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This study aimed to assess the therapeutic efficacy of moxibustion assisted therapy in combination with Qishen Tongmai Yin No. 1 on arteriosclerosis obliterans (ASO) patients. The impact on clinical symptoms, sign scores, foot dorsum temperature, foot dorsum artery blood flow, and overall clinical efficacy were analyzed. Sixty-three ASO patients from Beijing Xiaotangshan Hospital and Beijing Shijitan Hospital (January 2020-December 2021) were divided into 3 groups: a Qi Shen Tong Mai Yin I-only group, a moxibustion-only group, and a combined treatment group receiving both moxibustion and Qi Shen Tong Mai Yin No. 1. The treatment group took Qi Shen Tong Mai Yin No. 1 orally 3 times daily for 1 month. Moxibustion, employing a mild method, was applied once daily for 35 minutes over a month. Key acupoints included bilateral kidney Shu, Guan Yuan, Ming Men, Zu San Li, Wei Zhong, San Yin Jiao, and Yao Yang Guan. Posttreatment, clinical symptom scores, and dorsum foot parameters were measured, including foot temperature and dorsum foot artery blood flow. Total effective and cure rates were calculated. Pretreatment, no significant differences existed among the 3 groups (P > .05). Posttreatment, the clinical efficacy, dorsalis pedis temperature, dorsalis pedis artery blood flow, and symptom scores significantly improved in all groups (P < .05). Differences in these indicators were also significant among the 3 groups (P < .05). Moxibustion assisted therapy combined with Qishen Tongmai Yin No. 1 enhances total effective and cure rates in ASO patients, improving foot temperature, blood flow, microcirculation, and overall clinical efficacy. Additionally, this combination reduces scores for intermittent claudication, pain, skin temperature, soreness, skin color, and numbness, mitigating disease progression. Safety evaluation indicated no adverse events during treatment, demonstrating the safety of the combined therapy., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Summary: Adequate arterial inflow is mandatory for a successful free tissue transfer. Maximizing this inflow appears to be especially important during distal lower extremity reconstruction, where perfusion pressures can be significantly lower than in the trunk or head and neck. In the current study, the authors used color and pulsed-wave Doppler ultrasonography to analyze blood flow volumes in the foot in accordance with the ankle position. Twenty feet of 10 healthy subjects were included in the analyses. All subjects were examined by Doppler ultrasonography at three different ankle angles (dorsiflexion at 90 degrees, relaxed position, and complete plantar flexion). The average flow volumes of the dorsalis pedis artery varied dramatically at the different ankle positions, as follows: dorsiflexion, 19.81 ± 3.88 ml/minute; relaxed position, 11.71 ± 4.72 ml/minute; and plantar flexion, 3.47 ± 1.41 ml/minute. The average flow volume of the posterior tibial artery also varied dramatically at these different ankle positions: dorsiflexion, 9.08 ± 8.25 ml/minute; relaxed position, 14.78 ± 2.45 ml/minute; and plantar flexion, 19.03 ± 5.03 ml/minute. The ankle position dramatically affects the flow velocity in the anterior and posterior tibial vessels, which is an important consideration when performing free tissue transfer reconstruction of the foot. Ankle dorsiflexion would be recommended when using the anterior tibial artery as a recipient vessel, whereas plantar flexion of the ankle would be advised when the posterior tibial artery is used as a recipient vessel., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Rationale: Degloving foot injuries are challenging to treat and associated with life-long sequelae for patients. An appropriate debridement of ischemic soft tissues with maximal preservation of glabrous skin is key during the reconstruction of these injuries. Indocyanine green (ICG) fluorescence angiography is an established technique for the intraoperative evaluation of tissue perfusion., Patient Concerns: Two patients sustained complex foot injuries in traffic accidents, including multiple fracture dislocations and extensive degloving of the plantar skin., Diagnosis: Clinical inspection revealed significant degloving of the glabrous skin in both patients., Interventions: