• Journal of the Korean Orthopaedic Association
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• v.52 no.1
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• pp.40-48
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• 2017

Purpose: Soft tissue reconstruction of a defect around the foot and ankle is a particularly challenging procedure due to the anatomical and functional characteristics of this area. Hence, only a limited number of treatment options are available. Moreover, if patients wish to avoid additional scars on the ipsilateral lower leg for cosmetic reasons, even fewer options are available for treatment. The authors used an anterolateral thigh perforator flap for soft tissue defects in this area, when other surgical options were inadequate. The aim of this study was to report the clinical results and the efficacy of this procedure. Materials and Methods: Sixteen cases of soft tissue defects around the foot and ankle were included. Participants included 12 male and 4 female subjects, and the mean age was 34 years. The most common cause of defect was acute trauma, and the average follow-up period was 33 months. Flap survival time, surgical complications, and ambulation status at the final follow-up stage were evaluated. Results: All 16 flaps successfully survived, except for one case with partial flap necrosis that was thought to be due to weight bearing earlier than scheduled. All patients were able to walk independently without any aid at the final follow-up stage. No patients showed other significant surgical complications. Conclusion: The anterolateral thigh perforator flap is a good alternative for soft tissue defects of the foot and ankle, when other options are not applicable. This study also demonstrated that surgery using an anterolateral thigh perforator flap is safe and highly reliable.

• The Journal of the Korean bone and joint tumor society
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• v.14 no.1
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• pp.33-43
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• 2008

Purpose: To evaluate the clinical usability of reconstructive methods, and how to select flap after wide excision of malignant soft tissue tumor in ankle and foot. Materials and Methods: The 15 cases shown in the 14 patients (In case of a male patient, reconstruction was performed two times due to local recurrence.) with malignant soft tissue tumor in ankle and foot, who underwent reconstruction after wide excision from March 2000 until March 2007. Oncologic, surgical and functional results were evaluated. Results: The method of reconstruction used were anterolateral thigh perforator flap (5cases), Reversed superficial sural artery flap (4 cases), dorsalis pedis flap (3 cases), local flap (3cases). The defect, mean size was $5.5{\times}5.7\;cm$, was reconstructed with rotation flap or free flap, mean size was $5.9{\times}6.0\;cm$, skin graft for remnant. The mean operation time was 310 minutes (120~540 minutes); it took 256 minutes to reconstruct by rotation flap, and 420 minutes by free flap. As oncologic results, 7 patients were no evidence of disease, 6 patients were alive with disease and 1 patient was expired by pulmonary metastasis at the time of the last follow-up. 4 patients had local recurrence and 4 pateints had distant metastases. As functional results, 14 patients were evaluated with average score of 68.8% using the system of the Musculoskeletal Tumor Society. Conclusion: The dorsalis pedis and reverse superficial sural artery rotation flap which is easy procedure, has less complication and takes short operation time, can be primarily considered to reconstruct a small defect. And the anterolateral thigh perforator flap is suitable for coverage of a large defects after wide excision of malignant soft tissue tumor in ankle and foot.

• Archives of Reconstructive Microsurgery
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• v.5 no.1
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• pp.24-34
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• 1996

There are many kinds of free flaps for management of extensive soft tissue defect of extremities in orthopaedic field. Free vascularized scapular flap is one of the most useful and relatively easy to application. This flap has been utilize clinically from early eighties by many microsurgical pioneers. Authors performed 102 cases of this flap from 1984 to 1995. We have to consider about the surgical anatomy of the flap, technique of the donor harvesting procedures, vascular varieties and anatomical abnormalities and success rate and the weak points of the procedure. This flap nourished by cutaneous branches from circumflex scapular vessels emerges from the lateral aspect of the subscapular artery 2.5-5cm from its lateral origin passing through the triangular space(bounded by subscapularis, teres minor, teres major, long head of triceps). The terminal cutaneous branch runs posteriorly around the lateral border of the scapular and divided into two major branches, those transeverse horizontally and obliquely to the fascial plane of overlying skin of the scapular body. We can utilize these arteries for scapular and parascapular flap. The vascular pedicle ranged from 5 to 10 cm long depends on the dissection, usually two venae comitantes accompanied circumflex scapular artery and its major branches. The diameter of the circumflex scapular artery is more than 1mm in adult, rare vascular variation. Surgical techniques : The scapular flap can be dissected conveniently with prone or lateral decubitus position, prone position is more easier in my experience. There are two kinds of surgical approaches, most of the surgeon prefer elevation of the flap from its outer border towards its base which known easier and quicker, but I prefer elevation of the flap from its outer border because of the lowering the possibilities of damage to vasculature in the flap itself which runs just underneath the subcutaneous tissue of the flap and provide more quicker elevation of the flap with blunt finger dissection after secure pedicle dissection and confirmed the course from the base of the pedicle. There are minimal donor site morbidity with direct skin closure if the flap size is not so larger than 10cm width. This flap has versatility in the design of the flap shape and size, if we need more longer and larger one, we can use parascapular flap or both. Even more, the flap can be used with latissimus dorsi musculocutaneous flap and serratus anterior flap which have common vascular pedicle from subscapular artery, some instance can combined with osteocutaneous flap if we include the lateral border of the scapular bone or parts of the ribs with serratus anterior. The most important shortcoming of the scapular free flap is non sensating, there are no reasonable sensory nerves to the flap to anastomose with recipient site nerve. Results : Among our 102 cases, overall success rate was 89%, most of the causes of the failure was recipient site vascular problems such as damaged recipient arterial conditions, and there were two cases of vascular anomalies in our series. Patients ages from 3 years old to 62 years old. Six cases of combined flap with latissimus dorsi, 4 cases of osteocutaneous flap for bone reconstruction, 62 parascapular flap was performed - we prefer parascapular flap to scapular. Statistical analysis of the size of the flap has less meaningful because of the flap has great versatility in size. In the length of the pedicle depends on the recipient site condition, we can adjust the pedicle length. The longest vascular pedicle was 14 cm in length from the axillary artery to the enter point cutaneous tissue. In conclusion, scapular free flap is one of the most useful modalities to manage the large intractable soft tissue defect. It has almost constant vascular pedicle with rare anatomical variation, easy to dissect great versatility in size and shape, low donor morbidity, thin and hairless skin.

