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The arterial lesions in the lower limbs of diabetic foot patients are very complex, and restoring arterial blood flow in the lower limbs is the key to improving the quality of life and limb preservation rate of diabetic foot patients. The current endovascular treatment technique is the main choice in China because of its minimally invasive nature and rapid postoperative recovery. In order to provide better and more standardized treatment for diabetic foot and benefit patients, the Diabetic Foot Sub-Committee of the China Association for the Promotion of International Exchange of Healthcare and the Diabetic Foot Committee of the Chinese Chapter Congress of the International Union of Angiology have developed this consensus based on the literature and the clinical experience of various experts, including the objectives and principles of diabetic foot treatment and the selection of endovascular treatment methods for vascular lesions.

Objective: To report the anatomy basis and clinical application of the flap based on the perforator of plantar arch., Methods: From December 2013 to June 2016,25 cadaveric feet which were injected with a mixture of red gelatin were used to observe: the origins, courses, branches, distributions of the dorsal perforators flap based on the plantar arch; the anastomoses between the back perforators of plantar arch and rete arteriosum of dorsale pedis. Based on the anatomy research,11 cases with soft tissue defect at forefoot were treated with the perforator flaps., Results: 11 flaps survived completely with primary healing. The flaps were followed up for 2-36 months with good match of texture and color., Conclusions: The flap based on the perforator of plantar arch has constant and rich blood supply. The technique is easily performed and can be used as an optional flap without major vessel for defect at forefoot.

Objective: To investigate the effect of reverse saphenous nerve neurocutaneous flaps for skin defects of forefoot., Methods: In the anatomic study, 50 cadaveric feet were injected with red latex and the anastomosis, distribution and external diameters of medialtarsal artery, medial anterior malleolus artery, medial plantar artery, the superficial branch of the medial basal hallucal artery and saphenousnerve nutritional vessels were observed. Based on anatomic research results, we designed the reverse saphenous nerve neurocutaneous flaps for repairing skin defects of forefoot., Results: The blood supply of reverse saphenous nerve neurocutaneous flaps were based on the vasoganglion, which consist of arterial arch at the superior border of abductor hallucis and arterial network on the surface of abductor hallucis around the saphenous nerve and medial pedis flap. From Oct. 2006 to Oct. 2011, the reverse saphenous nerve neurocutaneous flaps were used to repair skin defects of forefoot in 11 cases. The flap size ranged from 2.5 cm x 3.5 cm to 7.5 cm x 8.5 cm. The wounds at donor site were covered with full-thickness skin graft. All flaps survived completely with no ulcer at the donor site. 11 cases were followed up for 6 to 18 months( mean, 10 months). The skin color and texture were satisfactory. The patients could walk very well., Conclusions: It is reliable to repair the skin defects of forefoot with reverse saphenous nerve neurocutaneous flaps. It is easily performed with less morbidity. This flap should be considered as a preferential way to reconstruct skin defects of forefoot.

Objective: To investigate the vascular supply of intrinsic muscles of foot and anatomic basis for muscular flap design., Methods: A radiopaque injectate (lead oxide-gelatin mixtures, 26 ml/kg) was injected into 10 fresh cadavers. The dissected regions were photographed and each intrinsic muscles on the foot was removed and radiographed. The number, type, diameter of vascular branches of muscles and their distributions were observed. The area of the vascular territory supplied by each source vessel was calculated using Scion Image for Windows software., Results: There were significant architectural differences among the intrinsic muscles. The muscles length varied from 22.5mm to 116.2mm [average, (66.1 +/- 23.2)mm]. The measured fiber length were relatively consistent, ranging from 14.2 mm to 27.5 mm [average, (20.2 +/- 4.5)mm]. There are 63 vascular branches into the 23 foot muscles, each muscle having average branches of 3.2 +/- 0.8. The average diameter of branches, the length and width of each vascular territorial area is (0.8 +/- 0.3) mm, (2.2 +/- 0.8) cm, and (0.9 +/- 0.4) cm, respectively. Other findings included that some muscles were not present in some cadavers., Conclusions: The blood supply of intrinsic muscles of foot is abundant with different diameter and distributions of branches. There is an anatomic basis for muscular or musculoosseous flap design. There are 7 intrinsic muscles with large and reliable vascular supply which can be chosen as muscular flaps.

