Chimeric free flaps based on end-to-side anastomosis for complex lower extremity reconstruction

Chimeric free flaps based on end-to-side anastomosis for complex lower extremity reconstruction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Chimeric free flaps based on end-to-side anastomosis for complex lower extremity reconstruction Yingluo Gu, Yongyang Sun, Ke Xu, Nan Yi, Jianzhong Qin, Yong Zhang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4072764/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Complex lower extremity defects are difficult to cover and often require multiple free tissue transfers. Chimeric anterolateral thigh free flaps (ALTF) and peroneal artery perforator free flaps (PAPF) have been designed specifically as an alternative for reconstruction with arterial end-to-side (ETS) anastomosis. We aimed to assess our institutional experience with this technique and to define its role in complex lower extremity reconstruction. Methods : From July 2012 to March 2023, 27 patients with complex lower extremity defects underwent reconstruction with chimeric ALTF or PAPF. Patients were performed with retrograde flaps for repairing refractory wounds of tibia plateau fracture and antegrade flaps for distal 2/3 tibia and beyond. Demographic, clinical, and follow-up data on the patients were recorded with a special focus on complication profiles during a follow-up of 6 to 60 months. Results : The mean defect size measured 121.1 ± 215.1 cm 2 and the chimeric ALTF or PAPF flaps measured 143.9 ± 177.8 cm 2 . One patient lost the first free flap but successfully had a chimeric PAPF then. Three patients suffered partial free flap loss, and another three had minor complications. All six survived after an additional exploration, wound dressing, or antibiotics treatment. The retrograde flaps achieved similar blood flow to the antegrade flaps. Patients are all satisfied with functional and aesthetic outcomes. Conclusions : Given the incidence of complications, utilizing chimeric ALTF and PAPF either with retrograde or antegrade flow based on arterial ETS anastomosis is a reliable surgical option for complex lower extremity reconstructions. chimeric free flaps end-to-side anastomosis extremity reconstructions Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Complex lower extremity injury due to high-energy trauma remains a severe clinical challenge 1 . These injuries are characterized by soft tissue defects, bone exposure, bone defects, and recurrent infection, which require debridement surgeries before secondary reconstruction. In these cases, a simple free flap is insufficient because the recipient site may require skin, fat, fascia, muscle, bone even lymph nodes. Fasciocutaneous and muscle flaps can resolve conventional defects but without the flexibility of rotating independent flaps 2,3 . Besides, the Masquelet induced membrane technique (IMT) may require 4 to 96 weeks to form the induced membrane 4 , bone transport can achieve early weight-bearing accompanied with complications such as needle site infections, chronic skin irritation, and ankle stiffness 5 , and both cannot handle soft tissue defects. Very few methods contain multiple components to reconstruct defects while minimizing donor-site and recipient-site morbidity. Since the first introduction, chimeric free flaps have been recently widely used to treat complicated defects 6 . Some flaps have their disadvantages, for example, the anatomical complexity of circumflex iliac artery flaps 7 , position changes of latissimus dorsi flaps during surgery, etc. Chimeric anterolateral thigh free flaps (ALTF) and peroneal artery perforator free flaps (PAPF) have become popular these days, because multiple tissue components can be harvested in various combinations, thus fulfilling three-dimensional reconstruction requirements 8 . Based on plastic surgery principles, end-to-side (ETS) anastomosis is recommended for arteries to minimize donor-site morbidity without sacrificing major vessels 9 . An ultrasound study of 20 free flaps revealed that the blood flow depends on flap type -- blood flow volume was significantly higher in the myocutaneous flaps than in the fasciocutaneous flaps, not on arterial incision of free flaps using the ETS technique 10 . Combined with the postoperative outcomes, we consider that ETS can provide lobular flaps with stable blood flow. As only a few existing studies have reported the combination of ETS anastomoses and chimeric flaps, we aimed to validate the feasibility of chimeric ALTF and PAPF consisting of isolated skin, muscle, fascia, and bone flaps based on arterial ETS anastomoses for complex lower extremity reconstruction. Meanwhile, we retrospectively access the outcomes and complications of retrograde flaps and antegrade flaps in these cases to learn the relation between blood flow direction and flaps’ survival. Patients and methods Patients Over 11 years (July 2012 to March 2023), 27 patients with complex lower extremity defects underwent chimeric ALTF or PAPF reconstruction under the Second Affiliated Hospital of Soochow University ethics committee-approved protocol. All patients with previous debridement surgeries and chimeric flap reconstruction were included in this retrospective investigation for a follow-up of 6 to 60 months. Inclusion criteria: ( 1 ) patients suffered soft tissue, bone (defect ≥ 4cm), tendon defects in lower extremities; ( 2 ) a single flap cannot cover the defects; ( 3 ) simple debridement anastomosis or skin grafting cannot reconstruct the defect; ( 4 ) none of the patients had sustained complete benefit from previous surgeries such as debridement, skin-grafting, internal fracture fixation. ( 5 ) patients do not have serious underlying diseases. Exclusion criteria: ( 1 ) soft tissue defects of lower extremities can be covered by a single flap; ( 2 ) there are no deep tissue defects or dead cavity; ( 3 ) simple debridement or skin grafting can reconstruct the defect; ( 4 ) patients have serious underlying diseases. Medical files and patient data were screened for patient demographics, intraoperative and perioperative details, flap survival, and complications. The severity of the defects was estimated by the Hannover fracture scale (HFS) 11 . Surgical complications like total or partial flap loss, thrombosis, hematoma, wound dehiscence, infection, and other recipient-site/donor-site complications were recorded. Flap selection For patients with less than 4cm bone defect, we choose autogenous bone transplantation. If the defect distance is ≥ 4cm, chimeric PAPF is preferred, and large area defect can add chimeric ALTF. Defects with small/medium soft tissue defects and pedicles < 8cm can be covered by chimeric PAPF. Small/medium defects requiring pedicles ≥ 8cm and large/multiple defects are flexibly reconstructed with chimeric ALTF (Fig. 1 ). The chimeric flaps included independent skin, fascia, muscle, or bone flaps containing individual paddles supplied by seperate perforators with no restriction on each pedicle rotation. The flap dimensions were designed larger than the defects with a slightly longer pedicle. Skin flaps were used to cover exposed vessels and bones; fascia flaps were used to cover tendinous tissues. Bone flaps and muscle flaps were designed to eliminate dead space or enhance resistance to infection 12,13 . Anterograde flaps have an angle of less than 90 degrees between the blood flow direction of donor blood vessels and recipient blood vessels, while retrograde flaps have an angle of more than 90 degrees between them. Since the perforation point of the anterior tibial artery (aTA) is often located in the upper third of the tibia, the ETS anastomosis in platform fracture is often selected below this, resulting in a retrograde blood supply 14 . The distal 2/3 of the aTA and dorsalis pedis artery (DPA) were usually selected as recipient arteries because of the easy dissection. Other arteries, such as the posterior tibial artery (pTA) and peroneal artery (PA) can also be selected (Fig. 2). Surgical technique All flaps were harvested similarly. To harvest chimeric ALTF, the descending branch of the lateral circumflex femoral artery (LCFA) should be first confirmed with a handhold Doppler, and then the relatively superficial perforating branch and the proximal LCFA were traced back to the intermuscular septa or across muscles. To harvest chimeric PAPF, the perforating branch of the PA between the extensor digitorum longus and the peroneus brevis muscle was dissected after confirming the small head of the upper fibula and the external malleolus of the lower end. Leaving 6-8cm proximal to the lateral malleolus is essential to maintain ankle joint integrity. The medial fibula was dissected, and the proximal PA was retained for the vascular pedicle. ETS anastomoses were performed with a 9 − 0 prolene monofilament. A smaller hole was made than the donor vessel with a 90°angle between two arteries. A six-point suture with an equal distance was performed using an interrupted vertical mattress suture. Most veins were operated with end-to-end (ETE) anastomosis. Postoperative monitoring techniques included evaluation of color, capillary refill, turgor, surface temperature, and the presence of bleeding. Free flaps should be frequently monitored, particularly during the initial postoperative period. Emergent exploration and repair must be performed soon after the obstruction occurs. Results The retrospective review revealed 27 patients (26 male and 1 female) who underwent complex lower