2.2. Surgical method

Patient took supine position. After onset of general anesthesia, the operational field was disinfected to thoroughly debride the wound surface, remove the inactivated tissue, repair stump and expose the bone cross section. The dorsalis pedis artery and two companion veins, small saphenous vein revealed in anatomy were chosen as blood supply vessels for the recipient area. The deep peroneal nerve, sural nerve and plantar lateral nerve were chosen as recipient area nerve. By bipedal contrast, bone defect length and skin area were measured and designed. The wound received pressure dressing by complex iodine diluted gauze.

Vascularized fibular flap design is shown in Fig. 2. Ultrasound Doppler detection of lateral peroneal artery of contralateral calf was performed before the operation for skin perforation and marking. Flap and fibular length was designed based on dorsal wound surface with the marking point as the center. The flap area was 12 cm × 7 cm, and fibular length was 9 cm. Cut off appropriate length of lateral leg nervus cutaneus so that it remains in the flap. Find the peroneal artery, vein, peroneal artery perforation and fibular nutrition branch in the posteromedial fibula. Clamp the peroneal artery, vein, to facilitate foot blood supply. Cut off the required fibula with the swing saw according to the design line (Fig. 3), the free fibula shall carry a little muscular sleeve to protect the fibular blood vessel bundle. Dissociate appropriate length of the proximal and distal ends of the fibula arteries and veins to fit proximal and distal ends of descending branch of the dorsal and lateral circumflex femoral artery and vein, so that flow-through flap connecting free anterolateral femoral flap was formed.

Design vascularized fibular flap Fig. 3 cut fibular flap.

Cut fibula flap.

Ultrasound Doppler detection of descending branch of lateral circumflex femoral artery of contralateral calf was performed before the operation for skin perforation and marking. Flap was designed and cut based on dorsal wound surface with the marking point as the center. In area of 12 cm × 10 cm, the flap shall carry tensor fasciae latae to increase the plantar thickness, enhance wear resistance of the flap. The proximal and distal ends of descending branch of lateral circumflex femoral artery and vein were protected during the operation. Dissociate appropriate length of lateral femoral nerve for standby use (Fig. 4).

Anterolateral thigh flap.

Maintain the integrity of fibular vascular periosteum muscular sleeve after the cut, cut the fibula with swing saw at the design point 3 cm away from the distal end, and fold the two segments of fibula into a right angle towards the periosteal side (Fig. 5). Insert the proximal fibular flap into the tarsal bone with 1.5 g Kirschner to replace the fifth metatarsal, fix the other right angle and the medial remaining third metatarsal to form a transverse arch for bony support repair (Fig. 6). In the fixation process, the three-dimensional structure position of the reconstructed fifth metatarsal head should be adjusted according to the contralateral arch. Upwarp and sagging which affect the repair effect are not allowed. Under the microscope, the proximal end of peroneal artery and vein shall fit the dorsal foot artery and vein, the distal end of the peroneal artery and vein shall fit descending branch of lateral circumflex femoral artery and vein, small saphenous vein of peroneal artery flap and lateral leg nervus cutaneus shall fit the dorsal vein and deep peroneal nerve respectively, anterolateral femoral flap superficial vein and the femoral lateral nerve shall fit the saphenous vein of lateral malleolus and sural nerve respectively. Cover the fibular flap to repair dorsal foot, cover the anterolateral femoral flap to the repair the pelma. Close the wound.

Fixation of bone graft.

Healing of bone graft.