Objective: To evaluate the effect of lateral supramalleolar artery descending branch antidromic flap for the repair of soft tissue defects in the foot and ankle., Methods: From May 2009 to October 2013,12 patients with soft tissue defects combined with tendon and bone exposure in the foot and ankle were treated by lateral supramalleolar artery descending branch antidromic flap for the repair of soft tissue defects in the foot and ankle, including 9 males and 3 females with an average age of 37.5 years old ranging from 19 to 58 years. Ten cases had the soft tissue defects in the dorsum of foot and 2 in the ankle. The defect area of soft tissue was from 11 cm x 9 cm to 8 cm x 5 cm., Results: Twelve patients were follow-up for 3 to 12 months (averaged 7.3 months). The flaps of 9 cases were survived,the flaps edges of the other 3 cases were necrosis,and healed after dressing change. The flaps were slightly swelling without ulcer occurrence., Conclusion: Lateral supramalleolar artery descending branch antidromic flap can repairing the damage by one-stage operation with advantage of dissection easy,rich blood supply without sacrifice of major artery.

Objective: To investigate the feasibility and effectiveness of free popi iteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein for the repair of wound on the foot and ankle by anatomical observation and clinical application., Methods: Latex was poured into the blood vessels of 8 cadavers, then perforator vessel of posterolateral upper calf was dissected, and the popl iteal artery cutaneous branch flap was designed with a pedicle of 2.5 cm in length; the lateral tarsal artery of the foot was dissected, could be freed to 6 cm in length; the diameter of these vessels was measured, and the number of the accompanying veins was counted. Between March 2010 and January 2013, 13 cases of foot and ankle wounds were repaired with popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein. The size of flaps ranged from 6.0 cm x 4.0 cm to 7.5 cm x 5.5 cm. There were 11 males and 2 females, aged from 41 to 65 years (mean, 47.3 years). The causes of injury included traffic accident in 8 cases, crushing in 4 cases, and twist by machine in 1 case. The size of wounds, ranged from 5.0 cm x 3.5 cm to 7.0 cm x 5.0 cm. The donor sites were sutured directly., Results: According to anatomical observation, the popliteal artery cutaneous branch flap was designed by using the lateral popliteal artery perforator for shaft. The vessel of the pedicle perforator flaps from the popliteal artery cutaneous branch flap matched well with the lateral tarsal artery., Clinical Results: vascular crisis occurred in 2 flaps, which survived after symptomatic treatment; the other flaps survived, with primary healing of wound and incision at donor site. The patients were all followed up 5-18 months (mean, 11 months). The flap had normal color and good elasticity. Second stage operation was performed to make the flap thinner in 3 female patients because of bulky flaps. The remaining patients had no obvious fat flap. According to American Orthopaedic Foot and Ankle Society (AOFAS) score for evaluation of the ankle function at 6 months after operation, the results were excellent in 7 cases, good in 5 cases, and fair in 1 case, with an excellent and good rate of 92.3%., Conclusion: Free popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein for the repair of wound on the foot and ankle is simple and effective. The donor site is hidden.

Objective: To investigate the difference between two methods for establishing rat models of complex regional pain syndrome type 1., Methods: Twenty-four adult SD rats were randomly allocated into control group, tibia fracture group and ischemia group (n=8), and complex regional pain syndrome type 1 was simulated in the latter two groups using different methods. The pain behaviors of the rats were observed and serum substance P level was detected with ELISA at different time points after the operations., Results: Limb loss occurred in 3 rats in tibia fracture group, and the other 5 rats showed a lowered pain threshold. At 8 h after modeling, the rats in ischemia group showed more obvious reduction of pain threshold than those in tibia fracture group. Serum substance P levels in the two model groups underwent similar alterations after modeling, both significantly higher than that in the control group (P<0.01). Microcirculation changes were more serious in tibia fracture group than in ischemia group. Ulcer-like lesions were found in the skin of some rats in tibia fracture group. No obvious pathologies were observed microscopically in the sciatic nerve in the two model groups., Conclusion: The two methods can both be effective to simulate complex regional pain syndrome type 1, but tibia fracture results in more sustained symptoms and pathological changes in the microcirculation.