• Journal of Gastric Cancer
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• v.9 no.4
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• pp.215-222
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• 2009

Purpose: Billroth II gastroenterostomy is a typical reconstruction method after distal gastrectomy for gastric carcinoma, but it has problems, especially frequent reflux esophagitis. Various methods have been tried to address this problem. Among them are Braun enteroenterostomy and Roux-en-Y gastroenterostomy, which are performed separately according to the size of the gastric remnant. The aim of our study was to determine whether these applications are compatible. Materials and Methods: Between September 2003 and April 2007, we performed Roux-en-Y gastroenterostomy operations (14 patients) when the size of the gastric remnant was <10%, Braun enteroenterostomy (17 patients) when the size was between 10 and 20%, and Billroth II gastroenterostomy (14 patients) when the size was between 20 and 40% after subtotal gastrectomy for gastric cancer by a single surgeon at our hospital. We analyzed the results of each treatment. We evaluated the symptoms and endoscopic findings using questionnaires and hospital records. To evaluate nutritional states, we reviewed albumin and hemoglobin levels and body weight changes. Results: All operations were performed safely mortality was 0% and postoperative complications were 8.9%. On endoscopy, reflux gastritis was observed to occur in 7.63%, 18.65% and 40.0%, respectively, of patients who had undergone Roux-en-Y, Braun and Billroth II operations (P=0.13). Reflux esophagitis was observed in 1 patient in the Roux-en-Y group and 1 patient in the Braun group. Endoscopic gastrostasis was observed in 2 patients in the Roux-en-Y group, one of which was thought to cause reflux esophagitis. Patients in the Roux-en-Y group and Braun groups ingested a lower volume of food than did those in the Billroth II group (respectively, 7.1%, 0.0% and 28.7%) and complained less of postprandial discomforts (respectively, 14.3%, 23.5% and 57.1%) and reflux symptoms (respectively 0.0%, 11.8% and 42.9%). Conclusion: The application of Braun enteroenterostomy and Roux-en-Y gastroenterostomy to the small gastric remnant may be effective for reducing reflux symptoms and abdominal discomfort after distal gastric resection. We recommend Roux-en-Y gastroenterostomy when the size of the gastric remnant is <10%, and Braun anastomosis in the others. It will need to be determined which reconstructive procedure is better for many different conditions.

• Journal of Gastric Cancer
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• v.7 no.4
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• pp.219-227
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• 2007

Purpose: Many reconstruction procedures have been developed in order to resolve patient complaints after a total gastrectomy. However, until now, there has been no general agreement with regard to the ideal reconstruction to perform after a total gastrectomy. Moreover, there have been few reports of the long-term effects of different reconstruction procedures. In this study, we compared the long-term nutritional status and quality of life for patients that received either a Roux-en-Y esophagojejunostomy (R-Y), jejunal interposition (JI), jejunal pouch interposition (JPI), or double tract reconstruction (DT), to determine the optimum reconstruction procedure after a total gastrectomy. Materials and Methods: The study consisted of 41 patients younger than 80 years who had undergone a total gastrectomy with curative resection and who had no evidence of recurrence at our hospital between August 2000 and January 2004. The patients were classified into the following four groups, according to the type of reconstruction; simple Roux-en-Y (R-Y group, n=15), jejunal interposition (JI; group, n=8), j Jejunal pouch interposition (JPI group, n=8), double tract interposition (DT group, n=10). The nutritional status was assessed by measuring body weight, serum albumin level, serum hemoglobin level, and the level of serum total protein, and the PNI (Prognostic nutritional index). Quality of life was assessed by GSRS. In addition, endoscopy was performed to confirm the presence of reflux esophagitis. Results: The laboratory findings showed no significant differences between the four groups except for a lower total protein and album level in the DT group after 3 years postoperatively (P=0.006, P=0.033). The percentage of body weight at 1 year, and 3 years postoperatively in the JI group (P=0.013, P=0.011) were significantly less than other groups (P=0.011, P=0.000). The frequency of postoperative symptoms and reflux esophagitis and eating capacity showed no significant differences between the four groups. The GSRS score in the JIP group was significantly better than for the other groups at 1 year, and 3 years postoperatively (P=0.028, P=0.003). Conclusion: We believe that the jejunal pouch interposition is the most useful of the four procedures for improving postoperative quality of life.