extremity reconstruction with chimeric ALTF or PAPF. The mean age of the patients was 47.6 ± 13.6 (range, 27–74) years. The defects were located on the lower leg (n = 10), tibial plateau (n = 5), foot (n = 9), ankle (n = 2) and thigh (n = 1). Additional complicating factors included osteomyelitis (n = 4), exposed bone (n = 9), bone defects (n = 10), recurrent ulcers (n = 5), skin necrosis (n = 3), refractory soft tissue defects (n = 5), and Achilles tendon exposure (n = 3). Systemic comorbidities and the Hannover fracture scale were recorded. Operations before reconstruction were 2.8 ± 1.3 (range, 1–6) times (Table 1 ). Table 1 Patient demographic data Case Age/ sex Preoperative diagnosis Etiology Defect location Additional local complicating factors Systemic comorbidities Hanover Fracture Scale Operations before free flap 1 59/M Tibiofibular fracture Trauma Lower leg Osteomyelitis O2 C2 2 2 50/F Metatarsal fracture Trauma Foot Exposed bone, bone defect O2 C2 2 3 40/M Femoral fracture Earthquake Thigh Exposed bone, bone defect, recurrent ulcer, skin necrosis O2 C3 6 4 74/M Tibial plateau fracture Trauma Tibial plateau Recurrent ulcer, skin necrosis HBP, DM O2 C1 3 5 33/M Calcaneal fracture Trauma Foot Osteomyelitis O2 C3 3 6 61/M Articular gout gout Foot Bone defect HBP, hyperuricemia O2 C1 1 7 56/M Tibial plateau fracture Trauma Lower leg Recurrent ulcer O2 C2 5 8 58/M Tibiofibular fracture Trauma Lower leg Refractory soft tissue defect O2 C3 4 9 47/M Foot fracture Trauma Foot Refractory soft tissue defect O3 C3 3 10 34/M Tibiofibular fracture Trauma Lower leg Exposed bone, bone defect O2 C3 4 11 64/M Metatarsal fracture Trauma foot Skin necrosis O2 C2 3 12 68/M Metatarsal fracture Trauma Foot Exposed bone, bone defect HBP O2 C3 1 13 27/M Tibiofibular fracture Trauma Lower leg Osteomyelitis O2 C2 3 14 31/M Tibiofibular fracture Trauma Lower leg Exposed bone, bone defect O2 C2 2 15 65/M Ankle fracture Trauma Ankle Achilles tendon exposure HBP, DM O2 C2 3 16 27/M Metatarsal fracture Trauma foot Achilles tendon exposure O3 C3 2 17 38/M tibial fracture Trauma Lower leg Exposed bone, bone defect HBP O2 C2 3 18 47/M tibiofibular fracture Trauma Lower leg Refractory soft tissue defect O2 C2 2 19 39/M fracture of tibial plateau Trauma Tibial plateau Recurrent ulcer DM O2 C2 3 20 56/M fracture of tibial plateau Trauma Tibial plateau Refractory soft tissue defect O2 C2 1 21 37/M fracture of tibial plateau Trauma Tibial plateau Osteomyelitis O2 C3 4 22 29/M metatarsal fracture Trauma Foot Exposed bone, bone defect O2 C2 2 23 41/M tibiofibular fracture Trauma Lower leg Refractory soft tissue defect O2 C2 2 24 60/M fracture of tibial plateau Trauma Tibial plateau Recurrent ulcer HBP O2 C2 3 25 38/M arthritic calculus gout Foot Exposed bone, bone defect Hyperuricemia O2 C3 1 26 56/M tibiofibular fracture Trauma Lower leg Exposed bone, bone defect O3 C3 5 27 51/M ankle fracture Trauma ankle Achilles tendon exposure O2 C2 2 Fifteen patients received chimeric ALTF and twelve received chimeric PAPF. Chimeric fabrication comprised vascularized fibula bones (range, 4-22cm) in eight patients, muscles in fifteen patients, vascularized fascia in two patients, and multiple skin flaps in seven patients. The defect size measured 121.1 ± 215.1 (range, 7.5–1075) cm 2 and was covered with flaps measuring 143.9 ± 177.8 (range, 13.5–760) cm 2 . The aTA, DPA, pTA, and PA were recipient arteries under the ETS pattern (Table 2 ). Typical surgery cases are presented in Fig. 3 and Fig. 4 . Table 2 Flap details and complications Case Flap type Other include structures Skin defect size (cm 2 ) Muscle size (cm 3 ) Flap size (cm 2 ) recipient artery Type of anastomosis Recipient-site complications Donor-site complications artery vein 1 ALTF Muscle 10x6 3x1x1 11x7 DPA ETS ETE 2 PAPF 5cm fibula 15x5 16x6 DPA ETS ETE Skin-grafting 3 PAPF 22cm fibula 14x6 15x7 PA ETS ETE flap total loss + artery thrombosis + 10cm femur shortening 4 ALTF Muscle 4x2.5 2x2x1 4.5x3 aTA ETS ETE Flap partial loss + artery thrombosis + secondary flap transfer 5 ALTF Muscle 8x6.5 3x2.5x2 9x7.5 pTA ETS ETE 6 PAPF Muscle 5x4 3x2.5x1 5.5x4.5 DPA ETS ETE 7 PAPF Muscle 3x2.5 2x1.5x1 5x3.5 aTA ETS ETE 8 ALTF Muscle, 2 flaps 20x12, 22x13 15x5x3 40x16 aTA + pTA ETS ETE 9 ALTF Muscle, 2 flaps 4x3, 7x3, 7x4 5x4x2.5 13x8, 19x15 aTA ETS ETE Poor blood supply infection 10 PAPF + ALTF 17.5cm fibula, 3 flaps 20x15, 15x10, 25x10, 25x15 20x12, 40x12, 8x5 pTA ETS ETE 11 PAPF Muscle 5x3 5x3x1.5 7x5 DPA ETS ETE 12 PAPF 5cm fibula 10x5 8.5x7.5 DPA ETS ETS infection 13 ALTF Muscle 13x8 4x3x3 15x10 pTA ETS ETE 14 PAPF 12cm fibula, 2 flaps 12x7 15x10, 8x5 aTA ETS ETE Partial skin necrosis 15 ALTF 2 flaps 7x4.5, 3x2 9x7.5, 5x3 pTA ETS ETE 16 ALTF 2 flaps 12x6, 18x9 10x7, 15x8 DPA ETS ETS hematoma infection 17 PAPF 8cm fibula 10x9 11x10 aTA ETS ETE 18 PAPF Muscle 12x10 3x3x1.5 12.5x11 pTA ETS ETE 19 ALTF Muscle 6x5 2.5x2x1 6.5x6 aTA ETS ETE 20 ALTF Muscle, fascia 12x7 3x3x2 13x8 aTA ETS ETE 21 ALTF Muscle 10x6 4x2x1.5 11x7 aTA ETS ETE 22 PAPF 4cm fibula 9x6 10x7 DPA ETS ETE 23 ALTF 2 flaps 15x8 16x9 aTA ETS ETE 24 ALTF Muscle 7x6 2x2x1.5 8x7 aTA ETS ETE 25 ALTF Muscle 4x4 2x1x1 5x5 DPA ETS ETE 26 PAPF 10cm fibula 12x9 13x10 aTA ETS ETE Flap partial loss 27 PAPF fascia 9x8 10x9 aTA ETS ETE One patient (case 3) who had experienced an earthquake lost the first flap due to chronic infection, massive soft tissue loss, and 10cm femur shortening. After several debridement surgeries, a chimeric PAPF covered the soft tissue defect and rebuilt bone stability. Three patients (case 4/14/26) experienced partial free flap loss. In cases 14 and 26, no additional free flap was necessary, while small defects were covered with local tissue transposition flaps. Case 4 caused by arterial thrombosis underwent an additional exploration to solve the complication. Another three patients (case 9/12/16) had minor flap complications cured with regular wound dressing, antibiotics, and conservative therapy. Case 2 with donor-site skin defects was cured by a subsequent skin graft. Case 10/16 with infection along the flaps’ edge in the donor-site area was cured by antibiotics and wound dressing. The recipient-site complication rate of retrograde flaps (case 4/7/19/20/21/24) was 16.67% (n = 1), while that of antegrade flaps was 28.57% (n = 6). Besides, the donor-site complication rate of retrograde flaps was zero (n = 0) and that of antegrade flaps was 14.29% (n = 3). The defect size in the retrograde group measured 38.92 ± 29.63 cm 2 and was covered with flaps measuring 51.17 ± 35.16 cm 2 . The defect size in the antegrade group measured 144.64 ± 239.45 cm 2 and was covered with flaps measuring 170.33 ± 193.60 cm 2 . Except for one patient who received a secondary free flap in antegrade flaps for a donor-site complication, all achieved satisfactory results after additional exploration or conservative therapy (Table 3 ). Table 3 Flap details of retrograde and antegrade flaps Retrograde flap (n = 6) Antegrade flap (n = 21) Skin defect size (cm 2 ) 38.92 ± 29.63 144.64 ± 239.45 Flap size (cm 2 ) 51.17 ± 35.16 170.33 ± 193.60 Recipient-site complications 16.67% (n = 1) 28.57% (n = 6) Donor-site complications 0 (n = 0) 14.29% (n = 3) Discussion Complex lower extremity defects from high-energy trauma can hardly be repaired by simple free flaps, which pose a reconstructive challenge to surgeons. An ideal reconstruction would result in reinstated function and aesthetic appearance. Several methods have been reported, however, cases of severe soft defects have not been reported. As listed in Table 1 , high-energy trauma often leads to complications, such as refractory soft tissue defects, recurrent ulcers, skin necrosis, osteomyelitis, Achilles tendon exposure, exposed bones, and even extensive bone defects. Traditional free flap reconstruction failed to achieve satisfactory results because a single ALTF or PAPF failed to solve skin, soft tissue, and bone defects simultaneously. Moreover, the ETE method sacrifices the main artery, leaving little space for distal blood supply and subsequent vascular surgeries 15 . To solve the problem, a chimeric free flap based on the ETS anastomosis is an ideal option for complex reconstruction. Bone defects should be given priority before soft tissue reconstruction, which often results from osteomyelitis, trauma, and congenital and acquired deformities 16 . Traditionally, the treatment is divided into non-vascularized and vascularized bones. Non-vascularized bones are allografts and autografts. Compared to allografts -- slower revascularization, autografts are ideal choices for less dead bone, no immune rejection, and less infection 17 . If the bone defects are longer (≥ 4cm), vascularized bone flaps would be chosen, such as the iliac and fibular flaps. Due to anatomical characteristics, the iliac flaps have thinner blood vessels, shorter pedicles, a maximum 10cm bone mass, and a higher proportion of cancellous bone, making them more suitable for oral and maxillofacial reconstruction 18,19 . By contrast, fibular flaps can provide more bone mass for structural support because the cortical bone to cancellous bone ratio is approximately 1:1. Considering that the collapse of the femoral head is significantly less in the implantation of a fibular flap than an iliac flap 20 . We also attached a video about reconstructing an 8cm tibia defect with a fibular flap to prove the ability of structural support, in which the affected limb demonstrated good load-bearing ( Video 1 ). Therefore, when there is a requirement for