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Assessment of the results regarding the reconstruction ofcomplex soft tissue defect at the foot and ankle region usinganterior lateral thigh flapsNew contributions of the thesis: The pr

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALH HANOI MEDICAL UNIVERSITY ======= VU THI DUNG RESEARCH ON THE USE OF ANTEROLATERAL THIGH FLAP IN TREATING COMPLEX SOFT TISSUE DEFECTS IN THE FOOT AND ANKLE Major: Surgery (Orthopedic and Plastic surgery) Code: 9720104 SUMMARY OF DOCTORAL THESIS IN MEDECINE HANOI – 2023 This research was accomplished at: HANOI MEDICAL UNIVERSITY Supervisor: Professor Trần Thiết Sơn, PhD, MD Reviewer 1: Reviewer 2: Reviewer 3: Thesis will be defended to Assessment Committee of Hanoi Medical University Organized at Hanoi Medical University At ……………………………………… The thesis can be found at: - National Library of Viet Nam - Central Medical Information Library LIST OF PUBLISHED RESEARCHES Vu Thị Dung, Pham Thi Viet Dung The results of free anterolateral thigh for reconstruction of the complex foot and ankle soft tissue defect Vietnam medical journal 2022; vol 512(1) – Vu Thi Dung, Tran Thiet Son, Pham Thi Viet Dung To evaluate the flexibility of the anterolateral thigh flap in reconstructing the complicated defect of the ankle and foot Vietnam medical journal 2023; vol 527(1) 336 – 340 THESIS INTRODUCTION The anatomical features of the foot and ankle region consist of multiple structures The skin covering the foot and ankle varies in thickness depending on the area: the ankle and instep are covered with a thin layer of skin, with little subcutaneous fat underneath When injured, these areas easily reveal special structures such as tendons, bones, and joints Surgical reconstruction of complex soft tissue defects in the foot and ankle region must ensure adequate skin coverage and functional restoration of tendons, bones, and joints to enable patients to walk and wear footwear This poses a challenge and requires appropriate treatment methods The anterior lateral thigh (ALT) flap was first described by Song et al in 1984 Since its introduction, the ALT flap has become a versatile and ideal source of tissue for reconstructing defects throughout the body The flap has many advantages, the ALT flap can be used as a adipocutaneous flap, myocutaneous flap, fasciocutaneous flap, or as a composite or chimeric flap Moreover, where the thickness can be reliably thinned during the same surgical procedure or combined with a muscle sling to cover dead spaces in the defect In Vietnam, the anterolateral thigh (ALT) flap has been extensively researched and applied in clinical treatment However, there haven't been many studies evaluating the effectiveness of using free ALT flaps for complex soft tissue reconstruction in the foot and ankle region Therefore, we conducted a research project titled: " Research on the use of anterolateral thigh flap in treating complex soft tissue defects in the foot and ankle" The research aims to achieve the following two objectives: Description of the foot and ankle soft tissue defect and proposal for the use of anterior lateral thigh flap in the management of complex soft tissue defects Assessment of the results regarding the reconstruction of complex soft tissue defect at the foot and ankle region using anterior lateral thigh flaps New contributions of the thesis:  The proposed indication for the use of the anterior lateral thigh (ALT) flap: for patients with soft tissue defects in the ankle region larger than cm², accompanied by exposed tendons or loss of tendons, bones, joints, blood vessels, or gravity-loaded related injuries such as fractures, chronic infections, or Achilles tendon defects  The thesis thoroughly describes the indications for using different types of ALT flaps that are suitable for various positions and degrees of injury It evaluates the results of utilizing these flaps for complex defects in the ankle region, thus demonstrating that the versatile design of the free ALT flap is a safe and reliable choice, ensuring both functional and aesthetic outcomes for complex soft tissue defects in the ankle region Thesis structure: Beside the introduction and conclusion, this thesis has 128 pages, including the following sections: introduction, pages, Chapter 1: Overview, 36 pages; Chapter 2: Subjects and research method, 18 pages; Chapter 3: Results, 27 pages; Chapter 4: Discussion, 40 pages, Conclusion, pages This thesis had 31 tables 60 figures pictures and photos 149 Vietnamese and English references CHAPTER OVERVIEW 1.1 Anatomical features of the foot and ankle region 1.1.1 Anatomy of the foot and ankle region The skin of the foot has a special structure In the ankle, dorsal, and area behind the heel, it's thin, moderately mobile, while in the ball of the