After fracture fixation, ICG fluorescence angiography-assisted debridement with immediate latissimus dorsi free flap reconstruction was performed., Outcomes: In both cases, this technique allowed a precise debridement with maximal preservation of the glabrous skin. The healing of the remaining glabrous skin was uneventful and the 6-month follow-up was characterized by stable soft tissues and satisfying ambulation., Lessons: ICG fluorescence angiography is a safe, user-friendly, and quick procedure with minimal risks, expanding the armamentarium of the reconstructive surgeon. It is highly useful for the debridement of extensive plantar degloving injuries and may also help to minimize the number of procedures and the risk of infection., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Summary: The authors present indocyanine green angiography to assess the effects of hyperbaric oxygen therapy and as a potential biomarker to predict healing of chronic wounds. They hypothesize that favorable initial response to hyperbaric oxygen therapy (improved perfusion) would be an early indicator of eventual response to the treatment (wound healing). Two groups were recruited: patients with chronic wounds and unwounded healthy controls. Inclusion criteria included adults with only one active wound of Wagner grade III diabetic foot ulcer or caused by soft-tissue radionecrosis. Patients with chronic wounds underwent 30 to 40 consecutive hyperbaric oxygen therapy sessions, once per day, 5 days per week; controls underwent two consecutive sessions. Indocyanine green angiography was performed before and after the sessions, and perfusion patterns were analyzed. Healing was determined clinically and defined as full skin epithelialization with no clinical evidence of wound drainage. Fourteen chronic-wound patients and 10 controls were enrolled. Unlike unwounded healthy volunteers, a significant increase in indocyanine green angiography perfusion was found in chronic-wound patients immediately after therapy (p < 0.03). Moreover, the authors found that 100 percent of the wounds that demonstrated improved perfusion from session 1 to session 2 went on to heal within 30 days of hyperbaric oxygen therapy completion, compared with none in the subgroup that did not demonstrate improved perfusion (p < 0.01). This study demonstrates a beneficial impact of hyperbaric oxygen therapy on perfusion in chronic wounds by ameliorating hypoxia and improving angiogenesis, and also proposes a potential role for indocyanine green angiography in early identification of those who would benefit the most from hyperbaric oxygen therapy., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: Far-infrared irradiation (FIR) is used in the medical field to improve wound healing, hemodialysis with peripheral artery occlusive disease, and osteoarthritis but seldom used in ameliorating poor lower extremity circulation. The purpose of this study was to evaluate the effect of FIR on changes in foot skin surface temperature (FSST) and autonomic nerve system (ANS) activity to evaluate its effectiveness in improving lower limb circulation., Methods: A randomized controlled study was conducted. Subjects (n = 44), all over the age of 50 years and satisfying the inclusion criteria, were randomly allocated into 2 groups. The intervention group received FIR on a lower limb for 40 minutes and the control group received no intervention. Left big toe (LBT), right big toe (RBT), left foot dorsal (LFD), right foot dorsal (RFD) surface skin temperature, autonomic nervous activity, and blood pressure were assessed., Results: The main results were skin surface temperature at the LBT increased from 30.8 ± 0.4°C to 34.8 ± 0.4°C, at RBT increased from 29.6 ± 0.4°C to 35.3 ± 0.4°C and LFD increased from 31.9 ± 0.3°C to 36.4 ± 0.4°C, RFD increased from 30.7 ± 0.3°C to 37.7 ± 0.2°C. FIR caused a significant increase of the FSST ranging in a 4°C to 7°C increase after 40 minutes irradiation (P < .001). The ANS low-frequency (LF) and high-frequency (HF) activity showed a statistically significant increase in the FIR group (P < .05) but not the LF/HF ratio., Conclusion: FIR significantly increased the FSST from between 4°C and 7°C after 40 minutes irradiation, which might improve lower extremity circulation and regulation of ANS activity.