weight-bearing reconstruction, the fibular flap is preferred. In this report, we present that chimeric ALTF and PAPF can cover kinds of complex lower extremity defects (Table 2 ) . Chimeric ALTF can provide a large area, thick fat, massive muscles, and a long vessel pedicle 21 , while chimeric PAPF can provide a smaller area but is sufficient for moderate skin defects, thin fat, muscles, a short vessel pedicle, and a maximum of 22cm bones 22,23 . All cases in this study achieved relatively reinstated function and aesthetic appearance. Other flaps, such as the latissimus dorsi flap, forearm perforator radial artery flap, an superficial circumflex iliac artery perforator flap, may require position changes, influence flexibility of upper extremities, and have small vessel diameter problems 24,25 . The flow-through technique has more requirements: the recipient sites have a vascular injury, and the donor sites require the removal of part of the main vessels along with entire perforator vessels 26 . Therefore, chimeric ALTF and PAPF are superior to other flaps for flexible reconstruction. Successful microvascular free flap transfer is highly dependent on sufficient microvascular anastomoses. While ETE anastomosis is significantly successful for stable hemodynamic improvement, many studies have suggested that no significant differences exist in extremity perfusion and flap failure between ETS to ETE 15,27,28 . As presented in Table 2 , the success rate after the first ETS flap was over 85%. This rate climbed to 88% after conservative treatment (n = 2) and over 96% after exploratory surgeries (n = 2). Based on the mature microsurgical technique, well-filled vessels, and no blood leakage were observed after vascular recanalization (Fig. 3 C, 4 E). Albertengo et al. reported that in ETE anastomosis, the intima, media, and outer membrane of arteries at the recipient site are completely severed, which would cause turbulence and thrombosis with the contraction of the middle smooth muscles. However, in ETS anastomosis, the contraction or spasm of smooth muscles will enlarge the opening because they were partially cut off 29 . Furthermore, researches indicate that the blood flow in free flaps depends on the specific tissue composition rather than the recipient artery flow rate, for example, a muscle flap has more sufficient blood flow than a fasciocutaneous flap 30 . Most cases in our study underwent computed tomography angiography after reconstruction demonstrating rich blood supply. As a result, we believe that ETS in chimeric free flaps can preserve distal perfusion without increasing complications. It is worth noting that we designed retrograde flaps for some specialized defects because soft tissue defects around the knee account for a considerable proportion. The main reasons are trauma and complications of total knee arthroplasty. The skin around the tibial plateau is thin, surgical trauma is severe, and some patients require secondary reconstruction, in which cases, traditional free flaps provide limited solutions for bone, tendon, joint, and internal fixation exposure. During intraoperative anatomy, aTA often emerges from the intermuscular septum near the proximal 1/3 of the tibia. Because platform fractures often result in scars on both sides of the knee, and local blood vessels may be damaged, a local transfer of the medial gastrocnemius flap is not considered. Our group designed chimeric retrograde ALTF or PAPF for defects in the proximal 1/3 of the plateau area (Fig. 2). Chimeric ALTF or PAPF can provide a relatively large vessel diameter compared with other free flaps, which ensures relatively abundant blood perfusion under retrograde situations. The defects of the distal 2/3 of the tibia and the beyond are designed as chimeric antegrade free flaps, in which the reconstructed blood flow was always satisfactory. In this research, the complication rates of retrograde flaps and antegrade flaps were 16.67% and 28.57%. While the retrograde cases were fewer than the antegrade ones, the lower complication rate reveals that applying chimeric ALTF or PAPF based on arterial ETS anastomosis becomes a reliable choice. All the surgeries were performed by the same group led by the same surgeon. Thus, the anastomotic technique depended on the expertise and training of surgeons. The surgical technique improved as cases accumulated, which may introduce bias. Our study is subject to the limitations inherent to retrospective, uncontrolled case reviews, including small sample size, lack of strict criteria for patient selection, and absence of prospective data collection, especially a final comprehensive strict functional assessment. All surgeries were performed at a single center. Further, prospective studies and data summarization are required to clarify the risks and prognosis in the future. Conclusion The clinical outcomes associated with the use of chimeric free flaps based on ETS anastomosis for complex lower extremity reconstruction are reliable in carefully selected patients. ETS anastomosis creates stable hemodynamics and a high flap survival rate. Patients with complex defects in the proximal 1/3 of the lower limb can choose retrograde flaps, whereas those with defects below this can choose antegrade flaps. Larger case series, prospective clinical trials, and quantitative hemodynamic data detection are needed to emphasize the importance. Declarations Conflict of interest: The authors have no financial interest to declare in relation to the content of this article. Funding: This work was supported by the Medical Application project of Nuclear Technology in subject Construction Lifting Project of the Second Affiliated Hospital of Soochow University (Grant No. XKTJ-HRC2021008). Author Contribution YLG wrote the main manuscript text. YYS and KX collected the data. NY, JZQ and YZ assisted the surgery. BJ and JJZ designed the surgery and revised the manuscript. All authors read and approved the final manuscript. References Murawski CD, Mittwede PN, Wawrose RA, Belayneh R, Tarkin IS. Management of High-Energy Tibial Pilon Fractures. Journal of Bone and Joint Surgery. 2023;105:1123–1137 Zheng X, Zheng C, Wang B, et al. Reconstruction of complex soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap. Int J Surg. 2016;26:25–31 Guo M, Thomas B, Goyal S, et al. Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures. 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A comparative study of flap survival rates in end-to-end and end-to-side microvascular anastomosis. Plast Reconstr Surg. 1981;67:194–199 Lorenzetti F, Suominen S, Tukiainen E, et al. Evaluation of blood flow in free microvascular flaps. J Reconstr Microsurg. 2001;17:163–167 Additional Declarations No competing interests reported. Supplementary Files supplementary1.docx Supplementary 1Hanover fracture scale video1.mp4 Video 1Digital Content 1, which shows that, 17 months after the chimeric PAPF surgery reconstructing an 8cm tibia defect, the affected limb demonstrates good load-bearing function. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4072764","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":279390962,"identity":"b1438bdc-a756-4e88-9368-e2df2d157560","order_by":0,"name":"Yingluo Gu","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yingluo","middleName":"","lastName":"Gu","suffix":""},{"id":279390963,"identity":"060c535b-b7fb-4899-963e-991105a63acc","order_by":1,"name":"Yongyang Sun","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yongyang","middleName":"","lastName":"Sun","suffix":""},{"id":279390965,"identity":"93945899-c079-4ec3-9726-fef1835c84c6","order_by":2,"name":"Ke Xu","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Xu","suffix":""},{"id":279390967,"identity":"fad45879-a3b6-42c5-9a66-61d52a625000","order_by":3,"name":"Nan Yi","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Yi","suffix":""},{"id":279390969,"identity":"9cb5c23b-5aea-4499-b0d7-a9e475f5e505","order_by":4,"name":"Jianzhong Qin","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jianzhong","middleName":"","lastName":"Qin","suffix":""},{"id":279390971,"identity":"7c7d09de-3980-4aae-8c92-fbb1dae943fb","order_by":5,"name":"Yong Zhang","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Zhang","suffix":""},{"id":279390974,"identity":"e63af79a-1dfd-452e-afb0-da1bed055926","order_by":6,"name":"Jiaju Zhao","email":"","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jiaju","middleName":"","lastName":"Zhao","suffix":""},{"id":279390976,"identity":"e025d9b7-4c8f-4f32-89b9-c9acea27315a","order_by":7,"name":"Bo Jiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYBACxmYQ0cDAw8/efOBAQoWEnDyxWuQke44lHnhwxsLYsIEoqxoYjA1u5CgffNhWkchwgIBq5nbmZw+/7rBJnNmQw3AgcZ5EAmMD88NHN/A6jM3cWPZMWmI/w9kDBxK3SeSxM7AZG+fg94uZtGTb4cSZjX0JIC3FjA08bNL4tbB/A2vZcJjH4EDiHInEhgMEtfCYSX5sO2xscAykpYE4LWXSjGfSgIHMlnAg4ZiEsWEzAb8Y9h/fJvlzhw0Pv/zjwx9/1NTJybM3P3yMV0sDMKB5UISY8SgHAVDyYPxBQNEoGAWjYBSMcAAAVXRTDEBkay4AAAAASUVORK5CYII=","orcid":"","institution":"The Second Affiliated Hospital of Soochow University","correspondingAuthor":true,"prefix":"","firstName":"Bo","middleName":"","lastName":"Jiang","suffix":""}],"badges":[],"createdAt":"2024-03-11 10:19:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4072764/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4072764/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52787141,"identity":"2416d9d0-81b6-43bf-bae2-f4f770ffe3c4","added_by":"auto","created_at":"2024-03-15 18:55:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":234689,"visible":true,"origin":"","legend":"\u003cp\u003eFlap selection.