5 cm, and the horizontal distance between the posterior tibial artery perforator and the saphenous nerve was 0.5-3.0 cm. The fine anatomy under microscope showed that the posterior tibial artery perforators had long upward and downward branches after crossing the deep fascia, and the ascending branches and descending branches were anastomosed longitudinally to form the nutrient cutaneous branch-chain in the medial lower leg. DR scan and transparent skin specimen both showed that longitudinal vascular chain was formed between the posterior tibial artery perforators, the transparent skin specimen also showed that longitudinal blood vessel chains included the direct connecting vessels in the adipose layer and the indirect connecting vessels in the subdermal layer. Conclusions: The cutaneous branch-chained vessels in the medial lower leg are constructed by posterior tibial artery perforators, direct connecting vessels, indirect connecting vessels, and traffic branches. The cutaneous branch-chained flap is reliable in terms of vascular anatomy, and can carry the saphenous nerve for partial restoration of its sensation, thus it is an ideal flap.

Background: Tibial artery calcification (TAC) is correlated with an increased risk of amputation and mortality in patients with chronic limb-threatening ischemia (CLTI). The association between calcification characteristics and adverse limb events of CLTI. However, it has not been assessed. This study aims to assess the relationship between the characteristics of TAC based on computed tomography angiography (CTA) scans and postoperative outcomes in patients with CLTI undergoing infrapopliteal endovascular therapy., Methods: This was a retrospective study of patients who underwent infrapopliteal endovascular revascularization for CLTI and had a preoperative CTA scan. Based on CTA, TAC was divided into the following categories: annularity, thickness, continuity and severity. Cox regression models using generalized estimating equations were performed to assess the relationship between calcification characteristics and postoperative outcomes. The outcomes evaluated were the occurrence of all cause mortality (ACM) and unplanned amputation., Results: Among the 148 patients undergoing endovascular, there were 50 (33.8%) patients died and 26 (17.6%) patients underwent unplanned amputation. Annular calcification was more common in the ACM group than in the non-ACM group. No significant differences were found between the two groups with regard to the probability of calcification in the thickness and the continuity (P>0.05). Patients in the unplanned amputation group had significantly annular, thin and continuity calcifications (P<0.05) than those in the non-unplanned amputation group. The presence of annular calcification was an independent predictor of ACM (hazard ratio (HR), 3.186; 95% confidence interval (CI), 1.781-5.702; P<0.001) and unplanned amputation (HR, 3.739; 95% CI, 1.707-8.191; P<0.05)., Conclusions: Among patients with CLTI, the occurrence of annular calcification in the tibial artery are related to a greater chance of ACM and unplanned amputation in the postoperative period. The circumferential degree of TAC of the operated limb can be considered as a marker of clinical prognosis in this group of patients.

Case: A 46-year-old man with vascular Ehlers-Danlos syndrome (EDS) had an open ankle fracture with a 10 × 5-cm skin defect on the medial side of the ankle. The patient underwent open reduction and internal fixation, as well as coverage of the skin defect with a posterior tibial artery perforator flap, which led to successful outcomes., Conclusion: We present the successful implementation of a posterior tibial artery perforator flap for the reconstruction of skin defects in a patient with vascular EDS. Despite the fragility of soft tissues, favorable surgical outcomes were observed., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C224)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Lower extremity vascular injuries have significant implications for trauma patients with regards to morbidity from limb loss. There is limited evidence on outcomes for patients with injuries to tibial arteries. Our study focuses on defining outcomes of traumatic vascular injury to vessels below the knee., Methods: A retrospective review using ICD-9 and 10 codes of all patients with below knee vascular injuries was performed at a Level 1 trauma center from November 2014 to June 2022. Interventions, outcomes, and complications were assessed., Results: Seventy-six patients were identified fitting inclusion criteria. The mean age was 35.3 +/- 15.2 years and 67 (88%) patients were male. Thirty-nine suffered penetrating trauma, 37 suffered blunt trauma. The most injured artery was posterior tibial artery (40%) followed by anterior tibial artery (36%). Injuries included 51 transections, 22 occlusions and 4 pseudoaneurysms. Forty-five (59%) patients underwent operative intervention. Thirty (67%) operations were performed by trauma surgery. Arterial ligation was performed in 30 cases (67%), arterial bypass in 12 (27%), and 2 (4%) primary amputations. Vascular surgery performed all bypasses. Overall amputation rate was 8% ( n = 6) with 3 for mangled extremity and 3 due to failed bypass graft. All amputations were associated with open fracture and amputations for failed bypass had multiple arterial injuries., Conclusion: The management of below knee vascular trauma requires a multidisciplinary approach. Patients requiring reconstruction are more likely to have multiple vessel injuries and may have significant risk of graft failure. These patients as well as those with extensive soft tissue injury and/or multi-vessel injuries are at increased risk for amputation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Pseudoaneurysms are false aneurysms that consist of turbulent blood flow between the outside layers of the arterial wall, the tunica media and tunica adventitia. Typically, pseudoaneurysms develop after injury to an artery, most often as a result of blunt trauma. Femoral pseudoaneurysms can also develop after catheter-based vascular interventions due to laceration of the artery from access needles, insufficient time or pressure held at the access site after the procedure, amongst other causes. Rarely, arterial injury during orthopedic pinning procedures has been known to cause pseudoaneurysms. There are only two documented cases within the literature in which a patient underwent closed intermedullary nailing of a proximal tibia fracture after trauma and developed an anterior tibial artery pseudoaneurysm. There are few reports of pseudoaneurysm development as the result of external fixation device placement presumably caused by the inability to directly visualize internal anatomy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Abstract: Variations in the division of popliteal artery and origin of the 3 vascular systems are well documented. Here, we report a case in which the posterior tibial artery originated from the peroneal artery, in lower leg and then followed the normal course. The anomaly was detected intraoperatively precluding the harvest of free fibula flap. The procedure was abandoned and fibula was fixed using plates and screws and a free radial forearm flap was done over 2 mini-plates, which spanned the bone gap. A second bone flap procedure was to be planned in another sitting.The anomalous origin of posterior tibial artery from the peroneal artery in lower leg did not fall into any of the categories described previously by Kim et al (Ann Surg 1989;210:776-81.). In the event such atypical anatomy is encountered, it must be delineated, and the surgical plan adjusted accordingly. Flexibility in surgical approach can prevent vascular catastrophe., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Traditional research methods have limited the application of anterior tibial artery perforator flap due to incomplete knowledge of the perforator. This study aimed to investigate the feasibility of three-dimensional digitalized virtual planning of free anterior tibial artery perforator flap for repairing soft tissue defects in extremities., Methods: A total of 11 patients with soft tissue defects in extremities were included. The patient underwent computed tomography angiography (CTA) of bilateral lower limbs, and then the three-dimensional models of bones, arteries, and skin were constructed. Septocutaneous perforators with appropriate length and diameter were selected to design anterior tibial artery perforator flaps in software, and the virtual flaps were superimposed onto the patient's donor site in a translucent state. During the operation, the flaps were dissected and anastomosed to the proximal blood vessel of the defects as designed., Results: Three-dimensional modeling showed clear anatomical relationships between bones, arteries, and skin. The origin, course, location, diameter, and length of the perforator obtained during the operation were consistent with those observed preoperatively. Eleven anterior tibial artery perforator flaps were successfully dissected and transplanted. Postoperative venous crisis occurred in one flap, partial epidermis necrosis occurred in another flap, while the remaining flaps completely survived. One flap was treated with debulking operation. The remaining flaps maintained aesthetic appearance, which did not affect the function of the affected limbs., Conclusions: Three-dimensional digitalized technology can provide comprehensive information on anterior tibial artery perforators, thus assisting in planning and dissecting patient-specific flaps for repairing soft tissue defects in extremities., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