foot, the epidermis is smooth, and the dermis is thicker, anchored to the bone foundation The heel is more firmly anchored to the thick calcaneus bone The ankle corresponds to the joint between the lower ends of the leg bones and the talus bone Based on the anatomical structure as well as the function and aesthetics of the foot and ankle area, Hallock G.G categorizes it into subunits of defects as follows:  Zone 1: Toe subunit  Zone 2: Forefoot pad subunit  Zone 3: Midfoot pad subunit  Zone 4: Heel subunit  Zone 5: Dorsal subunit  Zone 6: Ankle subunit, including the inner and outer malleoli  Zone 7: Area behind the heel, including the Achilles tendon Figure 1.1 Division of the foot and ankle subunits according to Hallock G 1.1.2 Blood supply to the foot and ankle region The foot and ankle region is supplied by two main arterial sources: the anterior tibial artery (ending as the dorsal foot artery) and the posterior tibial artery (ending as the medial and lateral plantar arteries) The terminal branches interconnect to form the superficial and deep plantar arterial arches 1.2 Clinical Characteristics of Defects in the Foot and Ankle Region Clinical morphology of skin defects in the foot and ankle region varies depending on the cause and mechanism of injury Based on understanding the cause, the extent of damage can be accurately assessed 1.2.1 Causes of injury 1.2.2 Level of injury Simple Skin Deficiency: Skin in the foot and ankle region is thin and mobile, making it prone to simple skin defects when injured, resulting in small to large areas of pure skin loss Soft Tissue Deficiency with Ligament, Tendon, Bone, or Joint Involvement: These are complex soft tissue defects that can encompass a wide area of the skin along with ligament, tendon, bone, blood vessel, and nerve damage, including tearing, fractures, or loss of these structures Combined Injuries: Injuries in the foot and ankle region can be associated with systemic conditions such as head trauma, chest injuries, abdominal injuries, vascular trauma, and nerve injuries 1.2.3 Size of defect Hidalgo and Shaw proposed clinical criteria for classifying defects in the foot and ankle region based on size, condition, and location of the defect The authors divided them into three levels:  Level I: Skin defects less than cm²  Level II: Larger soft tissue defects greater than cm², with or without amputation, without exposed bone  Level III: Extensive defects with exposed bones in the ankle, heel, or distal ends of the leg bones 1.3 Treatment Methods for Soft Tissue Deficiency in the Foot and Ankle Region 1.3.1 Treating Wounds in the Foot and Ankle Region 1.3.2 Soft Tissue Defect Reconstruction Techniques in the Foot and Ankle Region For soft tissue defects in the foot and ankle region, it is essential to adhere to the principles of debridement, thorough wound cleaning, and appropriate coverage techniques as early as possible 1.4 Anterior lateral thigh flap 1.4.1 Clinical anatomy of ALT flap The ALT flap, first described by Song YG in 1984, is characterized as a branch flap originating from the descending branch of the lateral circumflex femoral artery (LCFA) Over time, the ALT flap has been extensively studied in terms of its anatomy and widespread clinical applications The vascular pedicle of the ALT flap typically includes one artery and two vein along with accompanying sensory nerves from the lateral femoral cutaneous nerve The length of the vascular pedicle of the ALT flap is approximately to 15 cm, with some cases allowing for longer pedicles, up to 20 cm, when including distant perforator branches Regarding the size of the ALT flap, the anterior lateral thigh region offers a relatively large area for harvesting According to Wei F.C., when designing the ALT flap: - The length of the flap ranges from 16 cm (approximately - 35 cm) - The width of the flap ranges from cm (approximately - 25 cm) 1.4.3 Flexible applications of ALT flap in treating complex soft tissue defects in the foot and ankle region 1.4.3.1 Reconstruction the anterior plantar foot by ALT flap The anterior plantar foot is a critical weight-bearing area that enables humans to stand and walk It possesses unique histological characteristics, including a thick layer of skin and subcutaneous fat tissue These are challenging features to replace, and when damaged, they can significantly impact weight-bearing capacity and normal gait Ideal reconstruction of the anterior plantar foot aims to restore weight-bearing function in daily activities and recreate the contour of the foot to accommodate regular footwear 1.4.3.2 Reconstruction the dorsal foot, ankle and posterior heel by ALT flap The skin and subcutaneous fat tissue beneath the foot arch and ankle can be thin, and when damaged, they may expose tendons, toe bones, sesamoid bones, or