Objective: To investigate the operative procedure and the short-term therapeutic effects of medial plantar venous flaps for restoration of soft-tissue defects on the volar aspect of fingers., Methods: From May 2007 to July 2009, 13 cases (15 fingers) ofvolar soft tissue defects were treated with medial plantar venous flaps, including 7 males (9 fingers) and 6 females (6 fingers) with an average age of 30 years (range, 17-55 years). Soft tissue defects were caused by electric saws in 4 cases (5 fingers), by crush injury in 6 cases (6 fingers), and by burned scar removal in 3 cases (4 fingers). The size of soft tissue defects ranged from 1.0 cm x 0.9 cm to 5.8 cm x 3.3 cm, included 5 thumbs, 3 index fingers, 3 little fingers, 2 ring fingers, and 2 middle fingers. The emergency surgical treatment was performed in 10 traumatic cases after 2 to 12 hours (4 hours on average); and the elective surgical treatment was performed in the other 3 cases of scar after burn. The 15 medial plantar venous flaps, with size of 1.0 cm x 1.0 cm to 6.0 cm x 3.5 cm, were harvested to restore defects. Of them, 12 venous flaps had 1 superficial vein and the other 3 had 2 veins; and the veins of 13 venous flaps bridged a single digital artery and the veins of the other 2 flaps bridged both arteries. The donor sites were sutured directly or were covered with skin graft., Results: All 15 venous flaps survived completely, and the donor and recipient sites healed by first intention. Eleven cases (11 fingers) were followed up for 2 to 12 months. The texture and color of the flaps were similar to those of adjacent normal skin with a satisfactory appearance. The two-point discrimination was 6-9 mm. According to criterion for joint junction of total active range of motion/total active range of flexion, the results were excellent in 10 cases and good in 1 case; the excellent and good rate was 100%., Conclusion: The medial plantar venous flap has advantages of easy-to-operate, rich blood supply and high survival rate. So it is an ideal and reliable choice for volar soft tissue defects of fingers.

Objective: To investigate the effects of decompresion through double-incision of foot dorsum on the treatment of osteofascial compartment syndrome of the foot under the monitoring of saturation of blood oxygen., Methods: From January 2000 to June 2007, 26 cases of osteofascial compartment syndrome of the foot were decompressed through double-incision of foot dorsum under the monitoring of saturation of blood oxygen, and relaxation suture or skin grafting were operated within 3 to 10 days after decompressing. Among them, 22 patients were males and 4 were females, with an average age of 36.3 years old ranging from 22 to 68 years. According to AOFAS system, the pain, function, autonomic activities and support were evaluated., Results: All patients were followed-up for from 6 to 43 months with the average of 19 months. All patients were healed. According to AOFAS system, the total scores increased from preoperative (30.4 +/- 8.02) to postoperative (92.5 +/- 5.0) (t = 3.13, P < 0.01); the results were excellent in 21 cases, good in 4 and poor in 1., Conclusion: The patients of fracture-dislocated, swelling and injured in the soft tissue because of severe violence should observed closely on osteofascial compartment syndrome of the foot early. Feet are operated and thoroughly decompressed as soon as it is diagnosed as the compartment syndrome. Osteofascial compartment syndrome of the foot decompressed by foot dorsum double-incision is convenient and satisfied, and the operation is performed by internal fixation if it is displacedly fractured at the same time.

Objective: To study the clinical application of the neurovascular island flap of the calf supported by perforating branches of peroneal artery for the soft tissue defects of ankle and the foot., Methods: The flaps were used in 27 cases to repair the soft tissue defects of ankle and the lower leg from February 2004 to December 2007. Among them, 21 cases were male and 6 cases were female, ranging in age from 7 months to 64 years, with an average of 31.5 years. There were 7 cases with external malleolus, 5 cases with medial malleolus, 8 cases with dorsum of foot, 7 cases with achilles tendon. The range of soft tissue defects was from 2.5 cm x 3.5 cm to 10 cm x 24 cm and the range of flap was from 3 cm x 4 cm to 12 cm x 26.5 cm., Results: Seven cases were lightly swelling and distension after operation from 3 to 7 days. After 7 days, the swelling subsidised gradually and all flaps survived. In the follow-up for 3-12 months with an average of 5 months, all flaps showed fine appearance without fat and clumsy. The function of donor site was very well., Conclusion: The neurovascular island flap of the calf supported by perforating branches of peroneal artery can provide reliable blood supply, long reversed distance and wide repairing limitation and the proximal end of flap can reach to popliteal fossa. It is a good method to repair the defects of the lower leg and the foot.