The reconstruction of defects of the lateral malleolus involving the exposed fibular bone or tendon is challenging. This study aimed to evaluate the clinical application of the peroneal artery perforator flap with or without split-thickness skin grafting for soft tissue reconstruction of the bony defect of the lateral malleolus of the ankle joints. Reconstruction using a peroneal artery perforator flap with or without split-thickness skin grafting was performed for 15 patients (10 men, 5 women) between January 2007 and December 2018. The mean age was 53.7 years, and the mean size of the flaps was 40 cm 2 . The flaps were elevated in the form of a perforator flap, and split-thickness skin grafting was performed over the flaps and adjoining raw areas. The flaps survived in all cases; however, partial necrosis was observed in 3 cases. In cases of small-sized defects of the lateral malleolus of the ankle joints where a flap is required for the exposed bone or tendon, reconstruction using the peroneal artery perforator flap is advantageous, since the morbidity rate of the donor site is low and soft tissue is reconstructed.

Objective: To investigate the accuracy and reliability of augmented reality (AR) technique in locating the perforating vessels of the posterior tibial artery during the repair of soft tissue defects of the lower limbs with the posterior tibial artery perforator flap., Methods: Between June 2019 and June 2022, the posterior tibial artery perforator flap was used to repair the skin and soft tissue defects around the ankle in 10 cases. There were 7 males and 3 females with an average age of 53.7 years (mean, 33-69 years). The injury was caused by traffic accident in 5 cases, bruising by heavy weight in 4 cases, and machine injury in 1 case. The size of wound ranged from 5 cm×3 cm to 14 cm×7 cm. The interval between injury and operation was 7-24 days (mean, 12.8 days). The CT angiography of lower limbs before operation was performed and the data was used to reconstruct the three-dimensional images of perforating vessels and bones with Mimics software. The above images were projected and superimposed on the surface of the affected limb using AR technology, and the skin flap was designed and resected with precise positioning. The size of the flap ranged from 6 cm×4 cm to 15 cm×8 cm. The donor site was sutured directly or repaired with skin graft., Results: The 1-4 perforator branches of posterior tibial artery (mean, 3.4 perforator branches) in 10 patients were located by AR technique before operation. The location of perforator vessels during operation was basically consistent with that of AR before operation. The distance between the two locations ranged from 0 to 16 mm, with an average of 12.2 mm. The flap was successfully harvested and repaired according to the preoperative design. Nine flaps survived without vascular crisis. The local infection of skin graft occurred in 2 cases and the necrosis of the distal edge of the flap in 1 case, which healed after dressing change. The other skin grafts survived, and the incisions healed by first intention. All patients were followed up 6-12 months, with an average of 10.3 months. The flap was soft without obvious scar hyperplasia and contracture. At last follow-up, according to the American Orthopedic Foot and Ankle Association (AOFAS) score, the ankle function was excellent in 8 cases, good in 1 case, and poor in 1 case., Conclusion: AR technique can be used to determine the location of perforator vessels in the preoperative planning of the posterior tibial artery perforator flap, which can reduce the risk of flap necrosis, and the operation is simple.

