A 9-year-old male who presented after a traffic accident, a complex posttraumatic defect in the left foot and ankle that included a loss of substance of 7 x 10 cm with exposure of the tibial ankle tibial artery and a tibial tendon section of 5 cm.
1.
After the relevant debridement of devitalized tissue, the reconstruction of the defect is proposed 5 days after the trauma, by repairing the affected tendons, reconstruction of the tibial nerve with sural nerve graft ALM.
Preoperatively a 7 x 10 cm flap was designed in the left thigh based on a perforator located with Doppler.
After standard subfascial dissection of the flap following the description made by Wei et al. (4), we located a perforator with a very long intramuscular route and small diameter; then we decided to explore proximally the lateral circumflator branch of the femoral artery.
A larger caliber perforator is located at this level and a flap is redesigned to achieve sensitivity in a TFL perforator flap, drawing a new, more proximally thigh perforated skin island with a central thigh flap.
After tibial nerve repair with three 5-cm sural nerve grafts, flap transfer and fixation are performed.
The anastomoses are performed thermally to the posterior tibial artery and two veins, a posterior tibial comitant vein and the greater saphenous vein.
The lateral femoral cutaneous nerve of the flap is connected end-to-side to the proximal end of the tibial nerve.
Finally, direct closure of the donor site was performed.
The total intervention time was 7 hours and 30 minutes.
The postoperative period was uneventful and the patient was discharged 18 days after surgery.
1.
The physiotherapy program started from the first week after surgery, partially supporting the foot (with help of protective clothing and splint) one month after surgery and walking with total foot support at 6 weeks.
Four months after surgery, the contour of the foot was adequate, allowing the patient to use a normal footwear, with an ankle range of motion of 45 or plantar flexion test and 15o dorsal flexion test.
