Superficial circumflex iliac artery based fascial pedicle bi-lobed iliac bone flap transfer for reconstruction of foot composite tissue defects

Superficial circumflex iliac artery based fascial pedicle bi-lobed iliac bone flap transfer for reconstruction of foot composite tissue defects | 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 Superficial circumflex iliac artery based fascial pedicle bi-lobed iliac bone flap transfer for reconstruction of foot composite tissue defects Lei Xu, Wen Ju, Lei Li, Qianheng Jin, Yujun Zhang, Linfeng Tang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3842914/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: To investigate the clinical efficacy of repairing the large-sized compound tissue defects in the foot with the free superficial circumflex iliac artery (SCIA) based fascial pedicle bi-lobed iliac bone flap. Methods: A retrospective analysis from October 2009 to February 2017 was performed, and 11 patients were identified with large-sized compound tissue defects repaired with the free SCIA based fascial pedicle bi-lobed iliac bone flap. The size of wound ranged from 12 cm × 10 cm to 15 cm × 13 cm and the length of the bony defect was from 4 cm to 7 cm. The flap sizes ranged from 13 cm × 10 cm to 16 cm × 14 cm, and the length of the dissected iliac ranged from 5 cm to 8 cm. The donor sites were primarily closed. Results: All 11 flaps survived engraftment including one case venous crisis occurred. After 6 months, only one of the cases resulted in swollen flaps which required repair. All other engrafted flaps were well appearing and the transplanted iliac healed smoothly, with a bone healing time of less than 12 weeks. The internal fixation was removed between 12 and 24 weeks post operation. Successful postoperative recovery of ankle joint flexion and extension resulted in normal gait. Conclusions: The free SCIA-based fascial pedicle bi-lobed iliac bone flap repaired the large-sized compound tissue defect in the foot, resulting in repaired bone defect, wound coverage, low donor site morbidity, and recovery of function. Iliac bone flap fascial pedicle Superficial circumflex iliac artery Microsurgery Foot reconstruction Figures Figure 1 Figure 2 Full Text In 1978, Taylor et al reported the first free graft of revascularized flaps of groin skin and iliac bone to repair of compound leg defects 1 . This method has been widely adopted in clinic, especially for reconstruction of small to medium size defects in the extremities 2 – 4 . However, the traditional iliac flap transplantation has several limitations. Fist, the iliac is supplied by multiple blood sources and relies on a large number of small musculoskeletal arteries to evenly supply the underlying bone. Furthermore, few of thick perforating arteries branch into the periosteum, making it difficult to dissect the free iliac flap. Finally, if the width of the donor flap exceeds 8 cm, an additional skin graft is required for closure, resulting in an additional donor site. The purpose of this study is to evaluate the clinical efficacy of free SCIA-based fascial pedicle bi-lobed iliac bone flap for repairing large-sized compound tissue defects in the foot (Figure 1). We will also explore the anatomical basis and significance of the free SCIA-based fascial pedicle bi-lobed iliac bone flap. We will summarize the surgical indications, anatomical basis, and precautions of this method by retrospectively analysis the 11 cases. Methods Retrospective review inclusion and exclusion criteria Ethics approval for the clinical was obtained from the Suzhou Ruihua Orthopedic Hospital. A retrospective review of patients treated between October 2009 and February 2017 was performed to identify patients who were treated for large-sized compound tissue defects in the foot repaired with free SCIA-based bi-lobed iliac bone flap. Inclusion and exclusion criteria were as follows. Inclusion criteria: 1) trauma-induced complex tissue defect in the foot; 2) simultaneous defects in metatarsal bones and foot skin; 3) the wound shows no signs of infection or infection has been effectively controlled; 4) the period of follow-up was more than 6 months; 5) the width of wound exceeds 8 cm. Exclusion criteria: 1) the soft tissue defects without metatarsal defect; 2) granulation tissue of wound surface is well covered, and no deep tissue is exposed; 3) the period of follow-up is less than 6 months; 4) the width of wound less than 8 cm. Patient Demographics From October 2009 to February 2017, 11 patients were identified as large-sized compound tissue defects. The average age of the 9 males and 2 females patients was 32 years (rang, 18–65 years). The size of wound ranged from 12 cm × 10 cm to 15 cm × 13 cm and the length of the bony defect was from 4 cm to 7 cm. The bony defect locations included the first metatarsal (5 cases), the second metatarsal (2 cases), and the fifth metatarsal (4 cases). The flap sizes ranged from 13 cm × 10 cm to 16 cm × 14 cm, and the length of the dissected iliac ranged from 5 cm to 8 cm. All patients were repaired with SCIA-based fascial pedicle bi-lobed iliac bone flap as elective surgery. Patients’ demographic data are shown in Table 1 . Table 1 Demographic Data Case Sex Age (yr) Length of Metatarsal Defect (cm) Defect Size (cm 2 ) Length of iliac transfer (cm) Size of bi-lobed Flaps (cm 2 ) Angle of flap rotating Timing of Reconstruction 1 M 18 4.0 12 × 10 5.0 13 × 6; 7 × 5 110° Secondary 2 M 39 5.0 15 × 10 6.0 16 × 6; 6 × 5 120° Secondary 3 F 26 4.0 13 × 10 5.0 14 × 6; 5 × 4 180° Secondary 4 M 30 6.0 15 × 10 7.0 16 × 6; 7 × 6 120° Secondary 5 M 32 5.0 12 × 10 6.0 13 × 6; 7 × 4 135° Secondary 6 F 23 5.0 14 × 10 5.0 15 × 6; 5 × 4 120° Secondary 7 M 65 4.0 15 × 11 5.0 16 × 7; 6 × 4 120° Secondary 8 M 20 4.0 14 × 13 5.0 15 × 6; 5 × 3 150° Secondary 9 M 37 7.0 15 × 11 8.0 16 × 6; 7 × 4 120° Secondary 10 M 41 5.0 13 × 10 6.0 14 × 6; 6 × 4 135° Secondary 11 M 21 7.0 12 × 10 8.0 13 × 6; 7 × 5 110° Secondary Surgical Techniques Debridement and wound preparation Surgeries were performed on all patients under epidural anesthesia. The wound was completely debrided and repeatedly rinsed with hydrogen peroxide and normal saline. Following wound preparation, patients with blood vessel, nerve, and tendon defects were treated in one-stage procedure. For those with fractures, internal fixation is applied after fracture reduction. In cases of metatarsal defects, cross fixation is achieved with two 1.2mm Kirschner wires, restoring alignment and height to establish proper metatarsal biomechanics (Fig. 2 A- B). For individuals with remaining or partially avulsed skin, thinning is performed followed by compression dressing. In cases of complete skin loss or severe contamination due to skin abrasion, excision is carried out, and the wound is covered with Vacuum Sealing Drainage (VSD) material. After removing the Vacuum Sealing Drainage (VSD) on days 5 to 7, assess the wound condition. If the wound is fresh with no purulent discharge, proceed with preoperative preparation for bone and skin flap repair. In cases where the wound is not fresh or shows persistent purulent discharge, perform additional debridement, replace the VSD, and repeat the process until the wound is fresh and free from purulent discharge. In this group, four cases achieved fresh and clean wound conditions after one debridement with Vacuum Sealing Drainage (VSD) negative pressure suction, six cases after two debridements with VSD, and one case after three debridements with VSD. Ultrasound guided detecting of the SCIA and designing of flap: the Doppler ultrasound began at the most obvious pulsation point of femoral artery at the groin as a primary landmark (Fig. 2 C). A line was then drawn between that point and the anterior superior iliac spine. Along this axis, 1–2 perforator points were marked, and the periosteal branch entering the iliac bone was detected and marked with a line. The pattern of fabric was designed slightly enlarge by 10% according to the shape of the wound and the start and end points of the metatarsal defect were marked on the fabric. The pattern of fabric was cut into two parts from the wide side, which can be split into a long and narrow shape by rotating proper angle. Flap excision: After outlining