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4072764/v1/6208b9bbe9a98e9f11c6f713.png"},{"id":52787151,"identity":"43bee63c-eb6a-42b4-81a1-f0639db1ad2f","added_by":"auto","created_at":"2024-03-15 18:56:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":242221,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic illustration of the chimeric perforator flaps reconstructing complex lower extremity defects.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4072764/v1/36a678b9c20a31194f55ba46.png"},{"id":52787110,"identity":"6ec9499d-5a91-4eb8-80cf-2b8621cb2e8b","added_by":"auto","created_at":"2024-03-15 18:55:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":809138,"visible":true,"origin":"","legend":"\u003cp\u003eA 34-year-old man sustained a severe tibiofibular fracture. (A) Intraoperative imaging demonstrated the defect. (B) An ALTF was harvested. (C) One artery and two veins were performed ETS anastomosis. (D) Three weeks after the first flap, the skin paddle exhibited good contours. (E) Anteroposterior radiograph showed the tibiofibular fracture. (F) CTA revealed the integrity of aTA, pTA, and PA. (G) Intraoperative imaging demonstrated bone destruction at the 3-month follow-up. (H, I) A free chimeric fibular flap was harvested from another leg. (J) Eleven weeks after the second flap, the paddle exhibited good contours. (K, L) Anteroposterior radiographs showed bilateral legs under the load-weighing condition.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4072764/v1/9b91abc1f2ecf13835aa87c8.png"},{"id":52787045,"identity":"099cd850-586a-446f-be36-4e9bbd43a4a5","added_by":"auto","created_at":"2024-03-15 18:55:46","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1056277,"visible":true,"origin":"","legend":"\u003cp\u003eA 74-year-old man sustained a tibial plateau fracture. (A) Intraoperative imaging demonstrated recurrent skin ulcers. (B, C) A chimeric ALTF was designed and harvested. (D, E) The arterial ETS and venous ETE anastomosis were demonstrated under revascularization. (F) An intraoperative photograph after reconstruction. (G) A satisfactory result was demonstrated after one year. (H) DSA revealed good retrograde flow.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4072764/v1/54c5106ae001065d61384075.png"},{"id":54645625,"identity":"3e4a59ac-198b-4ec1-84d7-5265d9d3a146","added_by":"auto","created_at":"2024-04-14 11:22:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3058947,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4072764/v1/61e2bdcb-445e-45aa-ad30-a20a80f31e53.pdf"},{"id":52787049,"identity":"be892dac-3a19-4c8a-b862-b5c7b87333d2","added_by":"auto","created_at":"2024-03-15 18:55:47","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20140,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary 1\u003c/strong\u003eHanover fracture scale\u003c/p\u003e","description":"","filename":"supplementary1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4072764/v1/06da8ac9913b3a5437fd33ff.docx"},{"id":52787139,"identity":"5aa4f569-266c-4901-a395-b458ff0be396","added_by":"auto","created_at":"2024-03-15 18:55:52","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":34994806,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo 1\u003c/strong\u003eDigital Content 1, which shows that, 17 months after the chimeric PAPF surgery reconstructing an 8cm tibia defect, the affected limb demonstrates good load-bearing function.\u003c/p\u003e","description":"","filename":"video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4072764/v1/7ecbc73934596f64bd9c33b7.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Chimeric free flaps based on end-to-side anastomosis for complex lower extremity reconstruction","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComplex lower extremity injury due to high-energy trauma remains a severe clinical challenge\u003csup\u003e1\u003c/sup\u003e. These injuries are characterized by soft tissue defects, bone exposure, bone defects, and recurrent infection, which require debridement surgeries before secondary reconstruction. In these cases, a simple free flap is insufficient because the recipient site may require skin, fat, fascia, muscle, bone even lymph nodes. Fasciocutaneous and muscle flaps can resolve conventional defects but without the flexibility of rotating independent flaps\u003csup\u003e2,3\u003c/sup\u003e. Besides, the Masquelet induced membrane technique (IMT) may require 4 to 96 weeks to form the induced membrane\u003csup\u003e4\u003c/sup\u003e, bone transport can achieve early weight-bearing accompanied with complications such as needle site infections, chronic skin irritation, and ankle stiffness\u003csup\u003e5\u003c/sup\u003e, and both cannot handle soft tissue defects. Very few methods contain multiple components to reconstruct defects while minimizing donor-site and recipient-site morbidity.\u003c/p\u003e \u003cp\u003eSince the first introduction, chimeric free flaps have been recently widely used to treat complicated defects\u003csup\u003e6\u003c/sup\u003e. Some flaps have their disadvantages, for example, the anatomical complexity of circumflex iliac artery flaps\u003csup\u003e7\u003c/sup\u003e, position changes of latissimus dorsi flaps during surgery, etc. Chimeric anterolateral thigh free flaps (ALTF) and peroneal artery perforator free flaps (PAPF) have become popular these days, because multiple tissue components can be harvested in various combinations, thus fulfilling three-dimensional reconstruction requirements\u003csup\u003e8\u003c/sup\u003e. Based on plastic surgery principles, end-to-side (ETS) anastomosis is recommended for arteries to minimize donor-site morbidity without sacrificing major vessels\u003csup\u003e9\u003c/sup\u003e. An ultrasound study of 20 free flaps revealed that the blood flow depends on flap type -- blood flow volume was significantly higher in the myocutaneous flaps than in the fasciocutaneous flaps, not on arterial incision of free flaps using the ETS technique\u003csup\u003e10\u003c/sup\u003e. Combined with the postoperative outcomes, we consider that ETS can provide lobular flaps with stable blood flow.\u003c/p\u003e \u003cp\u003eAs only a few existing studies have reported the combination of ETS anastomoses and chimeric flaps, we aimed to validate the feasibility of chimeric ALTF and PAPF consisting of isolated skin, muscle, fascia, and bone flaps based on arterial ETS anastomoses for complex lower extremity reconstruction. Meanwhile, we retrospectively access the outcomes and complications of retrograde flaps and antegrade flaps in these cases to learn the relation between blood flow direction and flaps\u0026rsquo; survival.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e Over 11 years (July 2012 to March 2023), 27 patients with complex lower extremity defects underwent chimeric ALTF or PAPF reconstruction under the Second Affiliated Hospital of Soochow University ethics committee-approved protocol. All patients with previous debridement surgeries and chimeric flap reconstruction were included in this retrospective investigation for a follow-up of 6 to 60 months. Inclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) patients suffered soft tissue, bone (defect\u0026thinsp;\u0026ge;\u0026thinsp;4cm), tendon defects in lower extremities; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) a single flap cannot cover the defects; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) simple debridement anastomosis or skin grafting cannot reconstruct the defect; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) none of the patients had sustained complete benefit from previous surgeries such as debridement, skin-grafting, internal fracture fixation. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) patients do not have serious underlying diseases. Exclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) soft tissue defects of lower extremities can be covered by a single flap; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) there are no deep tissue defects or dead cavity; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) simple debridement or skin grafting can reconstruct the defect; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) patients have serious underlying diseases.\u003c/p\u003e \u003cp\u003eMedical files and patient data were screened for patient demographics, intraoperative and perioperative details, flap survival, and complications. The severity of the defects was estimated by the Hannover fracture scale (HFS)\u003csup\u003e11\u003c/sup\u003e. Surgical complications like total or partial flap loss, thrombosis, hematoma, wound dehiscence, infection, and other recipient-site/donor-site complications were recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eFlap selection\u003c/h2\u003e \u003cp\u003eFor patients with less than 4cm bone defect, we choose autogenous bone transplantation. If the defect distance is \u0026ge;\u0026thinsp;4cm, chimeric PAPF is preferred, and large area defect can add chimeric ALTF. Defects with small/medium soft tissue defects and pedicles\u0026thinsp;\u0026lt;\u0026thinsp;8cm can be covered by chimeric PAPF. Small/medium defects requiring pedicles\u0026thinsp;\u0026ge;\u0026thinsp;8cm and large/multiple defects are flexibly reconstructed with chimeric ALTF (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe chimeric flaps included independent skin, fascia, muscle, or bone flaps containing individual paddles supplied by seperate perforators with no restriction on each pedicle rotation. The flap dimensions were designed larger than the defects with a slightly longer pedicle. Skin flaps were used to cover exposed vessels and bones; fascia flaps were used to cover tendinous tissues. Bone flaps and muscle flaps were designed to eliminate dead space or enhance resistance to infection\u003csup\u003e12,13\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAnterograde flaps have an angle of less than 90 degrees between the blood flow direction of donor blood vessels and recipient blood vessels, while retrograde flaps have an angle of more than 90 degrees between them. Since the perforation point of the anterior tibial artery (aTA) is often located in the upper third of the tibia, the ETS anastomosis in platform fracture is often selected below this, resulting in a retrograde blood supply\u003csup\u003e14\u003c/sup\u003e. The distal 2/3 of the aTA and dorsalis pedis artery (DPA) were usually selected as recipient arteries because of the easy dissection. Other arteries, such as the posterior tibial artery (pTA) and peroneal artery (PA) can also be selected (Fig.