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MINISTRY OF EDUCATION AND TRAINING MINISTRY OF NATIONAL DEFENSE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCE NGUYEN QUANG VINH ANATOMICAL AND CLINICAL INVESTIGATION OF THE FREE SENSORY FASCIOCUTANEOUS DELTOID FLAP FOR SOFT TISSUE DEFECTS RECONSTRUCTION OF THE FOOT WEIGHT-BEARING AREA Specialty: Orthopaedic Trauma and Reconstructive Surgery Code: 62720129 MEDICAL DOCTORAL THESIS SUMMARY HANOI 2019 THE WORK HAS BEEN COMPLETED AT 108 MILITARI CENTRAL HOSPITAL Scientific instructors: Prof., Dr of Science Nguyen The Hoang Reviewer 1: Prof., PhD Le Gia Vinh Reviewer 2: Assoc Prof., PhD Pham Dang Ninh Reviewer 3: Assoc Prof., PhD Lam Khanh The dissertation defense will take place in front of 2nd dissertation committee in 108 Institute Of Clinical Medical And Pharmaceutical Science at hour: DD/MM/YYYY This Study available at: National Library of Viet Nam Library of 108 Institute Of Clinical Medical And Pharmaceutical Science BACKGROUND The weight-bearing area of the foot has unique physiological and anatomy features (characteristics) to adapt to the role of bearing gravity Until now, the reconstruction of the weigth bearing area of the foot has always been a challenge due to the lack of comparable replacement materials The skin grafts are a simple method, however skin graft has no bearing gravity The local random flaps are only suitable for small defects The local neurovascular island flaps have treated a lot of defects in the weight-bearing area of the foot, but the applicability of local neurovascular island flaps was limited by the size and sometimes these flaps were not available If using crossflaps, cylinder flaps, the patient has to undergo many surgeries, suffering from long-term restrictive posture The reconstruction by free flaps has been successful since the 70s of last century and has flourished for more than last four decades Overcoming the initial challenges of covering defects only for the purpose of wound healing, the present challenge is the increasing functional and aesthetic requirements For defects in the weight-bearing area of the foot, covering is required a thin flap, good perfusion ability, sensation to protect the flap, size of the flap is large, hairless and possibly minor donor-site comorbidities The fasciocutaneous deltoid free flap is one of the few flaps that can meet most of the above criteria The fasciocutaneous deltoid free flap was discovered by Franklin J.D in 1984 Later, many authors applied this flap to cover the defects of the hands, feet and face Overall, the fasciocutaneous deltoid free flap was found to be suitable for covering defects in the weight-bearing area of the foot by the authors However, the anatomical studies on flap has been less informed These studies also did not mention much about the anatomical characteristics of the Posterior circumflex humeral vascular bundles and the sensory nerve branches of the flap About the thickness of this flap and especially the size of blood vessels of this flap on the body has not been mentioned by any author In Vietnam, the sensory deltoid free flap has been used in Military Central Hospital 108 since 2005 The initial results of using flap to treat defects in the weight-bearing area of the foot are encouraging However, there is currently no systematic study linking the anatomy study of the flap with clinical applications For all above reasons, we studied "Anatomical and clinical investigation of the free sensory fasciocutaneous deltoid flap for soft-tissue defects reconstruction of the foot weight-bearing area " Our goals were: Research on anatomical characteristics of fasciocutaneous deltoid free flap in Vietnamese adults Assess the results of clinical application to treat soft-tissue defects in the weight-bearing area of the foot Our contribution Using ultrasound to measure the thickness of the fasciocutaneous deltoid flap: In Vietnam, this is the first time this method has been performed The results show that this method is reliable, practical and scientific Determine the length, diameter and three-dimensional image of arterial system blood- supplying for deltoid flap