ankle joints Reconstructing the soft tissue in this area often requires the use of a thin flap to enable patients to wear regular shoes comfortably The primary goal of soft tissue reconstruction in the arch and ankle region is to preserve both function and aesthetics 1.4.3.3 Reconstruction the heel by ALT flap Reconstructing the heel remains a challenge for plastic surgeons and is an area of ongoing debate regarding techniques However, most authors agree that the flap used for heel reconstruction must withstand weight-bearing and maintain the anatomical shape of the heel Due to the unique characteristics of the skin in the heel region, optimal function can often be achieved using local and adjacent flaps Still, in the majority of cases, particularly with larger defects, free flaps are the preferred solution 1.4.3.4 Reconstruction the posterior heel with Achilles tendon defect by ALT flap Combined skin and Achilles tendon defects are complex and challenging due to the lack of suitable local tissue for reconstruction In the past, the treatment of such defects often involved multiple stages: initially covering the skin with a flap and later reconstructing the tendon Nowadays, the use of free ALT flaps has facilitated the simultaneous reconstruction of both the skin and the Achilles tendon in a single surgery 1.4.3.5 The ALT flap is used to reconstruct wide, complex soft tissue defects with dead space in the foot and ankle region 10 psychiatric disorders, and those who not consent to participate in the study and attend follow-up examinations 2.2 Research Methods 2.2.1 Research Design Group 1: Observational cross-sectional study Group 2: Non-controlled clinical intervention study 2.2.2 Cỡ mẫu Convenient sample size 2.2.3 Research process The research process was conducted through the following steps: 2.2.3.1 Clinical examination, patient assessment 2.2.3.2 Surgical planning for patients with complex soft tissue defects in the foot and ankle region reconstructed using anterolateral thigh (ALT) flaps 2.2.3.3 Prepare surgical instruments 2.2.3.4 Prepare the patient before surgery  At the flap recipient site  At the flap donor site: Identify the perforator branches and preoperative design of the anterior lateral thigh (ALT) flap 2.2.3.5 Sugical procedure  Prepare the recipient site  Harvest the flap and design the flap  Flap dissection: Dissection the cutaneous flap, dissection the composite myocutaneous flap, dissection the chimeric myocutaneous flap, dissection of the chimeric fasciocutaneous flap, dissection of the chimeric cutaneouscutaneous flap, flap thinning  Close the flap donor site  Transfer the flap to the recipient site 2.2.3.6 Follow-up, care and treatment after surgery 11 2.2.3.7 Research index Characteristics of the patient group with soft tissue defects in the foot and ankle region:  Age and gender  Characteristics of the soft tissue defect: o Cause of the defect o Location and extent of the soft tissue deficiency o Size of the defect o Composition and nature of the damaged tissue o Time elapsed from injury to flap reconstruction  Description the characteristics of ankle and foot defect, classify simple and complex defect Base on the location, size of defect, surgeon can choose the material and type of flap for each injury The results of ALT free flaps in 45 patients with complex defects at ankle and foot defects  Type of flap used  Flap size, thickness, and perforator characteristics  Viability of the reconstructed flap  Complications at the flap donor and recipient sites  Aesthetic and functional recovery at the recipient and donor sites 2.2.3.8 Result evaluation Reviews of near results: Donor site, receipient site Evaluation of distant results (Assessment after months)  Aesthetic recovery at the recipient site  Functional recovery  Evaluation of sensory functional recovery at the recipient site 2.3 Data processing methods The research data were processed by medical statistics using SPSS software version 16.0, with the usual statistical characteristics: 12 mean, standard deviation, percentage, testing the difference between rates rate by algorithm for discussion and comparison 2.4 Research ethics Researcher warrants the Helsinki Declaration on Ethics in Research The study was approved by the ethics committee of Hanoi Medical University under Decision No 84/HĐĐĐHYHN dated May 31, 2017 CHAPTER RESULTS 3.1 Results of the description of soft tissue defects in the foot and ankle region Our study was conducted on 162 patients with soft tissue defects in the foot and ankle region, ranging from mild to severe Among them, one patient had Chopart amputation in both feet, resulting in a total of 163 soft tissue defects in the foot and ankle region 3.1.1 Age and gender 3.1.2 Characteristics of injury 3.1.2.1 Cause of injury 3.1.2.2 Degree of injury