Objective: To explore an anatomical basis and incising scope for the medial plantar artery combined flaps and its feasibility of repairing heel and adjacent vast soft tissue defects., Methods: The origin, branches, course and distribution of the medial plantar artery were studied in 20 legs of adult cadavers. The largest area of healthy adult's medial plantar and medialis pedis scope that could be incised for the combined flap was measured. Ten cases of heel and adjacent vast soft tissue defects were repaired by the combined medial plantar and medialis pedis flaps. Age range 28-60 years old. The areas of flaps were 9 cm x 7 cm - 10 cm x 8 cm. Defects of tendo calcaneus were repaired by the tendon of abductor muscle and plantar fascia in 3 cases with skin grafts on the donor sites., Results: The medial plantar artery gave off deep branch (diameter: 1.5 mm +/- 0.3 mm) and superficial branch (diameter: 1.0 mm +/- 0.2 mm). The length of media plantar artery deep branch was (8.9 +/- 0.2) cm and gave off 3-5 cutaneous branches. The largest area of combined flap was about 10.4 cm x 9.2 cm - 9.1 cm x 8.2 cm. Ten flaps survived completely. Eight flaps were followed up for 1 month to 1.5 years. The color, texture and appearance of flaps were excellent. The flaps of two-point discrimination were not different with opposite medial region. The affected limb exercised freely and had no ulceration on the flap., Conclusions: The combined flap has a reliable blood supply and it can recover good sensation after operation. It is one of ideal flaps to repair heel and adjacent vast soft tissue defects. Its disadvantage is a complicated operation.

Objective: To investigate the operative method and effect of the reversed sural neurocutaneous flap in repairing soft tissue defects of the anterior foot and the ankle., Methods: From March 1999 to November 2004, 19 cases (17 male, 2 female) of soft tissue defects of the anterior foot and the ankle were repaired with the reversed sural neurocutaneous flaps. The flap sizes range from 18 cm x 9 cm to 30 cm x 18 cm., Results: All flaps survived well, while 1 flap had distal partial necrosis and healed after dressing change. The follow-up from 6 months to 2 years showed that all flaps were satisfactory., Conclusion: Sural neurocutaneous flap is easy to get and to survive. It is an effective method to repair the soft tissue defects of the anterior foot and the ankle.

Objective: To evaluate the effects of the therapy mainly for strengthening healthy energy to promote blood circulation in treating diabetic patients with gangrene., Methods: A series of 112 diabetic patients with gangrene were investigated before and after treatment in the changes of wounds, clinical symptoms and quality of life., Results: Fifty-eight cases were cured, 12 cases showed response, 36 cases improved, and 6 cases failure of treatment. The total obvious effect rate was 62.5% (70/112) and the amputation rate was 8.9% (10/112). The 104 diabetic cases of three-stage gangrene were classified into grade I, II and III. The total effect rates of the diabetic cases of grade I, II and III were 83.3% (30/36), 55.6% (35/63) and 20% (1/5), and the amputation rates were 0%, 12.7% (8/63), and 40% (2/5) respectively. After the treatment, the clinical symptoms, gangrene number, gangrene area and gangrene depth were obviously improved (P<0.05), and the quality of life was obviously improved (P<0.01), especially in physical condition, emotional well-being and therapeutic effects on patients (P<0.05)., Conclusion: Strengthening healthy energy to promote blood circulation is effective in treating diabetic patients with gangrene.

Objective: To investigate the anatomy of the medial pedis composite flaps with saphenous nerve and tendon and its application in the repair of tendo calcaneus and adjacent defects., Methods: 10 cadavers (20 sides) were observed. The origin, course, size and the distribution of the medial plantar artery were studied. 12 cases with tendo calcaneus and adjacent defects were reconstructed with the medial pedis composite flaps with saphenous nerve. Donor site defects were covered with free skin graft., Results: The medial plantar artery gives off deep branch [diameter (1.5 +/- 0.3) mm] and superficial branch [diameter (1.0 +/- 0.2) mm]. In 18 sides, the deep branches give off the medial branches and lateral branches. While in 2 sides, the superficial branches give off the medial branches and lateral branches with no big branches from the deep branches. There are branches of saphenous nerve and medial dorsal cutaneous nerve in the flap. All the flaps were survived. 8 cases were followed up for one months to one years. Good color, texture and function of the flaps were achieved., Conclusions: The medial pedis composite flaps with saphenous nerve can repair tendo calcaneus and adjacent defects. It is a easy and safe procedure with reliable anatomy and good results.