\u0026nbsp;2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cp\u003eAll flaps were harvested similarly. To harvest chimeric ALTF, the descending branch of the lateral circumflex femoral artery (LCFA) should be first confirmed with a handhold Doppler, and then the relatively superficial perforating branch and the proximal LCFA were traced back to the intermuscular septa or across muscles. To harvest chimeric PAPF, the perforating branch of the PA between the extensor digitorum longus and the peroneus brevis muscle was dissected after confirming the small head of the upper fibula and the external malleolus of the lower end. Leaving 6-8cm proximal to the lateral malleolus is essential to maintain ankle joint integrity. The medial fibula was dissected, and the proximal PA was retained for the vascular pedicle. ETS anastomoses were performed with a 9\u0026thinsp;\u0026minus;\u0026thinsp;0 prolene monofilament. A smaller hole was made than the donor vessel with a 90\u0026deg;angle between two arteries. A six-point suture with an equal distance was performed using an interrupted vertical mattress suture. Most veins were operated with end-to-end (ETE) anastomosis.\u003c/p\u003e \u003cp\u003ePostoperative monitoring techniques included evaluation of color, capillary refill, turgor, surface temperature, and the presence of bleeding. Free flaps should be frequently monitored, particularly during the initial postoperative period. Emergent exploration and repair must be performed soon after the obstruction occurs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe retrospective review revealed 27 patients (26 male and 1 female) who underwent complex lower extremity reconstruction with chimeric ALTF or PAPF. The mean age of the patients was 47.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6 (range, 27\u0026ndash;74) years. The defects were located on the lower leg (n\u0026thinsp;=\u0026thinsp;10), tibial plateau (n\u0026thinsp;=\u0026thinsp;5), foot (n\u0026thinsp;=\u0026thinsp;9), ankle (n\u0026thinsp;=\u0026thinsp;2) and thigh (n\u0026thinsp;=\u0026thinsp;1). Additional complicating factors included osteomyelitis (n\u0026thinsp;=\u0026thinsp;4), exposed bone (n\u0026thinsp;=\u0026thinsp;9), bone defects (n\u0026thinsp;=\u0026thinsp;10), recurrent ulcers (n\u0026thinsp;=\u0026thinsp;5), skin necrosis (n\u0026thinsp;=\u0026thinsp;3), refractory soft tissue defects (n\u0026thinsp;=\u0026thinsp;5), and Achilles tendon exposure (n\u0026thinsp;=\u0026thinsp;3). Systemic comorbidities and the Hannover fracture scale were recorded. Operations before reconstruction were 2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 (range, 1\u0026ndash;6) times (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePatient demographic data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"9\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge/ sex\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePreoperative diagnosis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEtiology\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDefect location\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdditional local complicating factors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSystemic comorbidities\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHanover Fracture Scale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOperations before free flap\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibiofibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteomyelitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetatarsal fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemoral fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEarthquake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect, recurrent ulcer, skin necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibial plateau fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecurrent ulcer, skin necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHBP, DM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalcaneal fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteomyelitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArticular gout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHBP, hyperuricemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibial plateau fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecurrent ulcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibiofibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRefractory soft tissue defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoot fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRefractory soft tissue defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO3 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibiofibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetatarsal fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetatarsal fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibiofibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteomyelitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibiofibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnkle fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnkle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAchilles tendon exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHBP, DM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetatarsal fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAchilles tendon exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO3 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etibial fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etibiofibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRefractory soft tissue defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efracture of tibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecurrent ulcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efracture of tibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRefractory soft tissue defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efracture of tibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteomyelitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emetatarsal fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etibiofibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRefractory soft tissue defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efracture of tibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibial plateau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecurrent ulcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003earthritic calculus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003egout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFoot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHyperuricemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etibiofibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExposed bone, bone defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO3 C3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eankle fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eankle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAchilles tendon exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eO2 C2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eFifteen patients received chimeric ALTF and twelve received chimeric PAPF. Chimeric fabrication comprised vascularized fibula bones (range, 4-22cm) in eight patients, muscles in fifteen patients, vascularized fascia in two patients, and multiple skin flaps in seven patients. The defect size measured 121.1\u0026thinsp;\u0026plusmn;\u0026thinsp;215.1 (range, 7.5\u0026ndash;1075) cm\u003csup\u003e2\u003c/sup\u003e and was covered with flaps measuring 143.9\u0026thinsp;\u0026plusmn;\u0026thinsp;177.8 (range, 13.5\u0026ndash;760) cm\u003csup\u003e2\u003c/sup\u003e. The aTA, DPA, pTA, and PA were recipient arteries under the ETS pattern (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Typical surgery cases are presented in Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFlap details and complications\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"13\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFlap type\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eOther include structures\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSkin defect size (cm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMuscle size (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFlap size (cm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003erecipient artery\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eType of anastomosis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eRecipient-site complications\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDonor-site complications\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eartery\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003evein\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10x6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3x1x1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11x7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5cm fibula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15x5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16x6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin-grafting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22cm fibula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14x6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15x7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eflap total loss\u0026thinsp;+\u0026thinsp;artery thrombosis\u0026thinsp;+\u0026thinsp;10cm femur shortening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4x2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2x2x1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5x3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFlap partial loss\u0026thinsp;+\u0026thinsp;artery thrombosis\u0026thinsp;+\u0026thinsp;secondary flap transfer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8x6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3x2.5x2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9x7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5x4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3x2.5x1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5x4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3x2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2x1.5x1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5x3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle, 2 flaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20x12, 22x13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15x5x3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40x16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u0026thinsp;+\u0026thinsp;pTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle, 2 flaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4x3, 7x3, 7x4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5x4x2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13x8, 19x15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePoor blood supply\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003einfection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u0026thinsp;+\u0026thinsp;ALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.5cm fibula, 3 flaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20x15, 15x10, 25x10, 25x15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20x12, 40x12, 8x5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5x3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5x3x1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7x5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5cm fibula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10x5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.5x7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003einfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13x8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4x3x3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15x10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12cm fibula, 2 flaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12x7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15x10, 8x5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePartial skin necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 flaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7x4.5, 3x2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9x7.5, 5x3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 flaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12x6, 18x9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10x7, 15x8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ehematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003einfection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8cm fibula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10x9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11x10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12x10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3x3x1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5x11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6x5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.5x2x1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.5x6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle, fascia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12x7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3x3x2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13x8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10x6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4x2x1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11x7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4cm fibula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9x6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10x7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 flaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15x8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16x9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7x6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2x2x1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8x7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALTF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuscle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4x4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2x1x1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5x5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10cm fibula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12x9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13x10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFlap partial loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePAPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efascia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9x8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10x9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eaTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eETS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOne patient (case 3) who had experienced an earthquake lost the first flap due to chronic infection, massive soft tissue loss, and 10cm femur shortening. After several debridement surgeries, a chimeric PAPF covered the soft tissue defect and rebuilt bone stability. Three patients (case 4/14/26) experienced partial free flap loss. In cases 14 and 26, no additional free flap was necessary, while small defects were covered with local tissue transposition flaps. Case 4 caused by arterial thrombosis underwent an additional exploration to solve the complication. Another three patients (case 9/12/16) had minor flap complications cured with regular wound dressing, antibiotics, and conservative therapy. Case 2 with donor-site skin defects was cured by a subsequent skin graft. Case 10/16 with infection along the flaps\u0026rsquo; edge in the donor-site area was cured by antibiotics and wound dressing.\u003c/p\u003e\n\u003cp\u003eThe recipient-site complication rate of retrograde flaps (case 4/7/19/20/21/24) was 16.67% (n\u0026thinsp;=\u0026thinsp;1), while that of antegrade flaps was 28.57% (n\u0026thinsp;=\u0026thinsp;6). Besides, the donor-site complication rate of retrograde flaps was zero (n\u0026thinsp;=\u0026thinsp;0) and that of antegrade flaps was 14.29% (n\u0026thinsp;=\u0026thinsp;3). The defect size in the retrograde group measured 38.92\u0026thinsp;\u0026plusmn;\u0026thinsp;29.63 cm\u003csup\u003e2\u003c/sup\u003e and was covered with flaps measuring 51.17\u0026thinsp;\u0026plusmn;\u0026thinsp;35.16 cm\u003csup\u003e2\u003c/sup\u003e. The defect size in the antegrade group measured 144.64\u0026thinsp;\u0026plusmn;\u0026thinsp;239.45 cm\u003csup\u003e2\u003c/sup\u003e and was covered with flaps measuring 170.33\u0026thinsp;\u0026plusmn;\u0026thinsp;193.60 cm\u003csup\u003e2\u003c/sup\u003e. Except for one patient who received a secondary free flap in antegrade flaps for a donor-site complication, all achieved satisfactory results after additional exploration or conservative therapy (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFlap details of retrograde and antegrade flaps\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRetrograde flap (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAntegrade flap (n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin defect size (cm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.92\u0026thinsp;\u0026plusmn;\u0026thinsp;29.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e144.64\u0026thinsp;\u0026plusmn;\u0026thinsp;239.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFlap size (cm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.17\u0026thinsp;\u0026plusmn;\u0026thinsp;35.