Pilon fractures of the distal tibia are usually the result of a high-energy trauma and can affect seriously the arterial vasculature carrying an increased risk of amputation at the malleolar level or higher. Such cases represent a challenge for the orthopedic surgeons and a multidisciplinary approach is mandatory in order to salvage the threatened limb. We present an unusual case of a closed pilon fracture with injury of all tibial vessels leading to acute limb threatening ischemia. The patient was treated successfully with external fixation and a short tibial-pedal bypass with use of an autologous reversed saphenous vein graft. This example dictates how a distal leg fracture can be dramatic and that awareness of vascular examination coupled with high suspicion of vascular damage can be limb-saving. Multidisciplinary approach is warranted since the topology and complexity of the ankle lesions necessitate staged orthopedic reconstructions with tibio-distal bypass and appropriate skin coverage of the distal anastomosis.

Background: Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap. The first description of the soleus muscle as an island flap supplied by one distal perforator was reported by Yajima et al (Plast Reconstr Surg. 1995;96:1162-1168). However, its use as a propeller flap supplied by the distal perforators and rotated for more than 90 degrees was not described yet., Obejectives: The aims of the study are to study the detailed vascular anatomy of the distal perforators of the soleus muscle flap and to demonstrate the applicability of using it as a propeller flap., Patients and Methods: A total number of 42 patients were included in this study. These patients had various distal leg and foot defects. All patients were assessed preoperatively by Doppler study and computed tomography angiography to define the vascular status of the leg. The muscle was raised as a reversed flow flap, based on 1 or more distal perforators and its feeding vessel (posterior tibial artery) after being dissected and divided proximally. The muscle was rotated for more than 90 degrees to reach distal leg defects and approximately 180 degrees to reach the foot defects., Results: All flaps survived completely with good and durable coverage. The vascularity of the limb was not affected in all patients. There was no functional donor site morbidity., Conclusions: The reversed flow hemisoleus muscle flap supplied by the distal perforators and the posterior tibial artery has a great arc of rotation that can cover all distal leg, ankle, and foot defects. Therefore, it can be used as alternative to free flap in lower extremity reconstruction. A new nomenclature is suggested for this flap which is the propeller hemisoleus muscle flap., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Vascular involvement manifests as aneurysms, stenosis, and arteriovenous malformations in patients with type I neurofibromatosis (NF-I). Aneurysms are rare; however, the renal artery is the most common site. Herein, we report a rare case of stent graft placement in an anterior tibial artery (ATA) pseudoaneurysm in a patient with NF-I., Patient Concerns: A 52-year-old woman with NF-1 was admitted to the emergency room with painful swelling in the left lower leg. At presentation, the patient's blood pressure was 100/60 mmHg and the hemoglobin level was 9 g/dL., Diagnoses: Computed tomography scan revealed a small aneurysm arising from the left ATA and an adjacent large hematoma., Intervention: Stent graft placement was performed to treat ATA pseudoaneurysm., Outcomes: After stent graft placement, the aneurysm disappeared and the distal flow was patent through the ATA., Lessons: Stent graft placement should be considered as another option for endovascular treatment in patients in whom coil embolization or surgery cannot be performed., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Distally based peroneal artery perforator-plus fasciocutaneous (DPAPF) flaps are widely used to reconstruct soft tissue defects of the lower extremity. Treatment for soft tissue defect combined with chronic osteomyelitis in the lateral malleolus has rarely been reported. The aim of this study was to elaborate the superiority of the DPAPF flap and provide referential experience for using the DPAPF flap in this situation. Between June 2010 and December 2017, soft tissue defects in the setting of chronic osteomyelitis in the lateral malleolus were reconstructed with DPAPF flaps in 17 patients. After thorough debridement, the defect was repaired with the DPAPF flap, and patients subsequently followed an antibiotic regimen for 6 weeks. Follow-up periods for all patients were at least 24 months. The reconstruction outcomes and the satisfaction of the 17 patients were evaluated. Of the 17 flaps, 16 survived uneventfully, except one occurrence of partial necrosis. No infection occurred in the follow-up period. In the study, 17 patients except one were satisfied with flap appearance. All the patients were satisfied with the reconstruction outcomes. In a one-stage procedure, the use of DPAPF flaps is ideal for reconstructing soft tissue defects in the setting of chronic osteomyelitis in the lateral malleolus.