Objective: To explore the better method of repairing the soft tissue defect of the distal foot., Methods: The soft tissue defect in the distal foot of six patients were repaired by the distally based dorsum pedis island flap pedicled with the bust deep artery and(or) the first dorsal metatarsal artery., Results: Six patients were repaired in one stage, the biggest defect was 8 cm x 6 cm, all patients were followed-up 1 to 4 years, the function of foot was evidently improved, the patients were all satisfied with the operative results., Conclusions: The bust deep artery and (or) the first dorsal metatarsal artery, with reliable blood supply, were easily dissected and with good texture. So far this kind of flap is a good choice in repairing the defects of the soft tissue in the distal foot.

Objective: To find a better method of emergency repair of skin and soft tissue defects in the lower leg, ankle and foot., Methods: The distally based superficial sural artery flap was designed on the posterior aspect of the leg. From February 2000 to December 2003, 18 patients with skin and soft tissue detects of the lower leg, ankle and foot were treated with island fasciocutaneous flap supplied by superficial sural artery by emergency. The size of the flap ranged form 4 cm x 5 cm to 11 cm x 12 cm., Results: The flaps survived totally in 16 cases and necrosed partially in 2 cases. After 1-2 year postoperative follow-up, the results were satisfactory except that in 2 flaps., Conclusion: The island fasciocutaneous flap supplied by superficial sural artery may provide a useful method for emergency repair of soft tissue defect of the lower limbs.

Objective: To provide a new reconstructive method to treat refractory ulcers on the sole of the forefoot., Methods: The reversed medial plantar flap with the medial plantar pedal artery and vein as pedicle was used to treat the refractory ulcers on the sole of the forefoot in 5 cases. The size of the flap was 3.5-5.0 cm x 4.0-5.5 cm. The deformities were corrected at the same time and the flaps were protected after operation., Results: All flaps survived without complications. There was no recurrence after 6-month following-up. The patients could walk., Conclusion: The distal ends of medial plantar pedal artery and vein have plenty anastomoses with dorsal pedal artery and deep plantar arch. The reversed medial plantar flap has reliable blood supply by these anastomoses. The reversed medial plantar flap should be a choice in treating refractory ulcers on the sole of the forefoot.

Objective: This is to report the design and application of the medialis pedis flap., Methods: Based on the medial fasciocutaneous branches of the dorsal pedal artery, a medialis pedis flap can be raised. The flap had been used in 18 patients with soft tissue defects of the dorsum pedis, ankle region, lower leg or hand., Results: The anatomic observation of the blood supply to the medial region of the foot showed that a constant distribution of fasciocutaneous branches issued from the dorsal pedal artery was an important blood supply to this area. All flaps used in the 18 patients survived completely with satisfactory results and minimal morbidity at the donor site., Conclusion: We believe that the medial fasciocutaneous branches of the dorsal pedal artery are the reliable pedicle of the medialis pedis flap. The flap is useful for reconstruction of the soft tissue defects around the foot, ankle, lower leg or hand.

A new flap, the reverse medial planter island flap based on the distal end of the medial plantar artery (MPA) is introduced. It is found that the MPA is connected with the plantar profund artery via the first plantar metatarsal artery or the big lateral branch of the MPA, joining the common digital artery that comes from the arch of the plantar artery. This flap was used in 3 cases of electric injury with satisfactory results. It suggests that the reverse medial plantar island flap is an ideal flap for reconstruction of the defects in the weight-bearing area of the forefoot.

This paper reports the effect of electroacupuncture (EA) on peripheral microcirculation in 12 acute experimental arthritic rats and 6 healthy rats. The results showed that after EA an obvious improvement in footback-microcirculation of acute experimental arthritic rats appeared, namely, the disturbance of microcirculation on the area of pathological changes was alleviated. The auricular microcirculation was strengthened as well. There were no obvious changes of peripheral microcirculation in healthy rats after EA. That indicates EA has therapeutic effects of promoting blood circulation and reducing extravasated blood, antiphlogosis and detumescence on the area of pathological changes in acute experimental arthritic rat.