on the living organism through CTA-320 For deltoid flap, this is the first time this method has been used Detecting anatomical abnormalities related to the original types, course of the posterior circumflex humeral artery and cutanous branch artery This finding gives surgeons more confidence in using deltoid free flap on clinically Determine the participation of deltoid flap in walking through footprint: In Vietnam, this is the first time this method has been applied Currently, the deltoid flap is rarely used and reported in the literature This study contributes to affirming that deltoid flap is a suitable and reliable material when choosing flaps that cover expose tendons, bone, joint defects in weight-bearing area of the foot STRUCTURE OF THE THESIS Total page: 127 - Introduction: pages - Chapter Overview: 31 pages - Chapter Method: 29 pages - Chapter Result: 28 pages - Chapter Discussion: 34 pages - Conclusion: pages - Include: 13 tables, figures, 67 photos - References: 144 (Vietnamese: 29, Foreign languages: 115) - reports related to our study has been announced Chapter 1: OVERVIEW 1.1 Anatomy and physiological characteristics of weight- bearing area of the foot 1.2 Treatment of defects in weight-bearing area of the foot 1.2.1 Skin grafts method 1.2.2 The local random flaps 1.2.3 The local neurovascular island flaps 1.2.4 The flaps moves from afar 1.2.4.1 The flaps moves from afar without vascular anastomosis 1.2.4.2 The free flaps a The muscle flaps recontruction of soft-tissua defects in the weightbearing area of the foot b The fasciocutaneous flap and role of sensation when recontruction of defects in the weight- bearing area of the foot In 1990, Meland studied free flaps reconstruction in the weightbearing area of the foot and synthesized literature, showing the following trends in the choice of fasciocutaneous flaps Initial, the largest number used were the tensor fascia lata flaps They were reported early in the literature and had a high minor and major complication rate of 20-47%, respectively Eleven of these flaps were also innervated with a 36% ulceration rate despite adequate return of two-point discrimination in the 25-30mm Because of the thickness of this flap and its inability to withstand the stress forces of ambulation, most authors have now abandoned it Of particular interest is the noted success of the relatively more recently described, thin fasciocutaneous flaps that may provide sensory innervation (i.e., the radial forearm, dorsalis pedis, and the deltoid flap) This review included 24 of these flaps, all with very minor complications that responded well to local, conservative therapy The only major complication was an infection that required debridement in one radial forearm flap All of the innervated flaps eventually developed two-point discrimination in the 20-30 mm range and the flaps seemed to hold up very well to the stresses of ambulation They most certainly showed improved results when compared to the early, thicker fasciocutaneous flaps studied including the tensor fascia lata, scapular/parascapular, and groin flaps Summary: There are many options for recontruction of soft-tisue defects in the weight-bearing area of the foot Skin grafting is usually only considered a temporary solution The Cross-flap is only applied to save limbs in special cases Most commonly used in reconstruction in the weight-bearing area of the foot is local neurovascular flaps and free flaps With limit size defects is local neurovascular flaps is often chosen Nowadays, with the advancement of microsurgical techniques, along with the increasing demands on functional and aesthetic reconstruction, free flaps are increasingly more widely assigned The free flaps are often used to cover in the weight-bearing area of the foot is the free sensory fasciocutaneous flap and muscle flaps Because of the thickness of the flap, skin grafts must be grafted onto the surface and there is no sensation so muscle flaps only really fit deep cavities, osteoarthritis The free sensory fasciocutaneous flap, especially thin flaps such as the anterior thigh flap, radial forearm flap, lateral arm flap and deltoid flap are the preferred