Diabetic foot infection (DFI) should be treated by a multidisciplinary team to prevent amputation and morbid status. As physicians encountering DFI in outpatient clinic, a proper selection of antibiotic treatment and diagnostic approach for a vascular status is essential. We retrospectively investigated the patients with DFI from 2016 to 2017. All patients were examined for vascular status, wound status, and pathologic culture preceding the treatment. No statistical significance was observed between PEDIS grade 1 and 2 and 3 and 4 in culture status and culture results. Association analysis between vascular status and other variables, such as wound score and culture results, has no significant difference. Through these results, the helpful epidemiologic result of microbiology and necessity of examination for peripheral arterial disease were verified.

Buerger exercise can improve the peripheral circulation of lower extremities. However, the evidence and a quantitative assessment of skin perfusion immediately after this exercise in patients with diabetes feet are still rare.We recruited 30 patients with unilateral or bilateral diabetic ulcerated feet in Chang Gung Memorial Hospital, Chia-Yi Branch, from October 2012 to December 2013. Real-time dorsal foot skin perfusion pressures (SPPs) before and after Buerger exercise were measured and analyzed. In addition, the severity of ischemia and the presence of ulcers before exercise were also stratified.A total of 30 patients with a mean age of 63.4 ± 13.7 years old were enrolled in this study. Their mean duration of diabetes was 13.6 ± 8.2 years. Among them, 26 patients had unilateral and 4 patients had bilateral diabetes foot ulcers. Of the 34 wounded feet, 23 (68%) and 9 (27%) feet were classified as Wagner class II and III, respectively. The real-time SPP measurement indicated that Buerger exercise significantly increased the level of SPP by more than 10 mm Hg (n = 46, 58.3 vs 70.0 mm Hg, P < 0.001). In terms of pre-exercise dorsal foot circulation condition, the results showed that Buerger exercise increased the level of SPP in severe ischemia (n = 5, 22.1 vs 37.3 mm Hg, P = 0.043), moderate ischemia (n = 14, 42.2 vs 64.4 mm Hg, P = 0.001), and borderline-normal (n = 7, 52.9 vs 65.4 mm Hg, P = 0.028) groups, respectively. However, the 20 feet with SPP levels more than 60 mm Hg were not improved significantly after exercise (n = 20, 58.3 vs 71.5 mm Hg, P = 0.239). As to the presence of ulcers, Buerger exercise increased the level of SPP in either unwounded feet (n = 12, 58.5 vs 66.0 mm Hg, P = 0.012) or wounded feet (n = 34, 58.3 vs 71.5 mm Hg, P < 0.001). The majority of the ulcers was either completely healed (9/34 = 27%) or still improving (14/34 = 41%).This study quantitatively demonstrates the evidence of dorsal foot peripheral circulation improvement after Buerger exercise in patients with diabetes., Competing Interests: The authors have no funding and conflicts of interest to disclose.

An accurate and comprehensive understanding of lower extremity arterial anatomy is essential for the successful harvest and transfer of a free fibula osteoseptocutaneous flap (FFF). Minimum preoperative evaluation includes detailed history and physical including lower extremity pulse examination. Controversy exists regarding whether preoperative angiographic imaging should be performed for all patients. Elevation of an FFF necessitates division of the peroneal artery in the proximal lower leg and eradicates its downstream flow. For patients in whom the peroneal artery comprises the dominant arterial supply to the foot, FFF elevation is contraindicated. Detailed preoperative knowledge of patient-specific lower extremity arterial anatomy can help to avoid ischemia or limb loss resulting from FFF harvest. If preoperative angiographic imaging is omitted, careful attention must be paid to intraoperative anatomy. Should pedal perfusion rely on the peroneal artery, reconstructive options other than an FFF must be pursued. Given the complexity of surgical decision making, the authors propose an algorithm to guide the surgeon from the preoperative evaluation of the potential free fibula flap patient to the final execution of the surgical plan. The authors also provide 3 clinical patients in whom aberrant lower extremity anatomy was encountered and describe each patient's surgical course.