the shape on the prepared wound dressing, bisect the dressing along its width. Pay attention to the location of the metatarsal bone defect. Join the two halves of the bisected dressing to form an elongated shape, taking into account the position of the planned perforators marked by preoperative color Doppler ultrasound. Design the flap with this shape, and the junction of the dressing serves as the incision site for the flap. The flap can be designed as one large and one small segment or two segments of similar size, considering the connection of the flap in the form of a fascial pedicle. Therefore, careful planning is required for the flap junction. According to the splitting shape of fabric, the flap was designed based on the perforator of the preoperative Doppler ultrasound identification. The design line was draw according to the shape of the pattern of fabric and the position of the iliac bone was marked at the same time. A 3.0 cm longitudinal incision was performed at the most obvious pulsation point of femoral artery at the groin area. Cutting open the skin and subcutaneous tissue to locate the SCIA and superficial circumflex vein (SCIV). The flap was elevated from laterally to the mark of iliac bone, and the tendons of iliotibial band attached to the outer edge of iliac were cut off. The iliac bone flap was chiseled at the back of the anterior superior iliac spine according to the size of the needed iliac bone. The separation of flap and iliac should be avoided during the process of flap excision. The incising layers were located in the deep fascia layer except for the bone flap. From the inner side of the skin flap, the flap is dissected along the deep fascial layer towards the outer side until meeting with the bone flap. After complete osteotomy of the bone flap, the skin flap is fully elevated. Reverse dissection is then performed, freeing the flap to the pedicle. At this point, except for the vascular pedicle connection, the rest of the skin flap is completely freed. Bleeding from the cut surface of the skin paddle and the bone flap was observed (Fig. 2 E). From the junction where the two skin flaps are joined, incise the skin only, avoiding cutting through the subcutaneous tissues, especially the deep fascia. Use sharp tissue scissors to separate the two skin flaps, allowing the skin of both flaps to rotate completely and fold at a 90° angle (Fig. 2 F). Iliac bone extraction area was smoothed with a bone file and sealed with bone wax to stop bleeding. The donor sites were closed primarily in a multilayer fashion. The flap was transferred to the receipt site of the foot after pedicle division. The trimmed iliac was used to reconstruct the metatarsal defect using the Kirschner wire or steel plate. The vascular pedicle was introduced into the dorsalis plantar artery through the channel. The superficial circumflex iliac artery was anastomosed to the dorsalis plantar artery, and the SCIV was anastomosed to companion vein of the dorsalis pedis artery in an end-to-end fashion. Drainage strip was placed on the edge of the flap for the case of disorders of blood circulation. The wound was then covered by wound dressing and the external plaster fixation was needed. Postoperatively, the patients were administered anticoagulant, antispasmodic, and antibiotics to prevent coagulation, spasmodic and infection. The blood circulation of the flap should be closely observed and the blood circulation crisis should be solved in time once it happened. Surgical exploration was performed if the blood circulation crisis was not solved after conservation treatment for one hour. Results 11 flaps demonstrated complete survival. There was one occurrence of exudation at the margin of the flap, which healed after dressing change. The wounds in the donor sites and recipient sites were healed at one stage in other cases. The average follow-up period was 17 months (range, 10–48 months). Postoperative details and complications are presented in Table II . TABLE Ⅱ Flap Details and Complications Case Size of bi-lobed Flaps (cm 2 ) Length of iliac transfer (cm) Angle of flap rotating Bone Union (wk) Presence of complications Latest follow-up post operation (month) 1 13 × 6; 7 × 5 5.0 110° 9 None 20 2 16 × 6; 6 × 5 6.0 120° 8 None 10 3 14 × 6; 5 × 4 5.0 180° 11 Bloated flap 13 4 16 × 6; 7 × 6 7.0 120° 11 None 12 5 13 × 6; 7 × 4 6.0 135° 10 None 18 6 15 × 6; 5 × 4 5.0 120° 12 None 20 7 16 × 7; 6 × 4 5.0 120° 9 Venous crisis 11 8 15 × 6; 5 × 3 5.0 150° 12 None 17 9 16 × 6; 7 × 4 8.0 120° 12 None 13 10 14 × 6; 6 × 4 6.0 135° 11 None 48 11 13 × 6; 7 × 5 8.0 110° 12 None 23 Reception sites healing 11 flaps showed good contours. Additional thinning surgery was performed in only one case 6 months post operation due to a bloated flap. The flap healed well after the operation with minimal scarring without pigmentation. The flap innervated well, with restoration of pain, warmth, touch and protective sensation. The bone healed was presented at postoperative 8–12 weeks and the internal fixation was removed at postoperative 12–24 weeks (Fig. 2 G). The function of plantar flexion and ankle dorsiflexion recovered well, and normal gait was restored (Fig. 2 H). Donor sites healing Linear scar was left in the lower abdomen of the donor sites in all donor sites, and one patient experienced slightly hypertrophy without obvious contracture. No incisional hernia or bulge occurred. The skin around the incision appeared had paresthesia in the early stage post-surgery, but gradually recovered with follow-up, and did not affect the shape or function of hip joint and groin area. The iliac removal area collapsed slightly without tenderness. Complications Three days after the operation, one case of flaps appeared purple, with significant swelling and tensile blistering suggestive of venous crisis. A few stitches were immediately removed at the margin of the flap to unblock and drain fluid under the flap. About 50 ml of dark red blood clots were collected, the tension blister was pumped, and three long incisions of 0.5 cm were made on the surface of the flap. The tension of the flap decreases after wet application of heparin saline. The color of flap gradually turned red, and the skin flap survived, and the wound healed in the first stage. Discussion In 1979, Taylor et al reported the first graft of iliac bone flap based on the deep circumflex iliac artery (DCIA) 13 . Its natural cancellous and curvature bone-rich content contributed to its wide use, especially for reconstruction of the mandible and the maxilla 14 – 16 . However, when it was used to repair the compound tissue defects in the foot, the disadvantage of the DCIA based iliac bone flap are: 1) the skin paddle perfusion is unreliable 17 ; 2) the flap tends to be too bulky to repair the wound in the dorsal of foot; 3) donor-site herniation may occur 18 . In 2013, Iida et al first reported an iliac bone flap transfer based on the deep branch of the SCIA for head and neck reconstruction 19 .The SCIA-based iliac bone flap can address the disadvantages of DCIA based iliac bone flap, and recent reports have proved it 20 , 21 . The SCIA-based iliac bone flap transferred for reconstruction of compound tissue defects in the foot has several advantages as following: 1) the well-defined anatomy; 2) the flap can be taken as a superthin flap with longer pedicle; 3) a large skin paddle can be procured with bone flap 22 . Recently, the SCIA-based iliac bone flap is a feasible method for reconstruction of small to moderate-sized bony defects in extremities 23 , 24 . However, an additional donor site is required when it was applied to large-sized bony defects in extremities. In this study, the donor site of the large size of SCIA-based fascial pedicle iliac bone flap can be closed primarily by splitting the flap into two parts and rotating one of them to form a long and narrow flap. The SCIA divides into the deep branch and the superficial branch after taking off the femoral artery. After the bifurcation, the superficial branch of the SCIA gives off branches to the lateral of groin and to the anterior of iliac crest. The superficial branch can perfuse the skin beyond the umbilical plane, and it has a rich vascular network with the surrounding blood vessels 19 . Then the blood supply of the bi-lobed flap pedicled with fascia can be guaranteed. The deep branch of the SCIA gives off branches to the iliac crest, to the lateral femoral cutaneous nerve, and to the sartorius muscle 25 . The superficial iliac circumflex vein (SCIV), which is not accompanying with the superficial circumflex artery, was chosen as the drainage venous of the flap. The SCIV divides into the deep branches and shallow branches, and the caliber of venous ranged from 1.0 mm to 4.0 mm. The SCIV can provide sufficient venous return due to the thick caliber. In this study, the bi-lobed skin paddle was perfused by the superficial branch of the SCIA and the vascular network in deep fascia, and the iliac bone flap was perfused by the deep branch of the SCIA, and the SCIV act as the drainage venous. The intraoperative findings were relied on to ensure perfusion to the flap, namely, bleeding from the distal of the skin paddle and the cut ends of the bone. In case of damaging the blood vessel, the blood vessels were not intentionally separated and the blood vessel bundle was carefully kept in the tissue flap. The origin of the SCIA has great variation. Variation parameters, such as the origin of blood vessel, the number of blood vessel, whether the blood vessels are in the same trunk, and vessel caliber, are important factors that the surgeon should make clear preoperative. Therefore, preoperative vascular location is of great guiding significance in the design of SCIA-based fascial pedicle bi-lobed iliac bone flap, especially in terms of the angle of the rotating between the bi-lobed skin paddles. Currently, the most commonly-used flap perforating localization technology in clinic is Doppler ultrasound due to its non-invasive and low-cost. The Doppler ultrasound can not only show the distribution of the perforator, but also present the origin of the perforator 26 . Meanwhile, the caliber of the perforator is well known, which is convenient to find the anastomotic vessels in the receipt site. During the flap harvesting, the following caveats should be paid attention to: 1) do not deliberately look for perforating branches that enter the periosteum, especially the deep branch of the SCIA. The iliac bone flap should be chiseled out under the muscle in case of damaging the periosteal branches; 2) During the process of chiseling the iliac, the starting points of the tensor fascia lata and gluteus medius on the outer bone plate should be reserved to avoid damaging the blood vessel; 3) Don’t cut the anterior superior iliac spine, it is very important for patient to wear the trouser belt; 4) Pay attention to protect from the lateral femoral cutaneous nerve near the anterior superior iliac spine, where the nerve is flat and easy to identify; 5) The area of iliac bone removal must be polished and smooth, and hemostasis should be done carefully in case of postoperative pain and hematoma; 6) Hemostasis should be done well at the recipient sites, otherwise, hematoma will easily compress the vascular pedicle and then vascular crisis would occur. One flap in this study suffered vein crisis 3 days post operation due to the hematoma pressed vascular pedicle. After decompression treatment such as removing sutures and draining blood clot performed, the vein crisis was relieved and flap survived well. Conclusions The outcomes of the present study support a relatively large SCIA-based fascial pedicle bi-lobed iliac bone flap can be procured from the same donor site with low morbidity. It is especially useful in compound defects of both extensive soft tissue and bone and the donor site can be closed primarily. The satisfied results of reconstruction suggest that the SCIA based fascial pedicle bi-lobed iliac bone flap may be a feasible option for large size of compound tissue defects in the foot. Declarations Conflict of interest None declared Author Contribution Lei Xu: Conceptualization, Data curation, Formal analysis, Visualization, Writing – original draft, Writing – review & editing; Wen Ju, Lei Li, Qianheng Jin, Yujun Zhang, Linfeng Tang: Methodology, Data curation; Yi Fu: Investigation, prepared figures 1-2; Jihui Ju, Ruixing Hou: Project administration, Funding acquisition, Supervision, Writing – review & editing Acknowledgements This study was support mainly by a grant from Suzhou Science and Technology development Plan (Medical Innovation Applied Research) Project (SKY2023107, SKY2023108, SKYD2022073), and Suzhou Key Disciplines (SZXK202127). References Taylor GI, Watson N. One-stage repair of compound leg defects with free, revascularized flaps of groin skin and iliac bone. Plast Reconstr Surg 1978; 61:494–506 Lee J, Park HS, Whang JI. Reconstruction of the Fingertip Defect with a Free Radial Artery Superficial Palmar Branch Flap and Iliac Bone Graft. Archives of Hand and Microsurgery 2019; 24:376–380 Ju J, Li L, Zhou R, et al. Combined application of latissimus dorsi myocutaneous flap and iliac bone flap in the treatment of chronic osteomyelitis of the lower extremity. J Orthop Surg Res 2018; 13:117 Yang K, Zhao Z, Pan Y, et al. Resorption of Iliac Bone Grafts Following Wrap-Around Flap for Thumb Reconstruction: A Follow-Up Study. The Journal of Hand Surgery 2020; 45:61–64 Roger I, Worden A, Panattoni J, et al. Subtalar fusion with iliac bone free flap after a recalcitrant nonunion: Report of two cases. Microsurg 2016; 36:501–506 Li Z, Yu A, Yu G, et al. Repair of Massive Bone Defects of the Proximal Femur Using Iliac Bone Flaps of the Ascending Branch of the Lateral Circumflex Femoral Artery: A Retrospective Report. Ann Plas Surg 2020; 84:S235-S240 Andreini D, Mushtaq S, Pontone G, et al. CT perfusion versus coronary CT angiography in patients with suspected in-stent restenosis or CAD progression. JACC: Cardiovascular Imaging 2020; 13:732–742 Feng Y, Shu SJ. Diagnostic Value of Low-Dose 256-Slice Spiral CT Angiography, MR Angiography, and 3D-DSA in Cerebral Aneurysms. Dis Markers 2020;2020 Zheng L, Lv X, Shi Y, et al. Intraoral anastomosis of a vascularized iliac-crest flap in maxillofacial reconstruction. Journal of Plastic, Reconstructive & Aesthetic Surgery 2019; 72: 744–750 He Y, Jin S, Tian Z, et al. Superficial circumflex iliac artery perforator flap's imaging, anatomy and clinical applications in oral maxillofacial reconstruction. J Cranio Maxill Surg 2016; 44:242–248 Gentileschi S, Servillo M, De Bonis F, et al. Radioanatomical study of the pedicle of the superficial circumflex iliac perforator flap. J Reconstr Microsurg 2019; 35:669–676 Feng S, Min P, Grassetti L, et al. A prospective head-to-head comparison of color doppler ultrasound and computed tomographic angiography in the preoperative planning of lower extremity perforator flaps. Plast Reconstr Surg 2016; 137:335–347 Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work. Plast Reconstr Surg 1979; 64:745–759 Taylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plas Surg 1982; 9:361–376 Chen S, Chen H, Horng S, et al. Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing. Ann Plas Surg 2014; 73S18-S26 Wang L, Wei J, Yang X, et al. Preventing early-stage graft bone resorption by simultaneous innervation: innervated iliac bone flap for mandibular reconstruction. Plast Reconstr Surg 2017; 139:1152e-1161e Yoshimatsu H, Iida T, Yamamoto T, et al. Superficial circumflex iliac artery-based iliac bone flap transfer for reconstruction of bony defects. J Reconstr Microsurg 2018; 34:719–728 Schardt C, Schmid A, Bodem J, et al. Donor site morbidity and quality of life after microvascular head and neck reconstruction with free fibula and deep-circumflex iliac artery flaps. J Cranio Maxill Surg 2017; 45:304–311 Iida T, Narushima M, Yoshimatsu H, et al. A free vascularised iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction. Journal of Plastic, Reconstructive & Aesthetic Surgery 2013; 66:1596–1599 Yu Y, Zhang W, Liu X, et al. Double-barrel fibula flap versus vascularized iliac crest flap for mandibular reconstruction. J Oral Maxil Surg 2020; 78:844–850 Kim JH, Kim KN, Yoon CS. Reconstruction of moderate-sized distal limb defects using a superthin superficial circumflex iliac artery perforator flap. J Reconstr Microsurg 2015; 31:631–635 Berner JE, Nikkhah D, Zhao J, et al. The Versatility of the Superficial Circumflex Iliac Artery Perforator Flap: A Single Surgeon's 16-Year Experience for Limb Reconstruction and a Systematic Review. J Reconstr Microsurg 2020; 36:93–103 Li Y, Shao Z, Zhu Y, et al. Virtual Surgical Planning for Successful Second-Stage Mandibular Defect Reconstruction Using Vascularized Iliac Crest Bone Flap: A Valid and Reliable Method. Ann Plas Surg 2020; 84:183–187 Repo JP, Barner-Rasmussen I, Roine RP, et al. Role of free iliac crest flap in foot and ankle reconstruction. J Reconstr Microsurg 2016; 32:386–394 Yoshimatsu H, Steinbacher J, Meng S, et al. Superficial circumflex iliac artery perforator flap: an anatomical study of the correlation of the superficial and the deep branches of the artery and evaluation of perfusion from the deep branch to the sartorius muscle and the iliac bone. Plast Reconstr Surg 2019; 143:589–602 Lethaus B, Loberg C, Kloss Brandstätter A, et al. Color duplex ultrasonography versus handheld Doppler to plan anterior lateral thigh flaps. Microsurg 2017; 37:388–393 Additional Declarations No competing interests reported. 