Table 3.1 Description of the degree of injury Degree of injury Skin deficienc y in a nonweightbearing Skin deficienc y in a weight- Expose d tendons, tendon injuries Soft tissue defects involvin g tendons, Soft tissue defects involvin g tendons, Tota l 13 bearing area bones bones, blood vessels, and nerves 35 65 11 163 21,47 39,88 6,75 100 area Numbe 13 39 r Percent 7,97 23,93 (%) 3.1.2.3 Injury region 3.2 Complex soft tissue defects in the foot and ankle region covered using various forms of ALT flaps In the study, there were 45 patients with complex soft tissue defects in the foot and ankle region who were designated for the use of ALT flaps 3.2.1 Location of the soft tissue defect and indications for using ALT flap forms Table 3.2 Location of the soft tissue defect and the form of ALT flap usage Injury region Soft tissue defects in the ankle, ankle dorsum, posterior heel Soft tissue defects in the plantar foot, dorsal foot and ankle Soft tissue defects in the heel Soft tissue defects with dead space Soft tissue defects with exposed bone Flap type Total fascio-cutaneous flap or thinned cutaneous flap 34 22 6 2 Myo-cutaneous flap Myo-cutaneous chimeric flap 10 14 Myo-cutaneous chimeric flap Soft tissue defects in the posterior heel with Achilles defect Soft tissue defects in the ankle and dorsal foot Soft tissue defects in the plantar foot, dorsal foot Total Fascio-cutaneous chimeric flap Cutaneous cutaneous chimeric flap 1 45 54 3.2.2 Results of using the anterior lateral thigh (ALT) free flap The average flap size was 19.3 ± 5.2 x 9.3 ± 1.9 cm, with the smallest flap measuring x cm and the largest flap measuring 30 x 11 cmPhân bố số lượng mạch xuyên Table 3.3 Number of perforating blood vessels for the flap Characteristics of flap vascularization Number (n) Percent (%) perforator 14 31,11 perforators 26 57,78 perforators 11,11 Total 45 100 o The average length of the pedicle artery is 8.7 ± 2.8 cm, with the longest pedicle artery measuring 15 cm and the shortest measuring cm 3.2.3 Results after surgery one month  Flap survive: 15 2.22% 2.22% 95.56% Vạt sống Vạt thiểu dưỡng Vạt tháo bỏ Chart 3.1 Viability of the flap  Flap healing at the recipient site: In the study, the immediate flap healing rate was 41/45 (91.11%) There were 4/45 cases of delayed flap healing due to residual inflammation at the recipient site, which required wound cleaning and re-suturing in cases o Early complications Complications Recipient site Donor site Body Total necrosis Venous congestion Partial necrosis Hematoma Delay healing Delay healing Skin graft Blood deficiency Number of patients (n = 45) 1 4 1 Pneumonia Table 3.4 Early postoperative complications 3.2.4 Results after surgery six months Tỉ lệ (%) 2,22 2,22 2,22 8,89 8,89 2,22 2,22 11,1 2,22 16 Aesthetic recovery at the recipient site in the foot and ankle region Table 3.5 Assessment of aesthetics in the foot region: Aesthetic results Number (n=45) Percent % Excellent 32 71,11 Good 12 26,67 Normal 2,22 Poor 0 Total 45 100 Assessment of the patient's ability to wear shoes Table 3.6 Assessment of the ability to wear shoes of the same size Footwear status Number (n=45) Percent (%) Same size shoes 40 88,89 Only wears wide-size 8,89 shoes Wears orthopedic shoes 2,22 Total 45 100 Functional recovery of the foot and ankle region Assessed using the LEFS (Lower Extremity Functional Scale) scoring system Table 3.7 Assessment of foot function recovery Assessment recovery of Number (n=45) Percent % LEFS score > 64 40 88,89 LEFS score < 64 11,11 45 100 Total  foot function Late complications of the recipient site: 17 Table 3.8 Postoperative complications at months Late complications Recipient site Donor site Number Percent % (n=44) 2,27 0 0 0 Ulcer Infection Infection Thigh hernia Limited mobility CHAPTER DISCUSSION 4.1 Description of soft tissue defects in the foot and ankle region 4.1.1 Characteristics of soft tissue defects According to Hallock, complex foot injuries are defined as injuries involving multiple components (skin, bone, blood vessels, nerves), but soft tissue loss leading to significant defects is the primary determinant of whether the foot can be effectively restored Some authors suggest that when two out of four components are injured, with soft tissue loss affecting at least one subunit, the injury should be classified as complex Therefore, assessing the extent of injury using the subunits is necessary to classify the injury and determine specific, appropriate treatment methods to restore foot function and aesthetics and avoid the risk of amputation In our study, 23.93% of cases had simple non-weight-bearing soft tissue defects, while 76.07% had complex soft tissue defects (Grade III) with weight-bearing defects or injuries to tendons and bones Some cases involved bone loss combined with vascular injury