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170.33\u0026thinsp;\u0026plusmn;\u0026thinsp;193.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecipient-site complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.67% (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.57% (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDonor-site complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (n\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.29% (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eComplex lower extremity defects from high-energy trauma can hardly be repaired by simple free flaps, which pose a reconstructive challenge to surgeons. An ideal reconstruction would result in reinstated function and aesthetic appearance. Several methods have been reported, however, cases of severe soft defects have not been reported. As listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, high-energy trauma often leads to complications, such as refractory soft tissue defects, recurrent ulcers, skin necrosis, osteomyelitis, Achilles tendon exposure, exposed bones, and even extensive bone defects. Traditional free flap reconstruction failed to achieve satisfactory results because a single ALTF or PAPF failed to solve skin, soft tissue, and bone defects simultaneously. Moreover, the ETE method sacrifices the main artery, leaving little space for distal blood supply and subsequent vascular surgeries\u003csup\u003e15\u003c/sup\u003e. To solve the problem, a chimeric free flap based on the ETS anastomosis is an ideal option for complex reconstruction.\u003c/p\u003e \u003cp\u003eBone defects should be given priority before soft tissue reconstruction, which often results from osteomyelitis, trauma, and congenital and acquired deformities\u003csup\u003e16\u003c/sup\u003e. Traditionally, the treatment is divided into non-vascularized and vascularized bones. Non-vascularized bones are allografts and autografts. Compared to allografts -- slower revascularization, autografts are ideal choices for less dead bone, no immune rejection, and less infection\u003csup\u003e17\u003c/sup\u003e. If the bone defects are longer (\u0026ge;\u0026thinsp;4cm), vascularized bone flaps would be chosen, such as the iliac and fibular flaps. Due to anatomical characteristics, the iliac flaps have thinner blood vessels, shorter pedicles, a maximum 10cm bone mass, and a higher proportion of cancellous bone, making them more suitable for oral and maxillofacial reconstruction\u003csup\u003e18,19\u003c/sup\u003e. By contrast, fibular flaps can provide more bone mass for structural support because the cortical bone to cancellous bone ratio is approximately 1:1. Considering that the collapse of the femoral head is significantly less in the implantation of a fibular flap than an iliac flap\u003csup\u003e20\u003c/sup\u003e. We also attached a video about reconstructing an 8cm tibia defect with a fibular flap to prove the ability of structural support, in which the affected limb demonstrated good load-bearing (\u003cb\u003eVideo 1\u003c/b\u003e). Therefore, when there is a requirement for weight-bearing reconstruction, the fibular flap is preferred.\u003c/p\u003e \u003cp\u003eIn this report, we present that chimeric ALTF and PAPF can cover kinds of complex lower extremity defects (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Chimeric ALTF can provide a large area, thick fat, massive muscles, and a long vessel pedicle\u003csup\u003e21\u003c/sup\u003e, while chimeric PAPF can provide a smaller area but is sufficient for moderate skin defects, thin fat, muscles, a short vessel pedicle, and a maximum of 22cm bones\u003csup\u003e22,23\u003c/sup\u003e. All cases in this study achieved relatively reinstated function and aesthetic appearance. Other flaps, such as the latissimus dorsi flap, forearm perforator radial artery flap, an superficial circumflex iliac artery perforator flap, may require position changes, influence flexibility of upper extremities, and have small vessel diameter problems\u003csup\u003e24,25\u003c/sup\u003e. The flow-through technique has more requirements: the recipient sites have a vascular injury, and the donor sites require the removal of part of the main vessels along with entire perforator vessels\u003csup\u003e26\u003c/sup\u003e. Therefore, chimeric ALTF and PAPF are superior to other flaps for flexible reconstruction.\u003c/p\u003e \u003cp\u003eSuccessful microvascular free flap transfer is highly dependent on sufficient microvascular anastomoses. While ETE anastomosis is significantly successful for stable hemodynamic improvement, many studies have suggested that no significant differences exist in extremity perfusion and flap failure between ETS to ETE\u003csup\u003e15,27,28\u003c/sup\u003e. As presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the success rate after the first ETS flap was over 85%. This rate climbed to 88% after conservative treatment (n\u0026thinsp;=\u0026thinsp;2) and over 96% after exploratory surgeries (n\u0026thinsp;=\u0026thinsp;2). Based on the mature microsurgical technique, well-filled vessels, and no blood leakage were observed after vascular recanalization (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003eC, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003eE). Albertengo et al. reported that in ETE anastomosis, the intima, media, and outer membrane of arteries at the recipient site are completely severed, which would cause turbulence and thrombosis with the contraction of the middle smooth muscles. However, in ETS anastomosis, the contraction or spasm of smooth muscles will enlarge the opening because they were partially cut off\u003csup\u003e29\u003c/sup\u003e. Furthermore, researches indicate that the blood flow in free flaps depends on the specific tissue composition rather than the recipient artery flow rate, for example, a muscle flap has more sufficient blood flow than a fasciocutaneous flap\u003csup\u003e30\u003c/sup\u003e. Most cases in our study underwent computed tomography angiography after reconstruction demonstrating rich blood supply. As a result, we believe that ETS in chimeric free flaps can preserve distal perfusion without increasing complications.\u003c/p\u003e \u003cp\u003eIt is worth noting that we designed retrograde flaps for some specialized defects because soft tissue defects around the knee account for a considerable proportion. The main reasons are trauma and complications of total knee arthroplasty. The skin around the tibial plateau is thin, surgical trauma is severe, and some patients require secondary reconstruction, in which cases, traditional free flaps provide limited solutions for bone, tendon, joint, and internal fixation exposure. During intraoperative anatomy, aTA often emerges from the intermuscular septum near the proximal 1/3 of the tibia. Because platform fractures often result in scars on both sides of the knee, and local blood vessels may be damaged, a local transfer of the medial gastrocnemius flap is not considered. Our group designed chimeric retrograde ALTF or PAPF for defects in the proximal 1/3 of the plateau area (Fig.\u0026nbsp;2). Chimeric ALTF or PAPF can provide a relatively large vessel diameter compared with other free flaps, which ensures relatively abundant blood perfusion under retrograde situations. The defects of the distal 2/3 of the tibia and the beyond are designed as chimeric antegrade free flaps, in which the reconstructed blood flow was always satisfactory. In this research, the complication rates of retrograde flaps and antegrade flaps were 16.67% and 28.57%. While the retrograde cases were fewer than the antegrade ones, the lower complication rate reveals that applying chimeric ALTF or PAPF based on arterial ETS anastomosis becomes a reliable choice.\u003c/p\u003e \u003cp\u003eAll the surgeries were performed by the same group led by the same surgeon. Thus, the anastomotic technique depended on the expertise and training of surgeons. The surgical technique improved as cases accumulated, which may introduce bias. Our study is subject to the limitations inherent to retrospective, uncontrolled case reviews, including small sample size, lack of strict criteria for patient selection, and absence of prospective data collection, especially a final comprehensive strict functional assessment. All surgeries were performed at a single center. Further, prospective studies and data summarization are required to clarify the risks and prognosis in the future.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe clinical outcomes associated with the use of chimeric free flaps based on ETS anastomosis for complex lower extremity reconstruction are reliable in carefully selected patients. ETS anastomosis creates stable hemodynamics and a high flap survival rate. Patients with complex defects in the proximal 1/3 of the lower limb can choose retrograde flaps, whereas those with defects below this can choose antegrade flaps. Larger case series, prospective clinical trials, and quantitative hemodynamic data detection are needed to emphasize the importance.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest:\u003c/h2\u003e \u003cp\u003eThe authors have no financial interest to declare in relation to the content of this article.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis work was supported by the Medical Application project of Nuclear Technology in subject Construction Lifting Project of the Second Affiliated Hospital of Soochow University (Grant No. XKTJ-HRC2021008).