Residual pain after ankle replacement may implicate lesions in posteromedial structures, including the posterior tibial pedicle and tendon. The technique described here protects these structures, by positioning a malleable plate via a medial retromalleolar counter-approach. The technique seems not to cause any specific iatrogenicity. We advocate systematic implementation of this kind of protection in ankle replacement surgery. LEVEL OF EVIDENCE: IV, retrospective study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Objective: To explore the clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux. Methods: A retrospective observational study was conducted. From January 2020 to January 2021, 13 patients with skin and soft tissue defects of the hallux who met the inclusion criteria were admitted to Department of Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 12 males and 1 female, aged 26 to 53 years. Before operation, the perforating point of the superficial peroneal artery perforator was located by color Doppler ultrasound on the calf on the same side of the affected hallux and marked on the body surface. The operation was performed under spinal anesthesia combined with continuous epidural anesthesia. The area of skin and soft tissue defect after debridement was 4.5 cm×2.5 cm to 12.0 cm×3.0 cm. According to the size and shape of the wound, the superficial peroneal artery perforator flap was designed with the line between the fibular head and the lateral malleolus tip parallel shifting 2 cm to the tibial side as the flap axis line, and the perforating point of the perforator near the midpoint of the axis line as the center. The cut area of the flap was 5.0 cm×3.0 cm to 13.0 cm×4.0 cm, and part of the deep fascia was cut when the pedicle was freed. The donor site wound was sutured directly. During the operation, the number and type of the perforator and the cutting time of the flap were recorded, and the length of the perforator pedicle and diameter of the perforator were measured. The survival of the flap, the healing time and the healing condition of the donor and recipient areas were recorded after operation. The color, texture, elasticity of the flap, standing and walking functions of patients, the recovery of the donor area, and the patients' satisfaction with the recovery of the donor and recipient areas were recorded during the follow-up. At the last follow-up, the sensation of the flap was evaluated by the British Medical Association sensory function evaluation standard, the function of the affected limb was evaluated by the American Society of Foot and Ankle Surgery scoring system, and the excellent and good rate of the function of the affected limb was calculated. Results: A total of 13 perforators of the superficial peroneal artery were detected during the operation, all of which were septocutaneous perforators, and the perforator diameter was 0.3 to 0.5 mm. The vascular pedicle length was 2 to 5 cm. Flap cutting time was 11 to 26 minutes. The flaps of 13 patients all survived completely. The wounds at the donor and recipient sites healed well 9 to 18 days after operation. During follow-up of 6 to 14 months, the flaps had good color, texture, and elasticity; 11 patients had no obvious bloated appearance, and the other 2 patients underwent flap thinning and plastic surgery in the second stage because of their bloated appearance; all the patients returned to normal walking and standing functions. There was only one linear scar left in the donor site, with no obvious scar hyperplasia or hyperpigmentation. All the patients were satisfied with the recovery of the donor and recipient areas. At the last follow-up, the sensation of the flap was evaluated as grade S 3 in 2 cases, grade S 2 in 9 cases, and grade S 1 in 2 cases; the function of the affected limb was evaluated as excellent in 7 cases and good in 6 cases, with an excellent and good rate of 100%. Conclusions: The free superficial peroneal artery perforator flap has relatively constant vascular anatomy, which is thin and wear-resistant, with less damage to the donor site after flap excision, and can preserve the shape and function of the hallux to the greatest extent. It is an effective method for repairing skin and soft tissue defect of the hallux.

Objective: To explore the application value of infrared thermography (IRT) technique assisted peroneal artery perforator flap in repairing oral and maxillofacial defects., Methods: The clinical data of 20 patients with oral and maxillofacial malignant tumors treated with peroneal artery perforator flap between October 2020 and December 2021 were retrospectively analysed. There were 13 males and 7 females, with an average age of 56.5 years (range, 32-76 years). There were 8 cases of tongue cancer, 5 cases of parotid gland cancer, 4 cases of buccal cancer, and 3 cases of mandibular gingival cancer; and 12 cases of squamous cell carcinoma, 3 cases of adenoid cystic carcinoma, and 5 cases of mucoepidermoid carcinoma. Color Doppler ultrasound (CDU) and IRT technique were performed before operation to locate the peroneal artery perforator and assist in the design of the flap. The sensitivity, specificity, positive predictive value, and negative predictive value of CDU and IRT technique were compared with the actual exploration during operation. The accuracy of CDU and IRT technique in detecting the number of peroneal artery perforator and the most viable perforating points was compared. The patients were followed up regularly to observe the recovery of donor and recipient sites, the occurrence of complications, and the recurrence and metastasis of tumors., Results: The sensitivity, specificity, positive predictive value, and negative predictive value of peroneal artery perforators detected by IRT technique before operation were 72.22%, 50.00%, 92.86%, and 16.67% respectively, which were higher than those by CDU (64.17%, 33.33%, 84.62%, and 14.29% respectively). Forty-five peroneal artery perforators were found by CDU before operation, and 35 were confirmed during operation, with an accuracy rate of 77.8%; 43 "hot spots" were found by IRT technique, and 32 peroneal artery perforators were confirmed within the "hot spots" range during operation, with an accuracy rate of 74.4%; there was no significant difference between the two methods ( χ ²=0.096, P =0.757). The accuracy rates of the most viable perforating points found by CDU and IRT technique were 80.95% (17/21) and 94.74% (18/19), respectively, and there was no significant difference between them ( χ ²=0.115, P =0.734). The localization errors of CDU and IRT technique were (5.12±2.10) and (4.23±1.87) mm, respectively, and there was no significant difference between them ( t =1.416, P =0.165). All the perforator flaps survived, and the incisions of donor and recipient sites healed by first intention. All patients were followed up 5-18 months, with an average of 11 months. The skin flap was soft and had good blood supply, and the lower limb scar was concealed and the lower limb had good function. No lower limb swelling, pain, numbness, ankle instability, or other complications occurred, and no tumor recurrence and metastasis were found during the follow-up., Conclusion: Compared with the CDU, using the IRT technique to assist the preoperative peroneal artery perforator flap design to repair the oral and maxillofacial defects has a high clinical application value.

