Clinical Application And Angiographic Study Of Medial Plantar Flap

Part One: Reconstruction of the distal lower leg,ankle and foot with medial plantar flapObjective: To describe our experience and outcomes with distal lower leg,ankle and foot reconstruction using the medial plantar flap.Methods: From January 2007 to December 2017,29 consecutive patients from our department underwent reconstruction of soft tissue defects over the distal lower leg,ankle,heel,and plantar forefoot using medial plantar flaps.According to the defect location,the patients were divided into three groups: the distal lower leg and ankle group,the heel group,the plantar forefoot group.The analysis included the cause of defect,preoperative preparation,operation process and postoperative result.The long-term appearance satisfaction and functional recovery were evaluated.Results: We reviewed a total of 29 medial plantar flaps,including 22(75.9%)anterograde medial plantar flaps,and 7(24.1%)reverse medial plantar flaps.28(96.6%)flaps survived completely.Lateral partial necrosis occurred in 1(3.4%)flap.The mean follow-up period was 18.6 months.At last follow-up,all survived patients could walk for more than 1 hour in normal shoes.In the heel group and plantar forefoot group,all patients were satisfied with the cosmetic appearance of the flap.In the distal lower leg and ankle group,5(62.5%)patients complained about the flap appearance.All donor sites were covered with a split-thickness skin graft,no complications were encountered,and none of patients complained about the donor site scar.Conclusion: The medial plantar flap may be considered as an effective method for the repair of small to medium soft tissue defects in the distal lower leg,ankle,heel,and plantar forefoot.It provides the concealed donor site,excellent aesthetic appearance,and full functional recovery with few complications.In addition,the medial plantar flap has the best aesthetic appearance and functional recovery for heel and plantar forefoot reconstruction.Part Two: Application of medial plantar flap after anterior tibial artery injuryObjective: To evaluate the feasibility of the medial plantar flap transplantation in patients with anterior tibial artery injury.Methods: From January 2015 to August 2019,a total of 7 patients from our department who had soft tissue defects around the ankle region accompanied by anterior tibial artery injury were enrolled in the study.The DSA was performed to show the hemodynamics of the ipsilateral foot.The medial plantar flap was harvested only after it was confirmed that the blood from the deep plantar arch was enough to supply the distal foot.After operation,the blood circulation of the flap and the ipsilateral toes were observed.Results: All of the following anatomical structures can be observed in all DSA examinations,including the medial plantar artery,the lateral plantar artery,the deep plantar arch,the dorsalis pedis artery and its deep plantar artery,the anastomosis between the deep plantar arch and the deep plantar artery of dorsalis pedis artery,and the anastomosis between the deep plantar arch and the medial plantar artery.All digital subtraction angiography examinations showed that the anterior tibial artery was damaged and the blood flow from anterior tibial artery to dorsalis pedis artery`was interrupted.The blood from the posterior tibial artery was redistributed to the ipsilateral foot through three pathways.The medial plantar artery was mainly distributed in the medial plantar region,and its terminal branch was anastomosed with the deep plantar arch.All flaps survived completely.The ipsilateral toes had abundant blood supply after operation.The mean follow-up period was 13.7months.All flaps had no bloating and ulceration.No complications such as pain,ulcer and necrosis occurred in the ipsilateral toes.Conclusion: The DSA is able to accurately and intuitively evaluate the hemodynamics of foot in patients with anterior tibial artery injury.The DSA data and clinical practice proved that the anterior tibial artery injury is not the contraindication of the medial plantar flap.Part Three: Anatomical basis and application of reversed medial plantar flapObjective: To accurately investigate the hemodynamics of the ipsilateral foot using DSA,guide the transfer of reversed medial plantar flap for the plantar forefoot defect,and evaluate the reliability of the digital subtraction angiography(DSA)for guiding the reversed medial plantar flap transfer.Methods: From January 2015 to August 2019,a total of 5 patients suffered from soft tissue defect of the plantar forefoot were enrolled in the study from our department.The DSA was performed to show the hemodynamics of the ipsilateral foot and provide the evidence for the reversed medial plantar flap transplantation.Results: The medial plantar artery and the deep plantar arch can be observed in all DSA examinations.The superficial branch of the medial plantar artery can be observed in all DSA examinations,and the deep branch of the medial plantar artery only can be observed in 3 DSA examinations.The anastomosis between the deep plantar arch and the superficial branch of the medial plantar artery can be observed in all DSA examinations,and the anastomosis between the deep plantar arch and the deep branch of the medial plantar artery only can be observed in 2 DSA examinations.The mean follow-up period was 15.2 months.All flaps had no bloating and ulceration.Conclusion: DSA showed that the anatomical basis of reversed medial plantar flap was the anastomosis between the deep plantar arch and the superficial branch of the medial plantar artery which provided the imaging evidence for the application of the reversed medial plantar flap in the soft tissue defect of the anterior plantar.