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYLG wrote the main manuscript text. YYS and KX collected the data. NY, JZQ and YZ assisted the surgery. BJ and JJZ designed the surgery and revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMurawski CD, Mittwede PN, Wawrose RA, Belayneh R, Tarkin IS. Management of High-Energy Tibial Pilon Fractures. Journal of Bone and Joint Surgery. 2023;105:1123\u0026ndash;1137\u003c/li\u003e\n\u003cli\u003eZheng X, Zheng C, Wang B, et al. Reconstruction of complex soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap. Int J Surg. 2016;26:25\u0026ndash;31\u003c/li\u003e\n\u003cli\u003eGuo M, Thomas B, Goyal S, et al. Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures. J Plast Reconstr Aesthet Surg. 2023;77:111\u0026ndash;116\u003c/li\u003e\n\u003cli\u003eKhaled A, El-Gebaly O, El-Rosasy M. Masquelet-Ilizarov technique for the management of bone loss post debridement of infected tibial nonunion. Int Orthop. 2022;46:1937\u0026ndash;1944\u003c/li\u003e\n\u003cli\u003eAllesina L, Alessio-Mazzola M, Belluati A, Mosca S, Placella G, Salini V. Surgical treatment of critical size bone defects with Masquelet technique versus bone transport: a systematic review and meta-analysis of comparative studies. Arch Orthop Trauma Surg. 2023;143:7081\u0026ndash;7096\u003c/li\u003e\n\u003cli\u003eSui X, Khan UZ, Qing L, Yu F, Wu P, Tang J. The free chimeric medial sural artery perforator flap for individualised and three‐dimensional reconstruction of complex soft‐tissue defects in extremities. International Wound Journal. 2023;20:2679\u0026ndash;2687\u003c/li\u003e\n\u003cli\u003eKwon JG, Pereira N, Tonaree W, Brown E, Hong JP, Suh HP. Long Pedicled Superficial Circumflex Iliac Artery Flap Based on a Medial Superficial Branch. Plastic \u0026amp; Reconstructive Surgery. 2021;148:615e\u0026ndash;619e\u003c/li\u003e\n\u003cli\u003eWong C-H, Wei F-C. Anterolateral thigh flap. Eisele DW, ed. Head Neck. 2009:NA-NA\u003c/li\u003e\n\u003cli\u003eApostolides JG, Magarakis M, Rosson GD. Preserving the Internal Mammary Artery: End-to-Side Microvascular Arterial Anastomosis for DIEP and SIEA Flap Breast Reconstruction. Plastic and Reconstructive Surgery. 2011;128:225e\u0026ndash;232e\u003c/li\u003e\n\u003cli\u003eMotomiya M, Watanabe N, Nakamura S, Kameda Y, Kawamura D, Iwasaki N. Blood flow distribution after end-to-side anastomosis with wide arteriotomy in extremity free flap surgery. J Plast Reconstr Aesthet Surg. 2021;74:2495\u0026ndash;2503\u003c/li\u003e\n\u003cli\u003eKrettek C, Seekamp A, K\u0026ouml;ntopp H, Tscherne H. Hannover Fracture Scale \u0026rsquo;98--re-evaluation and new perspectives of an established extremity salvage score. Injury. 2001;32:317\u0026ndash;328\u003c/li\u003e\n\u003cli\u003eLo S, Yonjan I, Rose A, Roditi G, Drury C, MacLean A. In search of the ideal periosteal flap for bone non-union: The chimeric fibula-periosteal flap. J Plast Reconstr Aesthet Surg. 2023;83:221\u0026ndash;232\u003c/li\u003e\n\u003cli\u003eHuang W-C, Chen H-C, Wei F-C, Cheng M-H, Schnur DP. Chimeric flap in clinical use. Clin Plast Surg. 2003;30:457\u0026ndash;467\u003c/li\u003e\n\u003cli\u003eJaiswal D, Mathews S, Gupta H, et al. Utilizing the Retrograde Flow of Internal Mammary Vessels as a Donor Pedicle. Indian J Plast Surg. 2022;55:244\u0026ndash;250\u003c/li\u003e\n\u003cli\u003eBroer PN, Moellhoff N, Mayer JM, Heidekrueger PI, Ninkovic M, Ehrl D. Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions. J Reconstr Microsurg. 2020;36:432\u0026ndash;437\u003c/li\u003e\n\u003cli\u003eBibbo C. The Free Fibula Flap for Lower Extremity Reconstruction. Clin Podiatr Med Surg. 2021;38:117\u0026ndash;130\u003c/li\u003e\n\u003cli\u003eScarborough MT. Allograft-allograft healing? Salvage of massive allografts after fracture. Clin Orthop Relat Res. 2001:28\u0026ndash;33\u003c/li\u003e\n\u003cli\u003eZeng Y-R, He S, Feng W-J, et al. Vascularised greater trochanter bone graft, combined free iliac flap and impaction bone grafting for osteonecrosis of the femoral head. Int Orthop. 2013;37:391\u0026ndash;398\u003c/li\u003e\n\u003cli\u003eLiuFu J-F, Lv X-M, Yang Z-Y, et al. The effect of anterior superior iliac spine preservation on donor site morbidity and function after harvesting a vascularized iliac bone flap. Head Neck. 2023;45:2544\u0026ndash;2554\u003c/li\u003e\n\u003cli\u003eFeng W, Chen J, Wu K, et al. A comparative study of cortico-cancellous iliac bone graft with or without the combination of vascularized greater trochanter flap for the management of femoral head osteonecrosis: a minimum 6\u0026thinsp;years follow-up. BMC Musculoskelet Disord. 2019;20:298\u003c/li\u003e\n\u003cli\u003eHsu C-C, Loh CYY, Wei F-C. The Anterolateral Thigh Perforator Flap: Its Expanding Role in Lower Extremity Reconstruction. Clin Plast Surg. 2021;48:235\u0026ndash;248\u003c/li\u003e\n\u003cli\u003eHan HH, Lee YJ, Moon S-H. Foot reconstruction using a free proximal peroneal artery perforator flap: Anatomical study and clinical application. J Plast Reconstr Aesthet Surg. 2018;71:883\u0026ndash;888\u003c/li\u003e\n\u003cli\u003eSong J-L, Bao B-B, Chen C, Qian Y, Zheng X-Y. Free peroneal artery perforator flap for reconstruction of traumatic limb soft tissue defects: A retrospective case series study. Microsurgery. 2023\u003c/li\u003e\n\u003cli\u003eChang EI, Liu J. Prospective Comparison of Donor-Site Morbidity following Radial Forearm and Ulnar Artery Perforator Flap Harvest. Plast Reconstr Surg. 2020;145:1267\u0026ndash;1274\u003c/li\u003e\n\u003cli\u003eHong JP. The Superficial Circumflex Iliac Artery Perforator Flap in Lower Extremity Reconstruction. Clin Plast Surg. 2021;48:225\u0026ndash;233\u003c/li\u003e\n\u003cli\u003eFernandez-Garrido M, Lopez Penha TR, Qiu SS. Flow-Through Flaps in the Absence of an Arterial Gap for Extremity Defect Reconstruction: Minimizing the Donor-Site Morbidity. J Reconstr Microsurg. 2019;35:329\u0026ndash;334\u003c/li\u003e\n\u003cli\u003eTreiser MD, Miles MR, Albino FP, Giladi AM, Katz RD, Higgins JP. Long-Term Patency and Fluid Dynamics of Recipient Artery after End-to-Side Anastomosis for Free Tissue Transfer. Plast Reconstr Surg. 2021;148:800e\u0026ndash;803e\u003c/li\u003e\n\u003cli\u003eCho EH, Garcia RM, Blau J, et al. Microvascular Anastomoses Using End-to-End versus End-to-Side Technique in Lower Extremity Free Tissue Transfer. J Reconstr Microsurg. 2016;32:114\u0026ndash;120\u003c/li\u003e\n\u003cli\u003eAlbertengo JB, Rodriguez A, Buncke HJ, Hall EJ. A comparative study of flap survival rates in end-to-end and end-to-side microvascular anastomosis. Plast Reconstr Surg. 1981;67:194\u0026ndash;199\u003c/li\u003e\n\u003cli\u003eLorenzetti F, Suominen S, Tukiainen E, et al. Evaluation of blood flow in free microvascular flaps. J Reconstr Microsurg. 2001;17:163\u0026ndash;167\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"chimeric free flaps, end-to-side anastomosis, extremity reconstructions","lastPublishedDoi":"10.21203/rs.3.rs-4072764/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4072764/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eComplex lower extremity defects are difficult to cover and often require multiple free tissue transfers. Chimeric anterolateral thigh free flaps (ALTF) and peroneal artery perforator free flaps (PAPF) have been designed specifically as an alternative for reconstruction with arterial end-to-side (ETS) anastomosis. We aimed to assess our institutional experience with this technique and to define its role in complex lower extremity reconstruction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: From July 2012 to March 2023, 27 patients with complex lower extremity defects underwent reconstruction with chimeric ALTF or PAPF. Patients were performed with retrograde flaps for repairing refractory wounds of tibia plateau fracture and antegrade flaps for distal 2/3 tibia and beyond. Demographic, clinical, and follow-up data on the patients were recorded with a special focus on complication profiles during a follow-up of 6 to 60 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The mean defect size measured 121.1 ± 215.1 cm\u003csup\u003e2\u003c/sup\u003e and the chimeric ALTF or PAPF flaps measured 143.9 ± 177.8 cm\u003csup\u003e2\u003c/sup\u003e. One patient lost the first free flap but successfully had a chimeric PAPF then. Three patients suffered partial free flap loss, and another three had minor complications. All six survived after an additional exploration, wound dressing, or antibiotics treatment. The retrograde flaps achieved similar blood flow to the antegrade flaps. Patients are all satisfied with functional and aesthetic outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Given the incidence of complications, utilizing chimeric ALTF and PAPF either with retrograde or antegrade flow based on arterial ETS anastomosis is a reliable surgical option for complex lower extremity reconstructions.\u003c/p\u003e","manuscriptTitle":"Chimeric free flaps based on end-to-side anastomosis for complex lower extremity reconstruction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-15 18:50:53","doi":"10.21203/rs.3.rs-4072764/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3961932e-20df-43fa-97b9-46e42836005f","owner":[],"postedDate":"March 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-14T11:14:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-15 18:50:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4072764","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4072764","identity":"rs-4072764","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}