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-3842914","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":265810571,"identity":"bdecc96d-ecbb-44e8-9fe0-2ef15d50c818","order_by":0,"name":"Lei Xu","email":"","orcid":"","institution":"Suzhou Ruihua Orthopedic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Xu","suffix":""},{"id":265810572,"identity":"578d6b28-fdd3-4197-80ac-bbd93c9fde83","order_by":1,"name":"Wen Ju","email":"","orcid":"","institution":"Suzhou Ruihua Orthopedic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"Ju","suffix":""},{"id":265810573,"identity":"365eb5b8-37b2-4c5d-a618-824c69a49d98","order_by":2,"name":"Lei Li","email":"","orcid":"","institution":"Suzhou Ruihua Orthopedic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Li","suffix":""},{"id":265810574,"identity":"6644813b-6886-4707-bc4e-1dc35803d820","order_by":3,"name":"Qianheng Jin","email":"","orcid":"","institution":"Suzhou Ruihua Orthopedic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qianheng","middleName":"","lastName":"Jin","suffix":""},{"id":265810575,"identity":"094bbbc4-83e7-44be-a081-ea350a36100e","order_by":4,"name":"Yujun Zhang","email":"","orcid":"","institution":"Suzhou Ruihua Orthopedic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yujun","middleName":"","lastName":"Zhang","suffix":""},{"id":265810576,"identity":"e5df7400-1cc8-4143-882c-b2bd866d26e0","order_by":5,"name":"Linfeng Tang","email":"","orcid":"","institution":"Suzhou Ruihua Orthopedic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Linfeng","middleName":"","lastName":"Tang","suffix":""},{"id":265810577,"identity":"71d892dd-62f8-4d1d-91b8-584d2f50ad86","order_by":6,"name":"Yi Fu","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Fu","suffix":""},{"id":265810578,"identity":"b35d8100-e29a-4279-aaa4-730d286eba84","order_by":7,"name":"Ruixing Ruixing","email":"","orcid":"","institution":"Suzhou Ruihua Orthopedic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruixing","middleName":"","lastName":"Ruixing","suffix":""},{"id":265810579,"identity":"f0e57fa8-adc3-4b1b-8b27-9b015e1720fb","order_by":8,"name":"Jihui Ju","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIie3PMQrCMBSA4YRCXR64RkR7hZSACnqYhEK7VBdBHBzSpY6udfIKihcoBJyic0cn545OYkYnk1EwHzxI4P2QIOR5PwhLje98TYbmTM0ETklAWz1j7glCEPb2ZSqkcxIU17oPocoOVXJq0XoqZOdaWx524wxAzY9NuiRIZ0LCgtv+QhMgJiE5JbhUQhKg1kQBVVlU5eyJX25JXFQ85ajJRwRLt4Shtp7FR/1YTfglYyXk35O40uOneJEo2ibnpt1MB7uOtiX1x42bCb/uG1FX2lY8z/P+3hvgL0rMvUumWAAAAABJRU5ErkJggg==","orcid":"","institution":"Suzhou Ruihua Orthopedic Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jihui","middleName":"","lastName":"Ju","suffix":""}],"badges":[],"createdAt":"2024-01-07 15:44:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3842914/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3842914/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49386670,"identity":"612852c2-33b2-4bbf-a7f6-705f0d5efe2e","added_by":"auto","created_at":"2024-01-09 19:56:32","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":396182,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of reconstruction of compound tissue defect in the foot with the SCIA-based bi-lobed iliac bone flap. (\u003cstrong\u003eA\u003c/strong\u003e) The compound tissue defect in the foot. (\u003cstrong\u003eB-D\u003c/strong\u003e) Design and harvest of the SCIA-based fascial pedicle bi-lobed iliac bone flap. (\u003cstrong\u003eE\u003c/strong\u003e) Reconstruction of compound tissue defect in the foot.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3842914/v1/080f34ef3e68a3bd37140a20.jpeg"},{"id":49384905,"identity":"bf24ac53-0be5-4d82-95a5-acc62bf711c9","added_by":"auto","created_at":"2024-01-09 19:48:32","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":344658,"visible":true,"origin":"","legend":"\u003cp\u003e(\u003cstrong\u003eA)\u003c/strong\u003e A 65-year-old male presented with compound tissue defects in the left foot. (\u003cstrong\u003eB\u003c/strong\u003e)\u003cstrong\u003e \u003c/strong\u003eX-ray shows the defect of second metatarsal in the left foot. (\u003cstrong\u003eC\u003c/strong\u003e) Design of the SCIA-based bi-lobed iliac bone flap, the sizes of bi-lobed flap respectively were 7 cm ×4 cm and 13 cm ×6 cm, and the length of the iliac bone was 6 cm. (\u003cstrong\u003eD\u003c/strong\u003e) The SCIA-based iliac bone flap was raised. (\u003cstrong\u003eE\u003c/strong\u003e) The bi-lobed flap achieved by cutting open the skin of the iliac bone flap. (\u003cstrong\u003eF\u003c/strong\u003e) The fold of the bi-lobed iliac bone flap by rotating 135°. (\u003cstrong\u003eG-H\u003c/strong\u003e) Postoperative photograph at 18-month follow-up illustrating the bone union in the second metatarsal, good donor site integration and the satisfied contour of the foot.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3842914/v1/d006cd8ee1c67b9e6c98c4e0.jpeg"},{"id":49655297,"identity":"56b40b92-4121-47cf-8ba3-0b6e09c43990","added_by":"auto","created_at":"2024-01-16 03:22:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":524476,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3842914/v1/fa598616-cd47-48a5-a1f3-380afe51454d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Superficial circumflex iliac artery based fascial pedicle bi-lobed iliac bone flap transfer for reconstruction of foot composite tissue defects","fulltext":[{"header":"Full Text","content":"\u003cp\u003eIn 1978, Taylor et al reported the first free graft of revascularized flaps of groin skin and iliac bone to repair of compound leg defects \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. This method has been widely adopted in clinic, especially for reconstruction of small to medium size defects in the extremities \u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. However, the traditional iliac flap transplantation has several limitations. Fist, the iliac is supplied by multiple blood sources and relies on a large number of small musculoskeletal arteries to evenly supply the underlying bone. Furthermore, few of thick perforating arteries branch into the periosteum, making it difficult to dissect the free iliac flap. Finally, if the width of the donor flap exceeds 8 cm, an additional skin graft is required for closure, resulting in an additional donor site.\u003c/p\u003e\u003cp\u003eThe purpose of this study is to evaluate the clinical efficacy of free SCIA-based fascial pedicle bi-lobed iliac bone flap for repairing large-sized compound tissue defects in the foot (Figure 1). We will also explore the anatomical basis and significance of the free SCIA-based fascial pedicle bi-lobed iliac bone flap. We will summarize the surgical indications, anatomical basis, and precautions of this method by retrospectively analysis the 11 cases.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eRetrospective review inclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003efor the clinical was obtained from the Suzhou Ruihua Orthopedic Hospital. A retrospective review of patients treated between October 2009 and February 2017 was performed to identify patients who were treated for large-sized compound tissue defects in the foot repaired with free SCIA-based bi-lobed iliac bone flap. Inclusion and exclusion criteria were as follows. Inclusion criteria: 1) trauma-induced complex tissue defect in the foot; 2) simultaneous defects in metatarsal bones and foot skin; 3) the wound shows no signs of infection or infection has been effectively controlled; 4) the period of follow-up was more than 6 months; 5) the width of wound exceeds 8 cm.