ones, even with large imperfections, with shallow bone damage, superficial osteitis 1.3 The fasciocutaneous deltoid flap 1.3.1 Anatomy research situation of fasciocutaneous deltoid flap 1.3.1.1 In the world The fasciocutaneous deltoid free flap was discovered by Franklin J.D in 1984 The flap is the skin covering the deltoid muscle and posterolateral arm The axis of the flap is the path connecting acromion and medial epicondyle The flap is dominated sensation by the lateral brachial cutaneous nerve separated from axilary nerve The pedicle consists of cutaneous vascular bundles separated from Posterior circumflex humeral vascular bundles According to Franklin, the pedicle has a length of about - 8cm, posterior circumflex humeral artery has a diameter of about - 4mm, cutaneous branch artery has a diameter of about 1mm and usually has two dependent Posterior circumflex humeral artery (PCHA) and cutaneous branch artery’course and branch distribution: According to Franklin, from original in axillary artery, PCHA runs back through Velpeau quadrangle space and then go around the surgical neck of the humerus The PCHA is divided into several branches, including: the branch connected to the deltoid branch of the deep arm artery, the branch connected to the anterior humeral circumflex artery, the branches supply blood to the deltoid muscle and the cutaneous branch artery supply blood to the deltoid flap Cutaneous branch artery travels within the deltoid-triceps muscles wall to enter the flap Russell (1985) and Strauch (1993) described a bifurcation of cutaneous branch artery in the muscular septum, and the case of a branch going through the deltoid muscle However, both authors did not give statistial ratios Pedicle position enters the flap: According to Franklin, the pedicle position enters the flap at the back of point A (the intersection of the axis of the deltoid flap and the back edge of the deltoid muscle) and the average distance from point A is 2cm This distance according to Wang is 1.86cm and according to Meltem is 1.5cm In 2003, Wang was dissection the vascular network of deltoid flap at 21 cadavers The skin vascular network of deltoid flap consists of five layers and the vascular network of deep fascia is the most dense with 96.5 ± 14 artery branch / mm2 Through the continuity of the vascular network from the cutaneous branch artery to the vascular network from multiple musculocutaneous perforators, from the brachial artery, the transverse cervical artery, the thoracoacromial artery helps the flap to be well perfected and the flap blood supply area is expanded Wang is also the only author who mentioned the anatomical features of PCHA, and described this artery only penetrates the quadrangular space in 90 percent of cases, the remaining case it arose from the arch of the brachialis and profunda brachii and did not penetrate the quadrangular space 1.3.1.2 In Vietnam In 2013, dissection in 43 deltoid regions on formalin storage corpses, Nguyen Duc Nghia described the cutaneous branch artery always present and always derived from PCHA The cutaneous branch artery split branches at 74.42% (32/43 templates), in 5/43 templates (11.63%), after the split there was a branch that went through the deltoid muscle to enter the flap The author did not describe the posterior circumflex humeral bundle In general, the anatomy researchs on deltoid flap of authors in the country as well as in the world has focused mainly on the description of cutaneous branch bundle The research results show that deltoid flap has dense vascular network with lots of rich connections The anatomical characteristics of posterior circumflex humeral bundle have not been described According to the documents we found, the authors did not dissect deeply into the Velpeau quadrangle space to describe the anatomical characteristics of Posterior circumflex humeral bundle, as well as the sensory nerve branch of the flap The size of the pedicled deltoid flap has also been described by some authors, but the data are still very different The determination of the length and diameter of the pedicled deltoid flap on living organism has not been mentioned Regarding the