Objective: To investigate the effectiveness of groin flap combined with medial plantar artery perforator flap (MPAP) for degree Ⅲ-Ⅳ defects of multiple fingers., Methods: Between January 2018 and June 2019, 12 patients with degree Ⅲ-Ⅳ defects of multiple fingers caused by crushing were admitted. There were 9 males and 3 females with a median age of 29 years (range, 16-42 years). The mean interval between the injury and admission was 3 hours (range, 1-9 hours). The injured fingers of 7 cases were index and middle fingers, 4 cases were middle and ring fingers, and 1 case was index, middle, and ring fingers. All fingers were taken thorough debridement and covered by the vacuum sealing drainage device during the emergency operation. The mean interval between the debridement and flap repairing was 18 hours (range, 12-36 hours). During the first-stage operation, the iliac bone graft was used to reconstruct bone frame, and the proximal interphalangeal (PIP) joint from the foot was transferred as the digital PIP joint, then the thin groin flap and MPAP were tailored to cover the dorsal and palmar defects, respectively. The size of the groin flap was 7.0 cm×4.5 cm-14.0 cm×9.0 cm, and the size of the MPAP was 8.0 cm×4.5 cm-14.0 cm×6.5 cm. The abdominal donor site was directly sutured, and the foot was repaired with full-thickness skin grafting. The flaps were separated into the finger shape at the second-stage., Results: All the flaps survived, and the wounds healed by first intention; the incisions in the donor site healed by first intention, and the skin grafts survived completely. All patients were followed up 12-18 months (mean, 16 months). At last follow-up, the injured finger was similar to the contralateral one in terms of texture, appearance, and color. The mean two-point discrimination was 8 mm (range, 6-10 mm), and the sensate level recovered to the S 3 -S 4 . According to the Michigan Hand Outcomes Questionnaire (MHQ), the reconstructed hand function was excellent in 8 cases and good in 4 cases. There was no complication in the donor sites., Conclusion: The degree Ⅲ-Ⅳ defects of multiple fingers were repaired by the groin flap and MPAP, and the reconstructed fingers can perform good texture and motion with being sensate, with less sacrifice on the foot.

Background: A cross-leg flap can be used to treat severely injured lower limbs but associated with complications. Herein, we describe a technique of a parallel cross-leg free flap combined with posterior tibial artery perforator pedicle propeller cable bridge flap for the treatment of lower extremity wounds., Methods: The artery and veins of the free flap are anastomosed to the contralateral posterior tibial artery and vein, respectively. The vascular pedicle is wrapped with a posterior tibial artery perforator pedicle propeller flap. The legs are allowed to remain in a straight, relaxed position which is maintained with a bandage or Kirschner wire placed at the distal limbs. Pedicle division is performed around 21 days after flap creation, and the posterior artery is re-anastomosed and pedicled flap returned to its original position., Results: From June 2017 to March 2020, 7 patients with lower extremity wounds and tissue loss received reconstruction with this method. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operation time was 5 hours. The average time to ambulation was 4 weeks, and the average follow-up time was 13.7 months. All flaps survived, and limb salvage was successful in all patients. Patients were not uncomfortable with the limbs held in position until pedicle division, and there were no complications. At the final follow-up, the function of all limbs was normal, and the esthetic appearance was acceptable to all patients., Conclusions: The method described overcomes the disadvantages of traditional cross-leg flaps for the treatment.

Objective:  To illustrate the arterial vascularity of the proximal tibia three-dimensionally and to evaluate the impact of fragment rotation on the cranial tibial artery by tibia plateau levelling osteotomy (TPLO)., Methods:  Radiographic angiography and computed tomography (CT) were performed on 12 pelvic limbs from six large-breed canine cadavers before and after TPLO. Three-dimensional (3D) models of the stifle, including osseous and vascular structures, were obtained, and the integrity of the cranial tibial artery was assessed. Post-TPLO CT images were used to analyze compression of the cranial tibial artery by the rotated fragment., Results:  The uncompressed cranial tibial artery caliber, measured proximally and distally to the osteotomy, was 9.52 mm 2 (6.07-18.90 mm 2 ). In all adequately rotated fragments, the mean caliber of the artery on the level of the osteotomy was 1.57 mm 2 (0.89-2.93 mm 2 ) after TPLO. This represented a significant decrease of approximately 81%. Only slight cross-sectional area decrease (8.8%) was seen in one limb, which was revealed to have insufficient fragment rotation (2.83 mm). Another limb only showed signs of stretching of the artery (31.51%), which was under-rotated and medially displaced. Pre-TPLO 3D reconstructions were mainly consistent with previous anatomic studies except for the distance between tibial cortex and cranial tibial artery, which appeared closer., Conclusion:  Sufficient fragment rotation leads to compression of the cranial tibial artery. Intraoperative hemorrhage can be caused by laceration of the main cranial tibial artery or by multiple small branches reaching craniolaterally., Competing Interests: The programs to perform model construction were financially supported by ZIM (Zentrales Innovationsprogramm Mittelstand) and Frank Goblet, Steinbeis-Innovationszentrum Systemlösungen in Mess- und Automatisierungstechnik Mannheim declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. This script is part of a dissertation., (Thieme. All rights reserved.)

Background: Soft tissue lower limb reconstruction often requires free tissue transfer. We investigated whether the target vessels used for micro-vascular anastomosis in the lower limb influences microsurgical outcomes., Methods: Data from Plastic Surgery Departments of a major tertiary hospital in the United Kingdom (Leeds General Infirmary, LGI) and Australia (Princess Alexandra Hospital, PAH) were retrospectively analysed. Patients who underwent lower limb free flap reconstruction using the posterior (PTA) or anterior tibial artery (ATA) were included. Patient demographics, free flap and microvascular anastomosis details were analysed. Primary outcome was flap failure. Secondary outcome was return to theatre., Results: Two hundred and thirty-four free flaps were included (PAH 115; LGI 119). 60% were muscle flaps. Eighty-one percent of patients were male, with trauma the cause in 82%. PTA was used for microsurgical anastomosis in 70% of cases. Venae comitantes were preferred (96%) for venous anastomosis. PTA group showed a higher proportion of patients with trauma as the mechanism of injury. ATA group was more likely to have an end-to-end arterial anastomosis configuration. Total flap loss was 3.8%. There was no clinically significant difference in flap failure or return to theatre using ATA versus PTA., Conclusions: Incidence of lower limb free flap failure is low (<5%) and not influenced by use of ATA versus PTA for microsurgical anastomosis. The choice of target vessels for microsurgical reconstruction of the lower limb should be predicated upon factors other than aversion to one or another vessel. If all other microsurgical considerations are equal, the surgeon can exercise personal preference., (© 2022 Royal Australasian College of Surgeons.)