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eExclusion criteria: 1) the soft tissue defects without metatarsal defect; 2) granulation tissue of wound surface is well covered, and no deep tissue is exposed; 3) the period of follow-up is less than 6 months; 4) the width of wound less than 8 cm.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Demographics\u003c/h2\u003e \u003cp\u003eFrom October 2009 to February 2017, 11 patients were identified as large-sized compound tissue defects. The average age of the 9 males and 2 females patients was 32 years (rang, 18\u0026ndash;65 years). The size of wound ranged from 12 cm \u0026times; 10 cm to 15 cm \u0026times; 13 cm and the length of the bony defect was from 4 cm to 7 cm. The bony defect locations included the first metatarsal (5 cases), the second metatarsal (2 cases), and the fifth metatarsal (4 cases). The flap sizes ranged from 13 cm \u0026times; 10 cm to 16 cm \u0026times; 14 cm, and the length of the dissected iliac ranged from 5 cm to 8 cm. All patients were repaired with SCIA-based fascial pedicle bi-lobed iliac bone flap as elective surgery. Patients\u0026rsquo; demographic data are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026times;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge \u003cem\u003e(yr)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLength of Metatarsal\u003c/p\u003e \u003cp\u003eDefect \u003cem\u003e(cm)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDefect Size \u003cem\u003e(cm\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLength of iliac transfer \u003cem\u003e(cm)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSize of bi-lobed Flaps \u003cem\u003e(cm\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAngle of flap rotating\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTiming of Reconstruction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e12 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 \u0026times; 6;\u003c/p\u003e \u003cp\u003e7 \u0026times; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e110\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e15 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 \u0026times; 6;\u003c/p\u003e \u003cp\u003e6 \u0026times; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e120\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e13 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 \u0026times; 6;\u003c/p\u003e \u003cp\u003e5 \u0026times; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e180\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e15 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 \u0026times; 6;\u003c/p\u003e \u003cp\u003e7 \u0026times; 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e120\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e12 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 \u0026times; 6;\u003c/p\u003e \u003cp\u003e7 \u0026times; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e135\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e14 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15 \u0026times; 6;\u003c/p\u003e \u003cp\u003e5 \u0026times; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e120\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e15 \u0026times; 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 \u0026times; 7;\u003c/p\u003e \u003cp\u003e6 \u0026times; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e120\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e14 \u0026times; 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15 \u0026times; 6;\u003c/p\u003e \u003cp\u003e5 \u0026times; 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e150\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e15 \u0026times; 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 \u0026times; 6;\u003c/p\u003e \u003cp\u003e7 \u0026times; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e120\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e13 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 \u0026times; 6;\u003c/p\u003e \u003cp\u003e6 \u0026times; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e135\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c5\"\u003e \u003cp\u003e12 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 \u0026times; 6;\u003c/p\u003e \u003cp\u003e7 \u0026times; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e110\u0026deg;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eSurgical Techniques\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eDebridement and wound preparation\u003c/strong\u003e \u003cp\u003eSurgeries were performed on all patients under epidural anesthesia. The wound was completely debrided and repeatedly rinsed with hydrogen peroxide and normal saline. Following wound preparation, patients with blood vessel, nerve, and tendon defects were treated in one-stage procedure. For those with fractures, internal fixation is applied after fracture reduction. In cases of metatarsal defects, cross fixation is achieved with two 1.2mm Kirschner wires, restoring alignment and height to establish proper metatarsal biomechanics (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA- B). For individuals with remaining or partially avulsed skin, thinning is performed followed by compression dressing. In cases of complete skin loss or severe contamination due to skin abrasion, excision is carried out, and the wound is covered with Vacuum Sealing Drainage (VSD) material. After removing the Vacuum Sealing Drainage (VSD) on days 5 to 7, assess the wound condition. If the wound is fresh with no purulent discharge, proceed with preoperative preparation for bone and skin flap repair. In cases where the wound is not fresh or shows persistent purulent discharge, perform additional debridement, replace the VSD, and repeat the process until the wound is fresh and free from purulent discharge. In this group, four cases achieved fresh and clean wound conditions after one debridement with Vacuum Sealing Drainage (VSD) negative pressure suction, six cases after two debridements with VSD, and one case after three debridements with VSD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eUltrasound guided detecting of the SCIA and designing of flap: the Doppler ultrasound began at the most obvious pulsation point of femoral artery at the groin as a primary landmark (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). A line was then drawn between that point and the anterior superior iliac spine. Along this axis, 1\u0026ndash;2 perforator points were marked, and the periosteal branch entering the iliac bone was detected and marked with a line. The pattern of fabric was designed slightly enlarge by 10% according to the shape of the wound and the start and end points of the metatarsal defect were marked on the fabric. The pattern of fabric was cut into two parts from the wide side, which can be split into a long and narrow shape by rotating proper angle.