thickness of deltoid flap, the authors all considered deltoid flap to be a thin flap, but no author had ever measured the thickness 1.3.2 Situation of deltoid flap clinical application 1.3.2.1 In the world 2.3.2.2 In Vietnam Through international and national literature, the deltoid flap is applied to cover hand defects and especially in the weight-bearing area of the foot With the advantage of color, some authors also applied deltoid flap to recontruction of oral and maxillofacial In general, the authors stated that fasciocutaneous deltoid flap is a thin flap, hairless, the constant vascular pedicle with a convenient length and diameter, safe for free flap transfer The deltoid flap has a rich vascular network, good perfusion, helps to minimize the phenomenon of pressure ulcer caused by the lack of support and anti-bacterial infection Statistics of 125 deltoid flaps covering soft-tissue defects have been reported by 13 authors, including complex soft-tissue defects and bacterial infections All deltoid flap are alive (100%), which helps heal injuries and facilitate patients both functionally and aesthetically The deltoid flap has a sensory nerve branch, can be harvested with a large size, allowing the donor site to be directly closed, scars are easy to hide and not affect the function of the deltoid muscle as well as the shoulder joint after surgery Disadvantage factors of the flap are also shown, which is the difficult flap dissection process due to the multiple branching of the neurovascular pedicle in Velpeau quadrangle space In addition, Krishnan and Musharafieh have recommended that scar donor sites be at risk for hypertrophic, especially in young patients (two authors did not give specific statistics) From this fact, we found that the results of deltoid flap application in the treatment of soft-tissue defects in the weight-bearing area of the foot were positive However, thickness and sensory nerve branches of the flap have not been described The posterior circumflex humeral bundle characteristics are just mentioned very briefly The determination of the length and diameter of the pedicled deltoid flap on living organims has not been mentioned In addition, the number of patients of each author is small (< 20 patients) Some characteristics of reinnervation, the function of using the flap and the aesthetic problem of the whole tie-receiving place and donor site have not been specifically described by the authors From the above reasons, we believe that the implementation of the subject: "Anatomical and clinical investigation of the free sensory fasciocutaneous deltoid flap for soft-tissue defects reconstruction of the foot weight-bearing area" to have more general conclusions about the anatomy and results after shaping the flap is needed Chapter 2: SUBJECT AND METHODS 2.1 Research on anatomical characteristics of fasciocutaneous deltoid flap 2.1.1 Measure the thickness of deltoid flap through ultrasound - Subjects: 72 deltoid areas/36 patients, from 4/2015-12/2017 at department C7, of Military Central Hospital 108 - Methods: Using soft tissue ultrasound program with frequency probe 7-16 MHz on Logiq S8 machine manufactured by GE The probe is gently applied to the surface of the skin without subsidence, measuring the thickness of the deltoid flap in positions: (located on the axis and below 5cm A point), (point A- intersection of the axis of the flap and posterior deltoid muscle), (acromion), (located on the axis and on the acromion 5cm), and (two symmetrical positions via acromion and 5cm from the acromion, position in front and position in the back), and (two symmetrical positions over point A and 5cm from point A, position in front and position on the back) - Evaluation criteria: Average thickness at locations on the flap (mm) and average thickness of flap 2.1.2 Determination of blood artery system for deltoid flap through CTA-320 - Subjects: 54 shoulder and arm areas of 27 Vietnames adult patients, pre-surgical angiography with CT-320 at Diagnostic Imaging Department of Military Central Hospital 108 from 5/2015 - 5/2017 12 - Comorbity at the donor site: criteria: (1) Patient ’s satisfaction with scar at the