The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases-anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm 2 (mean 28.2 ± 23.8 [range 6-120] cm 2 ) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

BACKGROUND Acute arterial occlusion after total knee arthroplasty (TKA) is a rare but occasionally limb-threatening complication. Successful outcomes of surgical treatment for acute arterial occlusion after TKA have been frequently reported in the literature; however, few reports have described conservative treatment. This case report describes the successful conservative treatment of popliteal artery occlusion after TKA. CASE REPORT We report 2 cases of popliteal artery occlusion after TKA that were managed with conservative treatment. In Case 1, a 68-year-old woman presented with a weak dorsalis pedis pulse in the foot and weakness to dorsiflexion of the toe on the operative side immediately after TKA. The operative lower extremity arterial ultrasonography and computed tomography angiography demonstrated the popliteal artery occlusion. In Case 2, a 79-year-old woman presented a cold right foot and lack of popliteal and dorsalis pedis pulse in the operated extremity immediately after TKA, and Doppler ultrasound did not reveal a flow for the dorsalis pedis artery. In both patients, urgent angiographies showed popliteal artery occlusion, and blood flow was observable in the anterior tibial, peroneal, and foot arteries collateral perfusion. Thus, conservative treatments were chosen, and anticoagulant and vasodilator therapies were undergone in both patients. At 6 months after surgery, they were able to walk without intermittent claudication. CONCLUSIONS Conservative treatment can be a good option for popliteal artery occlusion after TKA in cases of rich collateral circulation.

Objective: To investigate the effectiveness of the wrap-around great toe flap combined with medial plantar artery perforator flap (MPAP) for repairing the completely degloved fingers., Methods: Between February 2018 and December 2019, 12 patients with the completely degloved fingers caused by machine strangulation were admitted. There were 9 males and 3 females with a median age of 32 years (range, 18-42 years). The injured finger was index finger in 7 cases, middle finger in 3 cases, and ring finger in 2 cases. The skin was avulsed from the metacarpophalangeal joint level, with the intact tendon and joint. The interval between injury and admission was 1-8 hours (mean, 5 hours). All fingers were taken debridement during the emergency operation. The size of the skin defect ranged from 8.0 cm×5.0 cm to 12.0 cm×7.5 cm. After flap thinning, the wrap-around great toe flap (8.0 m×2.0 cm-12.0 cm×3.5 cm) and MPAP (8.0 cm×4.0 cm-12.0 cm×5.5 cm) were used to repair the degloved finger. The donor sites were repaired with the full-thickness skin graft or the flap., Results: All flaps and skin grafts survived completely without significant complications and the wounds at recipient and donor sites healed by first intention. All patients were followed up 12-16 months (mean, 14 months). The texture, appearance, and color of the affected fingers were close to those of normal fingers, and the nails grew normally. At last follow-up, the mean two-point discrimination of the flap was 9 mm (range, 8-10 mm), and the sensation of the injured finger recovered to S 3 -S 4 . And 10 cases were rated as excellent and 2 cases as good according to the Michigan Hand Outcomes Questionnaire (MHQ). There was no complication such as pain from walking or skin ulceration at the donor site. The American Orthopaedic Foot and Ankle Society (AOFAS) score was excellent in 9 cases and good in 3 cases., Conclusion: Treating for the completely degloved fingers, the wrap-around great toe flap combined with MPAP can obtain good effectiveness in the respect of the sensation, function, and appearance.

