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We report the case of a traffic accident victim who suffered major tissue loss of the heal. We used two pediculated flaps to close the gap in a single procedure. The remaining tissue presented zones of necrosis from the plantar aspect to the posterior half of the calcaneum, up to the insertion of the calcaneus tendon, extending 5 cm on the posterior aspect of the heal. We decided to combine a medial plantar flap with a lateral supramalleolar flap. The thick medial plantar flap allowed cover of the calcaneum and sensitivity. The calcaneus tendon was covered with the lateral supramalleolar flap. The thickness of the flap was adapted to match the tissue defect. At six months, the patient had recovered walking function with satisfactory weight bearing on the heal. Flap sensitivity was satisfactory with no slipping phenomenon.

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A medial and volar approach to the base of the fifth metacarpus for exposing finger joint fractures is described. The dorsal approach does not expose well the joint surface of the base of the fifth metacarpus, hindering reconstruction of this important articulation. Carpometacarpal mobility of the ulnar joints contributes significantly to ulnar stability and grip force. An inverted "J" incision is made along the hypothenar eminence. The insertion of the tendon of the extensor carpi ulnaris is identified and the anterior fibers are disinserted. Capsulotomy is performed in front of the anterior border of the extensor carpi ulnaris tendon. This approach exposes well the medial two-thirds of the base of the fifth metacarpus. There is no risk of injury to the ulnar vessels nor to the dorsal sensitive branch of the ulnar nerve.

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PURPOSE OF THE STUDY: We report four cases of anterolateral thigh flap reconstructions, searching for the different advantages and disadvantages of this type of flap. MATERIAL AND METHOD: A pure skin flap was used to cover tissue loss on the plantar surface of the foot both in weight-bearing and non-weight-bearing zones as well as to cover the dorsal aspect of the first commissura of the hand. A musculocutaneous flap (fragment of the vastus lateralis) was associated with an iliac cancellous graft to treat septic nonunion of the tibia. A composite tendinocutaneous flap (fragment of the iliotibial band) was used to reconstruct extensor tendon and skin loss on the dorsal aspect of the hand. A perforating artery measuring more than 1 mm was used in all cases, but in one flap it was in the position described by Song. Side-to-side anastomosis was used in one case. For three cases, the sutured circumflex artery had the same caliber as the radial artery at the wrist level. In one case the circumflex artery had a diameter greater than the posterior tibial artery. Closure of the donor site was not possible immediately in one case. A thin skin graft was required in three cases. RESULTS: Skin healing after microsurgery was satisfactory in all cases, occurring within the usual delay. Bone healing in the patient with septic nonunion of the tibia was achieved at four months. The flap was reliable. In three cases the skin graft of the donor site only healed partially. DISCUSSION: The advantages of the antero lateral thigh flap are: surgery in the supine position, spinal anesthesia when the recipient site is on the lower limb, flap reliability, use of the flap as a bridging element, use as a composite flap. The disadvantages are: variable position of usable perforants, requirement for wide skin grafts > 6 cm to cover the donor site. CONCLUSION: The antero lateral thigh flap is a reliable flap that can be most useful when a bridging element is required and when the donor site can be closed directly.

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The authors present a case of successful replantation of a totally avulsed ear in a 37-year-old patient, using a termino-terminal arterial anastomosis on the superficial temporal artery. As no suitable vein could be identified in the amputated part, they relied on leech therapy and systemic anticoagulation for venous drainage. Despite an 18-hr ischemia, the ear survived completely.

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The authors report 35 cases of use of the supramalleolar flap described by Masquelet et al. in 1988. In 27 cases, the arterial blood supply was in a mixed (anterograde and retrograde) fashion since the perforating branch of the peroneal artery was spared. In eight cases the arterial blood supply was in a retrograde fashion due to the location of the skin loss. As described by Valenti et al. In 1991, the authors recommend the use of a distal subcutaneous pedicled to avoid skin grafting over the tendons at the distal part of the lag. In main cases of anterograde blood supply the superficial peroneal nerve could be spread. In 33 cases the plastic result was assessed as satisfactory. The coverage of the weight-bearing portion of the heel was done two times with no satisfactory result. Coverage of the medial malleolus area, Achilles tendon and dorsal skin of the foot represent the main indications and the best results. Five times, a venous congestion was observed with three cases of partial necrosis of the flap. The use of a large subcutaneous pedicle did not always prevent such venous problems, though this technical aspect improves the vascular reliability of the flap. The main local alternative is the distal pedicled sural flap that needs to divide the sural nerve and not allows coverage as distal as the supramalleolar flap. Except the distal coverage of the foot, the indications of these previous both flaps are similar. In case of foot coverage, the medial plantar flap based on the lateral plantar vascular bundle, as described by Martin et al. in 1991, is the other one local alternative. Free flaps are indicated for extensive skin losses, or when a poor distal vascularity of the leg does not allow reliability of distal pedicled flaps.

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INTRODUCTION: We compare retrospectively two groups of total trapezectomy did as treatment for primary osteoarthritis of trapeziometacarpal joint combined in 34 cases with tendon interposition arthroplasty (group A) and in 35 cases with suspensioplasty (group B). METHOD: In group A an 'anchovy' was made with half band of the abductor pollicis longus tendon and the palmarus longus tendon; in group B the same tendon samples were rolled around the flexor capi radialis tendon. The follow up is at least 18 months. RESULTS: Strength was nearly the same in the two groups. The suspensioplasty of the group B allows a better stability after trapezectomy than the anchovy of the group A, but with a small decrease in range of motion, without functional consequence. In both groups of patients, the range of motion was good. In the group B, the persistent pain was more frequent than in group A. Patients were satisfied with the ability of perform activities of daily life, but working patients were bothered by poor endurance. There was no statistical correlation between the power of the thumb and thumb shortening, but there was one between increasing of hyperextension of thumb metacarpophalangeal joint and decreasing power of pinch. DISCUSSION: Since the suspensioplasty has been tightenedless, the relief of pain has been better in the group B. Overall, the results in the two groups were nearly the same; the two procedures studied are satisfactory in most cases, but their result is too often inadequate with performance at work.

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The authors report a case of an Y anastomosis of a free flap on the peroneal artery. A 30-year-old patient, the victim of a multi-traumatism after a motorcycle accident, presented open tibia and peroneal fractures and skin defect at the dorsal aspect of the foot uncovering several fractures and luxations of the foot. When general state of health allowed the achievement of a free flap, the authors noted that the two tibial arteries were destroyed with an extensive thrombosis on each side of the injury which precluded the reconstruction of a reliable artery axis. The peroneal artery insured alone a good foot vascularization. A musculocutaneous serratus anterior free flap was revascularized on the peroneal artery after segmental bone resection on each side of the peroneal fracture. The necessity to preserve the peroneal artery for the foot and the diameter of the arteries imposed flowthrough fashion anastomosis. As a result, the authors believe that anastomosis of a free flap on peroneal artery is a safe procedure, particularly interesting when a preoperative peroneal fracture achieved the osteotomy.

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