donor site, (2) Deltoid muscle and shoulder joint function, (3) Scars formed after harvest flap and ( 4) Ability to hide scars + Investigation patient satisfaction with scar at the donor site: Includes levels: (1): Very satisfied, (2): Satisfied, (3): Accepted and (4): Not satisfied + Deltoid muscle and shoulder joint function: Very Good, Good, Fair and Poor + Cosmetic problem of scar after harvest flap: levels: good scar, spread scar, hypertrophic scar and keloid scar + Ability to hide scars: Very Good, Good, Fair and Poor + General classification of comorbity at the donor site: Based on the criteria above, the overall results are classified into corresponding levels: Very Good, Good, Average and Poor when that level is achieved at 3/4 criteria Chapter 3: RESULTS 3.1 Anatomical research results fasciocutaneous deltoid flap 3.1.1 Result of thickness of fasciocutaneous deltoid flap Table 3.1 The thickness of fasciocutaneous deltoid flap Data (n=72) Position 1: 5cm below point A Position 2: point A Position 3: acromion Position 4: 5cm above the acromion Position 5: in front of the acromion 5cm Position 6: 5cm behind the acromion Position 7: in front of point A 5cm Position 8: cm behind point A Average thickness of the flap Thinnest (mm) 4,7 6,5 3,2 3,0 3,2 3,4 3,4 4,8 Thickest (mm) 8,4 11,5 6,5 6,2 6,5 6,8 7,2 8,4 ± SD 6,11 ± 0,9 7,87 ± 1,17 4,11 ± 0,76 3,81 ± 0,7 3,99 ± 0,75 4,22 ± 0,78 4,76 ± 0,92 6,03 ± 0,89 5,14 ± 0,81 The average thickness of the flap through ultrasound is: 5.14 ± 0.81mm The thickest flap at the vascular position enters the flap (position 2) and thins towards the shoulder (Table 3.1) 13 3.1.2 Artery system results on CTA-320 3.1.2.1 Posterior circumflex humeral artery Origins and paths: Posterior circumflex humeral artery (PCHA) is always present, separated from axillay artery in 42/54 cases (77.78%), separated from subscapular artery in 7/54 cases (12.96%) When separated from axillay artery or subscapular artery, PCHA always passes through Velpeau quadrangle space In 5/54 cases (9.26%) PCHA separated from brachial artery and did not pass through Velpeau space Branches: The posterior circumflex humeral artery divides about 7-10 branches to supply blood to the deltoid area and connects to the anterior circumflex humeral artery, deep brachial artery The length and diameter of posterior circumflex humeral artery: diameter: 3,38± 0,58mm (2,2-4,5), length: 43,08±6,60mm (27,7 ± 60,2) 3.1.2.2 Cutaneous branch artery Origins: Cutaneous branch artery is always present in all 54/54 CTA-320 films (100%) and is derived from posterior circumflex humeral artery The length and diameter: length: 44,57 ± 4,83mm (34,5 - 56), diameter: 1,49 ± 0,28mm (1,1 - 2,5) Cutaneous branch artery ’s caurse and branches: The image of skin vascular network of deltoid flap is not shown clearly on CTA-320 in many cases, so this criterion is not statistically significant 3.1.3 Result of dissection on cadaver 3.1.3.1 Neurovascular pedicle and blood supply area a Artery: - Posterior circumflex humeral artery (PCHA): + Origins and paths: In 45/54 cases (83.33%) PCHA separated from axillay artery and in 6/54 cases (6.11%) separated from subscapular artery In these cases (51/54 cases = 94.44%) PCHA always passes through Velpeau quadrangle space In 3/54 cases (5.56%) PCHA was originally derived from brachial artery and did not cross Velpeau quadrangle space 14 + Branches: PCHA divides about 7-10 branches, include of about 3-5 blood supply branches for deltoid muscle, branch connected to the deltoid branch of deep brachial artery, branch connected to anterior circumflex humeral artery, branches for teres minor muscle, teres major muscle and cutaneous branch artery blood supply to the deltoid flap + The length and diameter: described in table 3.2 Table 3.2 Length and diameter of PCHA and accompany veins Data Cadaver form Diameter of artery Diameter of vein Diameter of vein 2* Length of artery Length of vein Min (mm) Max (mm) PC FC PC FC 2,42 2,48 3,95 3,69 2,17 3,12 4,14 3,82 1,15 2,48 3,25 2,93 32 35 50 45 34 29 46 45 ± SD (mm) PC n=32 2,98 ± 0,29 3,35 ± 0,32 2,35 ± 0,41 38,75 ± 4,28 40,59 ± 3,87 FC n=22 3,16 ± 0,26 3,51 ± 0,17 2,62 ± 0,12 39,05 ±2,70 40,59 ±4,16 p 0,018 0,038 0,045 0,757 0,998 *: n= 17 on preserve cadavers and n=11 on fresh cadavers (28/54 cases have veins) PC: preserve cadavers FC: fresh cadavers - Cutaneous branch artery: + Origins: Cutaneous branch artery is always separated from PCHA (100%) + Branches: Cutaneous branch artery is divided into branches in 46/54 cases (85.19%) The branching position may be in the deltoidtriceps muscles wall (31/54 cases = 57.41%), or in the flap (15/54 cases = 27.78%) In 8/54 cases (14.81%), Cutaneous branch artery only creates a single axis and this circuit always goes towards the acromion + Paths: Cutaneous branch artery goes into deltoid-triceps muscles wall to enter the blood supply to the flap In 4/54 cases (7.41%), the cutaneous branch artery split into branches, including one that passed through the deltoid muscle to enter the flap 15 + The length and diameter: described in table 3.4 Table 3.4 Length and diameter of cutaneous branch artery and accompany veins Data Cadaver form Diameter of artery Diameter of vein Diameter of vein 2* Length of artery Length of vein Min (mm) Max (mm) PC FC PC FC 1,02 1,08 1,53 1,66 1,21 1,40 1,97 1,85 0,83 1,15 1,59 1,53 35 36 52 60 34 38 53 58 ± SD (mm) PC n=32 1,26 ± 0,1 1,58 ± 0,17 1,21 ± 0,16 44,56 ± 3,43 44,28 ± 3,91 FC n=22 1,39 ± 0,13 1,67 ± 0,1 1,37 ± 0,1 45,5 ± 3,91 46,31± 3,52 p 0,00 0,018 0,001 0,355 0,056 *: n= 27 on preserve cadavers and n=16 on fresh cadavers (34/54 cases have veins) PC: preserve cadavers FC: fresh cadavers b Veins: - Posterior circumflex humeral vein: There may be or accompanying veins, in 28/54 cases (51.85%) there are veins, in 26/54 cases (48.15%) there are veins The length and diameter of veins are described in table 3.2 - Cutaneous branch vein: In 43/54 cases there were veins (79.63%), in 11/54 cases (20.37%) there was vein The veins size is described in table 3.4 c Blood supply area for transfusion of blue Methylene into cutaneous branch artery: The size of the methylene blue infusion area is measured vertically: 20.41 ± 1.62cm (17 - 23), measured horizontally: 12.36 ± 1.47cm (9-15) d The flap’ sensory nerve: The lateral brachial cutaneous nerve split from axillary nerve in Velpeau space, with a length of 6.54 ± 0.53cm (5.6 - 7.8), usually with 4-6 bundles and often divided into branches (branches up and branches down) before entering the flap 16 Dissection in the subcutaneous tissue of the flap on 32 preserve formol cadavers (5X magnifying), the distribution range of the upper branch: 5.3 - 7.8cm (7.02 ± 0.46), and of the branch down: 4.7 - 7.2cm (6.06 ± 0.61) e The secondary pedicle Although the flap still has a pedicle as the classical description, the branch connected to the deep brachial artery adds another branch to the blood supply to the flap This branch is the secondary peduncle and is found in 8/54 cases (14.81%) The secondary peduncle also has an artery with an average diameter: 0.92 ± 0.12mm and vein with an average diameter: 1.23 ± 0.14mm 3.1.3.2 Locate the position pedicle enter the flap In 49/54 cases (90.74%) the position pedicle enter the flap in the posterosuperior of the circle, in 5/54 cases (9.26%) this position is in the posteroinferior area The distance from the pedicle to point A is: 19.3 ± 0.42mm and to the acromion is: 7.87 ± 0.43cm 3.2 Clinical outcomes 3.2.1 Characteristics of patients studied 60 patients with 60 soft-tisue defects in the weight-bearing area of the foot, including 46 male and 14 female The average age of patients is: 33 ± 15 (8 - 74 years) Inside: + patients with peripheral nerve damage: patients with lower limb (due to sequelae of cerebral palsy patients and spinal cord injury patients), patient with diabetes + There are patients who had amputation on the opposite side because of previous injuries 3.2.2 Characteristics of soft-tisue defects and deltoid flap - The cause of soft-tisue defects (n = 60): + Ulcers in weight-bearing area of the foot on subparalytic lower limb patients: 4/60 patients (6.67%) + Ulcers caused by cancer: 3/60 patients (5%) + Soft-tisue defects caused by trauma: 53/60 BN (83,33%) 17 - Location of soft-tisue defects (n = 60): There were 52 soft-tisue