Objective: To explore the feasibility of peroneal perforating chimeric tissue flap in repairing the composite defects of calf and heel based on lower limb angiography, and the clinical effect., Methods: The digital subtraction angiography images of lower limbs of 50 patients met the selection criteria between May 2011 and October 2014 were used as the research object to observe the course of peroneal artery and its perforating vessels. Based on the observation results, between April 2015 and October 2020, the peroneal perforating chimeric tissue flap was designed to repair 7 cases of composite defects of the calf and heel. There were 5 males and 2 females with an average age of 38 years (range, 25-55 years). The causes of injury included traffic accident in 4 cases, falling from height in 2 cases, and machine strangulation in 1 case. There were 5 cases of calf skin defect and tibial defect. The size of skin defect ranged from 5 cm×3 cm to 11 cm×7 cm, and the length of bone defect was 5-8 cm. There were 2 cases of heel skin defect and calcaneal defect. The sizes of skin defects were 5.0 cm×4.0 cm and 7.5 cm×6.5 cm, and the bone defects were 3.0 cm×2.6 cm and 4.0 cm× 3.0 cm. For the calf defect, the size of skin flap ranged from 6 cm×4 cm to 12 cm×8 cm, and the length of the fibula was the same as that of the tibial defect. For the heel defect, the sizes of the skin flaps were 8.5 cm×5.5 cm and 13.0 cm×5.0 cm, and the lengths of the fibulae were 10 cm and 12 cm. Free transplantation was performed in 5 cases and pedicle transplantation in 2 cases. The wound at donor site was repaired with skin grafting or sutured directly., Results: The peroneal artery ran close to the fibula 7.25-8.40 cm below the fibula head and send out 5-7 perforating vessels, with an average of 6.5 vessels. Perforating vessels mainly appeared in four places, which were (9.75±0.91), (13.21±0.74), (18.15±1.22), and (21.40±0.75) cm below the fibular head, with the occurrence rates of 94%, 90%, 96%, and 88%, respectively. Clinical application of 7 cases of peroneal perforating chimeric tissue flap all survived, all wounds healed by first intention. The skin graft at donor site survived and the incision healed by first intention. All patients were followed up 6-36 months, with an average of 12 months. Peroneal perforator chimeric tissue flap had good shape and soft texture. X-ray films showed that the bone graft healed well, and the healing time was 6-11 months (mean, 7 months). No obvious bone resorption was observed during follow-up. Five patients had no pain when walking, and 1 had mild pain with claudication. Postoperative heel ulcers formed in 1 case and healed after wearing custom plantar pressure dispersing shoes. At 6 months after operation, 2 patients were rated as grade Ⅳ and 5 patients as grade Ⅴ according to Holden walking function score., Conclusion: The peroneal perforating vessel distribution is constant and the peroneal perforating chimeric tissue flap is safe and reliable for repairing the composite defects of calf and heel.

Purpose and Background: The posterior tibial artery perforator-plus fasciocutaneous (PTAPF) flap is commonly used for defects over the distal lower extremity. However, the causes of partial necrosis of the PTAPF flap are unknown. This paper aimed to explore the factors related to the partial necrosis of the PTAPF flap., Methods: A retrospective study was conducted on 59 patients who received the PTAPF flap for soft-tissue defects between September 2007 and September 2017. The clinical outcomes of the flap were evaluated, and the patient and surgical factors related to flap survival were analyzed., Results: Of the 59 patients, 9 (15.25%) flaps exhibited partial necrosis. No significant differences were found between the survival and partial necrosis groups regarding gender, age, soft tissue defect site, length and width of the fascia pedicle, length of the skin island, length-width ratio (LWR), and pivot point (P > 0.05). However, the survival group showed significantly less width of the skin island and total length of the flap than the partial necrosis group (P < 0.05). Multiple logistic regression analysis revealed that the width of the skin island was an independent risk factor affecting partial flap necrosis (OR = 4.028; P = 0.041)., Conclusions: The PTAPF flap can be effectively used to repair small and medium wounds of the lower and middle leg, ankle and foot. As the width of the skin island exceeds 6 cm, the risk of partial flap necrosis significantly increases., (© 2021. Springer-Verlag GmbH, DE part of Springer Nature.)

Congenital talipes equinovarus (CTEV), or clubfoot, is the the most common encountered musculoskeletal defect encountered at birth. Most cases present as an isolated deformity, with up to half of them presenting with bilateral deformity. CTEV have also been reported to present as part of syndromic phenomena. Dr Igancio Ponseti proposed a serial casting programme to correct the foot's cavus, forefoot adduction, varus and equinus. Up to 90% of infants will require a tendo-achilles (TA) tenotomy for the persisting equinus deformity. TA tenotomy is deemed a relatively safe procedure, with the most authors citing bleeding as the most common complication. The Achilles tendon finds itself surrounded by rich network of blood vessels and nerves. We present a case of a ruptured pseudoaneurysm from the posterior tibial artery after percutaneous TA tenotomy was performed. This is a very rare complication and to our knowledge, only one other posterior tibial artery pseudoaneurysm has been reported., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The posterolateral approach to the distal tibia is commonly used for stabilisation of ankle fractures as it allows good visualisation and direct reduction of the posterior distal tibia and malleolar fragments. This approach can also be used for internal fixation of an associated lateral malleolus fracture. The aim of our study is to describe the surgical anatomy of the peroneal artery (PA) in relation to the tibial plafond and the distal fibula; thereby suggesting a safe zone during proximal dissection of posterolateral approach., Methods: Using Computed Tomography Angiographic (CTA) study, the course of the PA in relation to the tibial plafond and distal fibula was analysed in 142 lower limbs (bilateral limbs of 71 adult patients; 43 males and 28 females). Axial, coronal, and sagittal CT sections were cross-linked to specify the position of the PA. The PA course was identified and the level of its distal bifurcation over the tibia was marked. Perpendicular measurements were made from this point to the tibial plafond and tip of distal fibula., Results: The PA bifurcated distally at mean 58.3±24.2mm (SD) (range: 37.0-115.0mm) proximal to the right tibial plafond and mean 81.9±24.4mm (range: 54.0-137.0mm) from the right distal fibular tip. In the contralateral side, the PA bifurcated at mean 57.9±23.3mm (range: 36.0-125.0mm) proximal to the left tibial plafond and 81.8±23.9mm (range: 54.0-147.0mm) from the left distal fibular tip. The difference between the right and the left side of distal bifurcation point diameter of the same patient was assessed, range (0.0-58.0mm) with median 2.0mm and IQR 10.0mm. Three different PA vasculature patterns were identified., Conclusions: It is important for surgeons to be aware of the surgical anatomy of PA to avoid inadvertent injury during posterolateral approach to distal tibia. The PA may bifurcate as close as 36mm from the tibial plafond with possible variation bilaterally. Therefore, special attention needs to be considered by the operating surgeon while dissecting in this region due to the wide anatomical variation in vasculature. However, once the PA is mobilised, any fixation modality including posterior buttress plate could be safely performed., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interest. This includes any financial or personal relationships that could inappropriately influence our work., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: Chronic limb-threatening ischemia (CLTI) is frequently due to multilevel, heavily calcified lesions, and it is often associated with desert foot. Effective revascularization currently presents an additional challenge due to the increasing age, comorbidities, and frailty related to these patients. Pure endovascular treatment often fails to achieve effective and durable revascularization and it is associated with still high amputation rates. We present a novel hybrid approach and discuss its usefulness for limb salvage in complex infrainguinal lesions., Methods: Two no-option patients for both anatomical and medical-comorbidity reasons, were treated consecutively for CLTI. Both of them had prior failed percutaneous endovascular treatment, and bypass revascularization had been ruled out. We describe the technical details of an aggressive, but still less invasive hybrid approach, consisting of open distal popliteal artery (PA) and tibial trifurcation endarterectomy plus patch angioplasty, associated with proximal endovascular treatment with inter-woven nitinol stent from the superficial femoral artery (SFA) to the endarterectomized area., Results: Technical success and salvage of the affected limb were achieved in both cases, presenting significant postoperative clinical and hemodynamic improvement and allowing early discharge hospital at home. There was no surgical wound infection or other complications., Conclusion: This hybrid approach through a single incision is safe and effective in the short term and can be used with excellent results for CLTI in high-risk and /or no-option patients., (Copyright © 2021. Published by Elsevier Inc.)