\u003c/p\u003e \u003cp\u003eFlap excision: After outlining the shape on the prepared wound dressing, bisect the dressing along its width. Pay attention to the location of the metatarsal bone defect. Join the two halves of the bisected dressing to form an elongated shape, taking into account the position of the planned perforators marked by preoperative color Doppler ultrasound. Design the flap with this shape, and the junction of the dressing serves as the incision site for the flap. The flap can be designed as one large and one small segment or two segments of similar size, considering the connection of the flap in the form of a fascial pedicle. Therefore, careful planning is required for the flap junction. According to the splitting shape of fabric, the flap was designed based on the perforator of the preoperative Doppler ultrasound identification. The design line was draw according to the shape of the pattern of fabric and the position of the iliac bone was marked at the same time. A 3.0 cm longitudinal incision was performed at the most obvious pulsation point of femoral artery at the groin area. Cutting open the skin and subcutaneous tissue to locate the SCIA and superficial circumflex vein (SCIV). The flap was elevated from laterally to the mark of iliac bone, and the tendons of iliotibial band attached to the outer edge of iliac were cut off. The iliac bone flap was chiseled at the back of the anterior superior iliac spine according to the size of the needed iliac bone. The separation of flap and iliac should be avoided during the process of flap excision. The incising layers were located in the deep fascia layer except for the bone flap. From the inner side of the skin flap, the flap is dissected along the deep fascial layer towards the outer side until meeting with the bone flap. After complete osteotomy of the bone flap, the skin flap is fully elevated. Reverse dissection is then performed, freeing the flap to the pedicle. At this point, except for the vascular pedicle connection, the rest of the skin flap is completely freed. Bleeding from the cut surface of the skin paddle and the bone flap was observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE). From the junction where the two skin flaps are joined, incise the skin only, avoiding cutting through the subcutaneous tissues, especially the deep fascia. Use sharp tissue scissors to separate the two skin flaps, allowing the skin of both flaps to rotate completely and fold at a 90\u0026deg; angle (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eF). Iliac bone extraction area was smoothed with a bone file and sealed with bone wax to stop bleeding. The donor sites were closed primarily in a multilayer fashion.\u003c/p\u003e \u003cp\u003eThe flap was transferred to the receipt site of the foot after pedicle division. The trimmed iliac was used to reconstruct the metatarsal defect using the Kirschner wire or steel plate. The vascular pedicle was introduced into the dorsalis plantar artery through the channel. The superficial circumflex iliac artery was anastomosed to the dorsalis plantar artery, and the SCIV was anastomosed to companion vein of the dorsalis pedis artery in an end-to-end fashion. Drainage strip was placed on the edge of the flap for the case of disorders of blood circulation. The wound was then covered by wound dressing and the external plaster fixation was needed.\u003c/p\u003e \u003cp\u003ePostoperatively, the patients were administered anticoagulant, antispasmodic, and antibiotics to prevent coagulation, spasmodic and infection. The blood circulation of the flap should be closely observed and the blood circulation crisis should be solved in time once it happened. Surgical exploration was performed if the blood circulation crisis was not solved after conservation treatment for one hour.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e11 flaps demonstrated complete survival. There was one occurrence of exudation at the margin of the flap, which healed after dressing change. The wounds in the donor sites and recipient sites were healed at one stage in other cases. The average follow-up period was 17 months (range, 10\u0026ndash;48 months). Postoperative details and complications are presented in \u003cb\u003eTable II\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e\u0026nbsp;TABLE Ⅱ Flap Details and Complications\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 37px;\"\u003e\n \u003ctd style=\"height: 37px;\" align=\"left\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 37px;\" align=\"left\"\u003e\n \u003cp\u003eSize of bi-lobed Flaps \u003cem\u003e(cm\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 37px;\" align=\"left\"\u003e\n \u003cp\u003eLength of iliac transfer \u003cem\u003e(cm)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 37px;\" align=\"left\"\u003e\n \u003cp\u003eAngle of flap rotating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 37px;\" align=\"left\"\u003e\n \u003cp\u003eBone Union \u003cem\u003e(wk)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 37px;\" align=\"left\"\u003e\n \u003cp\u003ePresence of complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 37px;\" align=\"left\"\u003e\n \u003cp\u003eLatest follow-up post operation (month)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e13 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e7 \u0026times; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e110\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e16 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e6 \u0026times; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e120\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e14 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e5 \u0026times; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e180\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eBloated flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e16 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e7 \u0026times; 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e120\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e13 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e7 \u0026times; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e135\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e15 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e5 \u0026times; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e120\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e16 \u0026times; 7;\u003c/p\u003e\n \u003cp\u003e6 \u0026times; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e120\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eVenous crisis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e15 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e5 \u0026times; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e150\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e16 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e7 \u0026times; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e120\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e14 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e6 \u0026times; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e135\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 59px;\"\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e13 \u0026times; 6;\u003c/p\u003e\n \u003cp\u003e7 \u0026times; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e110\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003e \u003cstrong\u003eReception sites healing\u003c/strong\u003e \u003cp\u003e11 flaps showed good contours. Additional thinning surgery was performed in only one case 6 months post operation due to a bloated flap. The flap healed well after the operation with minimal scarring without pigmentation. The flap innervated well, with restoration of pain, warmth, touch and protective sensation. The bone healed was presented at postoperative 8\u0026ndash;12 weeks and the internal fixation was removed at postoperative 12\u0026ndash;24 weeks (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eG). The function of plantar flexion and ankle dorsiflexion recovered well, and normal gait was restored (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eH).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDonor sites healing\u003c/strong\u003e \u003cp\u003eLinear scar was left in the lower abdomen of the donor sites in all donor sites, and one patient experienced slightly hypertrophy without obvious contracture. No incisional hernia or bulge occurred. The skin around the incision appeared had paresthesia in the early stage post-surgery, but gradually recovered with follow-up, and did not affect the shape or function of hip joint and groin area. The iliac removal area collapsed slightly without tenderness.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eComplications\u003c/strong\u003e \u003cp\u003eThree days after the operation, one case of flaps appeared purple, with significant swelling and tensile blistering suggestive of venous crisis. A few stitches were immediately removed at the margin of the flap to unblock and drain fluid under the flap. About 50 ml of dark red blood clots were collected, the tension blister was pumped, and three long incisions of 0.5 cm were made on the surface of the flap. The tension of the flap decreases after wet application of heparin saline. The color of flap gradually turned red, and the skin flap survived, and the wound healed in the first stage.