defects in the direct weight-bearing area of the foot (hindfooot and plantar regions), of which the hindfooot involved in 40/60 defects (66.67%) There are soft-tisue defects in the indirect weight-bearing areas (5 in dorsum and in posterio calcaneus of the foot) - Size of soft-tisue defects and flap (n = 60): The soft-tisue defects in this study have an average size: 111.8 cm2 (32 - 231cm2) The flaps are also taken with the same size, the average length of flaps is: 12.95 ± 4.06cm (7 - 22cm), the average width is: 8.23 ± 1.79cm (4 - 12cm) Of the flaps used, the smallest flap is x 4cm and the largest is 21 x 11cm - The reconstruction methods was used (n=60): 8/60 soft-tisue defects were reconstruction with sural flap or medial plantar flap, but the ulcer continued to recur - Infection status and grow bacteria result (n=60): In this study, there are 11 soft-tisue defects which are bad scars that are sterile Of the remaining 49 soft-tisue defects, 27 were subacute (wound) and 22 chronic (ulcers) Twelve soft-tisue defects were grown bacteria, the common bacteria were P Aeruginosa (6 cases) and S Aureus (4 cases), the rest were S Epidermidis (1 cases) and Proteus sp (1 cases) - Characteristics of soft-tisue defects and associated lesions( n=60): All soft-tisue defects after incise have tendon and bone exposed There were 21/60 cases (33.3%) with cordinate lesions including: patients with metatarsal fractures, patients with heel fractures, patients with partial loss of achille, patients completely lost anterio tibial tendon and extensor digitorum longus tendon - Pathology (n=21): Of the 21 patients who had a biopsy, 17 patients were chronically infected, benign tumor and patients with squamous cell carcinoma (T3N0M0) all patients were still alive 3.2.3 Results soon after surgery (n=60) 3.2.3.1 Ratio flap ’s surviving and results of cover soft-tissue defect 18 * Ratio flap ’s surviving (n=60): Whole flap survives: 59/60 (98,33%) Total necrotic flap: 1/60 (1,67%) * Results of cover soft-tissue defect (n=59): Good (first heal): 55/59 patients (93,22%) Moderate (second heal): 4/59 patients (6,78%) 3.2.3.2 Early complications and management results Vascular congestion: encountered in cases, of which case saved the flap Infection: case 3.2.4 The long-term results (≥ months, n = 58) There were 60 patients with 60 deltoid free flaps, of which 59 flaps lived completely and necrosis The number of flaps evaluated for longterm results was 58/59 flaps The longest follow-up was 12 years and months, the shortest was months, the average was 51.7±45 months 3.2.4.1 Results at recipient site (foot area): a Investigation patient ’s satisfaction (Appendix 5): Very satisfied: 32/58 patients (55,2%), Satisfied: 24/58 patients (41,4%), Accepted: 2/58 patients (3,4%) b Result of sensate recovery: * Patients without peripheral neuropathy (n = 53): + Good (S3+): 45/53 patients (84,9%) + Fair (S3): 8/53 patients (15,1%) * Patients group with peripheral neuropathy (n = 5, including subparalytic lower limb patients and diabetic patient): Before surgery there were patients: S2 and patients: S1 After surgery: patients at S2 and patients at S1 c Restoration of walking ability (n = 58): - Of the 52 patients with soft-tisue defects in the direct weightbearing area of the foot, 46 patients had foot prints The picture shows that all flaps are involved in the compression of the soles when walking - Result of restoration of walking ability: + Group A: No sequelae of subparalytic lower limb, opposite legs were healthy (n = 51): Very Good: 29/51 (56,9%), Good: 20/51 (39,2%), Fair: 2/51 BN (3,9%), Poor: BN 19 + Group B: Have sequelae of subparalytic lower limb, or have amputated on the opposite side: 7/7 patients (100%) d The durability of the flap (n = 58): - Group flaps reconstructed in the direct weight-bearing area of the foot (n = 50): Very good: 31/50 patients (62%), Good: 15/50 patients (30%), Fair: 4/50 Patient (8% - ulcerated flap) - Group flaps reconstructed in the indirect weight-bearing area of the foot (n=8): Very good: cases - In this study, the patients with a good sense of conserve flap also had better results on the durability of flap (p