Objective: We conducted a prospective evaluation of microperfusion parameters after tibial bypass surgery was performed. Differences between grafts with occlusions during follow-up and patent grafts were analyzed in relation to the pedal arch quality., Methods: Patients receiving tibial bypass grafts for chronic limb-threatening ischemia from 2019 to 2020 were included. Assessment of microcirculation (parameters: hemoglobin oxygen saturation [sO 2 ] and flow) was done by laser Doppler flowmetry and white light spectrometry (oxygen-to-see), supine and in elevation, whereas the macrocirculation was evaluated by the ankle-brachial index and duplex ultrasound examination. The quality of run-off was graded for each patient. Measurements were performed preoperatively, 1 day postoperatively, and after 6 months. Patients with graft occlusions during follow-up (OCCLUDED) and patients without occlusions (OPEN) were compared., Results: We included 42 patients (13 women, 29 men; mean age, 76.1 years; range, 60-89 years) were included. The patency of all grafts 1 day after the operation was confirmed by ultrasound examination. The overall analysis of the microcirculation showed significant changes in both the supine and elevated leg position between measurements taken preoperatively, 1 day after the operation, and after 6 months for the parameters sO 2 and FLOW (sO 2 supine, P = .001; sO 2 elevated, P < .001; FLOW supine, P < .001; FLOW elevated, P < .001). The comparison of the values 1 day after the operation yielded significantly decreased microperfusion parameters (both O 2 and FLOW) in the group that developed bypass occlusion in the later follow-up period (sO 2 supine: OCCLUDED, 35.7% [7.3-65.0] and OPEN, 48.7% [25.0-72.3] P = .011; FLOW supine: OCCLUDED, 27.7 A.U. [12.7-52.7] and OPEN, 57.3 A.U. [16.0-106.7], P = .008). No significant differences in the severity of the arch impairment was found between the OPEN and OCCLUDED groups (P = .651). Absolute values of the parameters sO 2 and flow showed no correlation with the pedal arch classification., Conclusions: Significantly poorer microperfusion was detected postoperatively in patients with later occurrence of graft occlusions despite patent grafts on the first postoperative day. Microperfusion measurements might be a possible tool for the prediction of graft failure., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Aims - to determine levels of specific coagulation factors pre-operatively and intraoperatively in patients treated with either open or endovascular surgery for occlusion of infrainguinal arteries. Study design: Randomized controlled trial. Methodology: The study included 96 patients with atherosclerotic stenotic-occlusion lesions of the infrainguinal arteries. They were divided into two groups, A and B. The patients were either treated with open surgeryor endovascular surgery. Markers assessed included fibrinogen, fibrin stabilizing factor, thromboplastic blood activity, soluble fibrin monomer complexes, Plasma recalcification time, Platelet aggregation, and D-dimers amongst others. These were checked pre-operatively and post-operatively. All markers noted were higher in the experimental group compared to the control group. When comparing pre-operatively and intraoperatively, the values were even higher in the latter. Values between open and endovascular repair were more or less comparable. Extended duration of intraoperative time can lead to significant elevation of coagulation markers regardless of choice of surgery. This is not influenced by the preoperative state of the patient. While it is expected for the levels to fall in the patients eventually in the coming days, until then they are at higher risk for complications such as DIC. These markers can be used to guide decisions on whether to prolong revascularization surgery in infrainguinal arteries.

Case: A 29-year-old woman presented with a low-energy, minimally displaced pilon fracture with progressive pain and paresthesias in the affected foot, ultimately requiring open reduction and internal fixation. Intraoperatively, the deep peroneal nerve and anterior tibial artery and vein were entrapped within the fracture. After freeing the bundle and fixing the fracture, the paresthesias improved and ultimately resolved., Conclusion: Injury to the anterior leg compartment neurovascular structures should be considered in low-energy, minimally displaced pilon fractures. In this instance, progressive neurologic symptoms not consistent with the radiographic findings indicated the patient for surgical exploration and fixation., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B762)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)