\u003c/p\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn 1979, Taylor et al reported the first graft of iliac bone flap based on the deep circumflex iliac artery (DCIA) \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Its natural cancellous and curvature bone-rich content contributed to its wide use, especially for reconstruction of the mandible and the maxilla \u003csup\u003e\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. However, when it was used to repair the compound tissue defects in the foot, the disadvantage of the DCIA based iliac bone flap are: 1) the skin paddle perfusion is unreliable \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e; 2) the flap tends to be too bulky to repair the wound in the dorsal of foot; 3) donor-site herniation may occur \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. In 2013, Iida et al first reported an iliac bone flap transfer based on the deep branch of the SCIA for head and neck reconstruction\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e .The SCIA-based iliac bone flap can address the disadvantages of DCIA based iliac bone flap, and recent reports have proved it \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. The SCIA-based iliac bone flap transferred for reconstruction of compound tissue defects in the foot has several advantages as following: 1) the well-defined anatomy; 2) the flap can be taken as a superthin flap with longer pedicle; 3) a large skin paddle can be procured with bone flap \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Recently, the SCIA-based iliac bone flap is a feasible method for reconstruction of small to moderate-sized bony defects in extremities \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. However, an additional donor site is required when it was applied to large-sized bony defects in extremities. In this study, the donor site of the large size of SCIA-based fascial pedicle iliac bone flap can be closed primarily by splitting the flap into two parts and rotating one of them to form a long and narrow flap.\u003c/p\u003e \u003cp\u003eThe SCIA divides into the deep branch and the superficial branch after taking off the femoral artery. After the bifurcation, the superficial branch of the SCIA gives off branches to the lateral of groin and to the anterior of iliac crest. The superficial branch can perfuse the skin beyond the umbilical plane, and it has a rich vascular network with the surrounding blood vessels \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Then the blood supply of the bi-lobed flap pedicled with fascia can be guaranteed. The deep branch of the SCIA gives off branches to the iliac crest, to the lateral femoral cutaneous nerve, and to the sartorius muscle \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. The superficial iliac circumflex vein (SCIV), which is not accompanying with the superficial circumflex artery, was chosen as the drainage venous of the flap. The SCIV divides into the deep branches and shallow branches, and the caliber of venous ranged from 1.0 mm to 4.0 mm. The SCIV can provide sufficient venous return due to the thick caliber. In this study, the bi-lobed skin paddle was perfused by the superficial branch of the SCIA and the vascular network in deep fascia, and the iliac bone flap was perfused by the deep branch of the SCIA, and the SCIV act as the drainage venous. The intraoperative findings were relied on to ensure perfusion to the flap, namely, bleeding from the distal of the skin paddle and the cut ends of the bone. In case of damaging the blood vessel, the blood vessels were not intentionally separated and the blood vessel bundle was carefully kept in the tissue flap.\u003c/p\u003e \u003cp\u003eThe origin of the SCIA has great variation. Variation parameters, such as the origin of blood vessel, the number of blood vessel, whether the blood vessels are in the same trunk, and vessel caliber, are important factors that the surgeon should make clear preoperative. Therefore, preoperative vascular location is of great guiding significance in the design of SCIA-based fascial pedicle bi-lobed iliac bone flap, especially in terms of the angle of the rotating between the bi-lobed skin paddles. Currently, the most commonly-used flap perforating localization technology in clinic is Doppler ultrasound due to its non-invasive and low-cost. The Doppler ultrasound can not only show the distribution of the perforator, but also present the origin of the perforator \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Meanwhile, the caliber of the perforator is well known, which is convenient to find the anastomotic vessels in the receipt site.\u003c/p\u003e \u003cp\u003eDuring the flap harvesting, the following caveats should be paid attention to: 1) do not deliberately look for perforating branches that enter the periosteum, especially the deep branch of the SCIA. The iliac bone flap should be chiseled out under the muscle in case of damaging the periosteal branches; 2) During the process of chiseling the iliac, the starting points of the tensor fascia lata and gluteus medius on the outer bone plate should be reserved to avoid damaging the blood vessel; 3) Don\u0026rsquo;t cut the anterior superior iliac spine, it is very important for patient to wear the trouser belt; 4) Pay attention to protect from the lateral femoral cutaneous nerve near the anterior superior iliac spine, where the nerve is flat and easy to identify; 5) The area of iliac bone removal must be polished and smooth, and hemostasis should be done carefully in case of postoperative pain and hematoma; 6) Hemostasis should be done well at the recipient sites, otherwise, hematoma will easily compress the vascular pedicle and then vascular crisis would occur. One flap in this study suffered vein crisis 3 days post operation due to the hematoma pressed vascular pedicle. After decompression treatment such as removing sutures and draining blood clot performed, the vein crisis was relieved and flap survived well.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe outcomes of the present study support a relatively large SCIA-based fascial pedicle bi-lobed iliac bone flap can be procured from the same donor site with low morbidity. It is especially useful in compound defects of both extensive soft tissue and bone and the donor site can be closed primarily. The satisfied results of reconstruction suggest that the SCIA based fascial pedicle bi-lobed iliac bone flap may be a feasible option for large size of compound tissue defects in the foot.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eNone declared\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLei Xu: Conceptualization, Data curation, Formal analysis, Visualization, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing; Wen Ju, Lei Li, Qianheng Jin, Yujun Zhang, Linfeng Tang: Methodology, Data curation; Yi Fu: Investigation, prepared figures 1-2; Jihui Ju, Ruixing Hou: Project administration, Funding acquisition, Supervision, Writing \u0026ndash; review \u0026amp; editing\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThis study was support mainly by a grant from Suzhou Science and Technology development Plan (Medical Innovation Applied Research) Project (SKY2023107, SKY2023108, SKYD2022073), and Suzhou Key Disciplines (SZXK202127).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTaylor GI, Watson N. One-stage repair of compound leg defects with free, revascularized flaps of groin skin and iliac bone. Plast Reconstr Surg 1978; 61:494\u0026ndash;506\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee J, Park HS, Whang JI. Reconstruction of the Fingertip Defect with a Free Radial Artery Superficial Palmar Branch Flap and Iliac Bone Graft. Archives of Hand and Microsurgery 2019; 24:376\u0026ndash;380\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJu J, Li L, Zhou R, et al. Combined application of latissimus dorsi myocutaneous flap and iliac bone flap in the treatment of chronic osteomyelitis of the lower extremity. J Orthop Surg Res 2018; 13:117\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang K, Zhao Z, Pan Y, et al. Resorption of Iliac Bone Grafts Following Wrap-Around Flap for Thumb Reconstruction: A Follow-Up Study. The Journal of Hand Surgery 2020; 45:61\u0026ndash;64\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoger I, Worden A, Panattoni J, et al. Subtalar fusion with iliac bone free flap after a recalcitrant nonunion: Report of two cases. Microsurg 2016; 36:501\u0026ndash;506\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Z, Yu A, Yu G, et al. Repair of Massive Bone Defects of the Proximal Femur Using Iliac Bone Flaps of the Ascending Branch of the Lateral Circumflex Femoral Artery: A Retrospective Report. Ann Plas Surg 2020; 84:S235-S240\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndreini D, Mushtaq S, Pontone G, et al. CT perfusion versus coronary CT angiography in patients with suspected in-stent restenosis or CAD progression. JACC: Cardiovascular Imaging 2020; 13:732\u0026ndash;742\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng Y, Shu SJ. Diagnostic Value of Low-Dose 256-Slice Spiral CT Angiography, MR Angiography, and 3D-DSA in Cerebral Aneurysms. Dis Markers 2020;2020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng L, Lv X, Shi Y, et al. Intraoral anastomosis of a vascularized iliac-crest flap in maxillofacial reconstruction. Journal of Plastic, Reconstructive \u0026amp; Aesthetic Surgery 2019; 72: 744\u0026ndash;750\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe Y, Jin S, Tian Z, et al. Superficial circumflex iliac artery perforator flap's imaging, anatomy and clinical applications in oral maxillofacial reconstruction. J Cranio Maxill Surg 2016; 44:242\u0026ndash;248\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGentileschi S, Servillo M, De Bonis F, et al. Radioanatomical study of the pedicle of the superficial circumflex iliac perforator flap. J Reconstr Microsurg 2019; 35:669\u0026ndash;676\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng S, Min P, Grassetti L, et al. A prospective head-to-head comparison of color doppler ultrasound and computed tomographic angiography in the preoperative planning of lower extremity perforator flaps. Plast Reconstr Surg 2016; 137:335\u0026ndash;347\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work. Plast Reconstr Surg 1979; 64:745\u0026ndash;759\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plas Surg 1982; 9:361\u0026ndash;376\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen S, Chen H, Horng S, et al. Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing. Ann Plas Surg 2014; 73S18-S26\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang L, Wei J, Yang X, et al. Preventing early-stage graft bone resorption by simultaneous innervation: innervated iliac bone flap for mandibular reconstruction. Plast Reconstr Surg 2017; 139:1152e-1161e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshimatsu H, Iida T, Yamamoto T, et al. Superficial circumflex iliac artery-based iliac bone flap transfer for reconstruction of bony defects. J Reconstr Microsurg 2018; 34:719\u0026ndash;728\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchardt C, Schmid A, Bodem J, et al. Donor site morbidity and quality of life after microvascular head and neck reconstruction with free fibula and deep-circumflex iliac artery flaps. J Cranio Maxill Surg 2017; 45:304\u0026ndash;311\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIida T, Narushima M, Yoshimatsu H, et al. A free vascularised iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction. Journal of Plastic, Reconstructive \u0026amp; Aesthetic Surgery 2013; 66:1596\u0026ndash;1599\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu Y, Zhang W, Liu X, et al. Double-barrel fibula flap versus vascularized iliac crest flap for mandibular reconstruction. J Oral Maxil Surg 2020; 78:844\u0026ndash;850\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JH, Kim KN, Yoon CS. Reconstruction of moderate-sized distal limb defects using a superthin superficial circumflex iliac artery perforator flap. J Reconstr Microsurg 2015; 31:631\u0026ndash;635\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerner JE, Nikkhah D, Zhao J, et al. The Versatility of the Superficial Circumflex Iliac Artery Perforator Flap: A Single Surgeon's 16-Year Experience for Limb Reconstruction and a Systematic Review. J Reconstr Microsurg 2020; 36:93\u0026ndash;103\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Shao Z, Zhu Y, et al. Virtual Surgical Planning for Successful Second-Stage Mandibular Defect Reconstruction Using Vascularized Iliac Crest Bone Flap: A Valid and Reliable Method. Ann Plas Surg 2020; 84:183\u0026ndash;187\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRepo JP, Barner-Rasmussen I, Roine RP, et al. Role of free iliac crest flap in foot and ankle reconstruction. J Reconstr Microsurg 2016; 32:386\u0026ndash;394\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshimatsu H, Steinbacher J, Meng S, et al. Superficial circumflex iliac artery perforator flap: an anatomical study of the correlation of the superficial and the deep branches of the artery and evaluation of perfusion from the deep branch to the sartorius muscle and the iliac bone. Plast Reconstr Surg 2019; 143:589\u0026ndash;602\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLethaus B, Loberg C, Kloss Brandst\u0026auml;tter A, et al. Color duplex ultrasonography versus handheld Doppler to plan anterior lateral thigh flaps. Microsurg 2017; 37:388\u0026ndash;393\u003c/span\u003e\u003c/li\u003e\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":"Iliac bone flap, fascial pedicle, Superficial circumflex iliac artery, Microsurgery, Foot reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-3842914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3842914/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTo investigate the clinical efficacy of repairing the large-sized compound tissue defects in the foot with the free superficial circumflex iliac artery (SCIA) based fascial pedicle bi-lobed iliac bone flap.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective analysis from October 2009 to February 2017 was performed, and 11 patients were identified with large-sized compound tissue defects repaired with the free SCIA based fascial pedicle bi-lobed iliac bone flap. The size of wound ranged from 12 cm × 10 cm to 15 cm × 13 cm and the length of the bony defect was from 4 cm to 7 cm. The flap sizes ranged from 13 cm × 10 cm to 16 cm × 14 cm, and the length of the dissected iliac ranged from 5 cm to 8 cm. The donor sites were primarily closed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e All 11 flaps survived engraftment including one case venous crisis occurred. After 6 months, only one of the cases resulted in swollen flaps which required repair. All other engrafted flaps were well appearing and the transplanted iliac healed smoothly, with a bone healing time of less than 12 weeks. The internal fixation was removed between 12 and 24 weeks post operation. Successful postoperative recovery of ankle joint flexion and extension resulted in normal gait.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The free SCIA-based fascial pedicle bi-lobed iliac bone flap repaired the large-sized compound tissue defect in the foot, resulting in repaired bone defect, wound coverage, low donor site morbidity, and recovery of function.\u003c/p\u003e","manuscriptTitle":"Superficial circumflex iliac artery based fascial pedicle bi-lobed iliac bone flap transfer for reconstruction of foot composite tissue defects","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-09 19:48:27","doi":"10.21203/rs.3.rs-3842914/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":"2259425b-3831-474b-858a-08e0a8577b80","owner":[],"postedDate":"January 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-16T03:14:41+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-09 19:48:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3842914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3842914","identity":"rs-3842914","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}