Background: It is widely known that blood pressure (BP) in the lower extremity is higher than in the upper extremity. However, whether this phenomenon remains the same during general anesthesia is still unclear. This study aims to investigate the difference between invasive dorsalis pedis artery (DPA) pressure and the most commonly used noninvasive arm pressure during sevoflurane anesthesia., Methods: A total of 50 normotensive Chinese patients were enrolled in this observational study. Invasive DPA pressure, noninvasive arm pressure, and systemic vascular resistance index were assessed simultaneously. BP data during the entire surgery were analyzed through a Bland-Altman plot for repeated measures. The concordance of BP variation in the DPA and the arm was analyzed using four-quadrant plots and linear regression. The time-dependent changes in BP and the systemic vascular resistance index were also evaluated., Results: Data from 46 effective cases were analyzed. Bias (95% limits of agreement) was -7.40 mmHg (-20.36 to +5.57 mmHg) for mean blood pressure, +3.54 mmHg (-20.32 to +27.41 mmHg) for systolic blood pressure, and -10.20 mmHg (-23.66 to +3.26 mmHg) for diastolic blood pressure, respectively. The concordance of BP variation at the two measurement sites was clinically acceptable. DPA pressure and vascular resistance in the lower limb decreased gradually during surgery., Conclusion: DPA pressure tends to be lower than arm pressure under sevoflurane anesthesia, especially the mean blood pressure and the diastolic blood pressure. Hence, noninvasive arm BP monitoring is recommend to be retained when invasive BP is measured at the DPA, so as to allow clinicians to comprehensively evaluate the BP condition of the patients and make appropriate therapeutic decisions.

The aim of this study was to represent the dorsalis pedis (DP) flap on sectioned images and surface models using Visible Korean for medical education and clinical training in the field of maxillofacial reconstructive surgery. Serially sectioned images of the foot were obtained from a cadaver. The important structures in the sectioned images were outlined and stacked to create a surface model. The PDF file (53 MB) of the assembled models is accessible for free download on the Department of Anatomy at Ajou University School of Medicine Web site (http://anatomy.co.kr). In this file, the significant anatomic structures of the DP flap can be inspected in the sectioned images. All surface models and stereoscopic structures of the DP flap are described in real time. We hope that these state-of-the-art sectioned images, outlined images, and surface models will help students and trainees gain a better understanding of the DP flap anatomy.

Unlabelled: The study describes 2 children at risk of limb amputation due to lower extremity active amniotic band syndrome, in which the constriction bands were released surgically using the extensive approach. Both patients presented almost the same clinical appearance: a deep constriction band localized in one third of the distal part of the leg and a pseudoconstriction at the ankle joint level resulting from the tightening of the retinaculum of extensors. In both the cases, after birth amniotic band syndrome caused progressive enlargement of the distal part of the foot, which was associated with edema and vascular insufficiency. Case 1, at the age of 3 months, underwent a primary excision and Z-plasty of the proximal constriction band, and after 6 weeks a secondary excision was performed covering the soft tissue bulk from the dorsal part of the foot formed due to vascular insufficiency progression. In contrast, case 2 underwent a more radical 1-staged surgery at the age of 4 weeks, that is, an excision and Z-plasty of the proximal constriction and the same radical excision of the soft tissue bulk. In addition, in both patients decompression fasciotomy was performed. A follow-up after surgery, respectively, at the age of 20 and 5 years, revealed a fully functional foot and restoration of blood supply. Thus, the 1-staged radical excision of constrictions combined with removal of the overgrown skin and pathologic soft tissue can be recommended for similar cases., Levels of Evidence: Level IV-case series.

In this study, we have evaluated the changes observed in the main arteries of the foot before and after the Ponseti technique. Arterial structures of seven patients were examined using Doppler ultrasound and the parameters studied included the course of the arteries, lumen filling, flow direction, pattern, and velocity. Before the treatment, the side with congenital talipes equinovarus deformity showed decreased blood flow in all arteries, except for the posterior tibial artery. At the second examination, the increase in the flow velocity of both arteries except tibialis anterior arteries was statistically significant. The Ponseti method results in normalization of the arterial structures in extremities with congenital talipes equinovarus.

The most dreaded major donor-site complication of free fibula flap is a foot ischemia, which is fortunately rare. Various authors have discussed the efficacy of the use of preoperative imaging methods including color Doppler, magnetic resonance angiography, and conventional angiography. A 25-year-old man presented with a 10-cm mandibular defect after a facial gunshot injury. Lower extremity color Doppler revealed triphasic peroneal, tibialis anterior, and posterior artery flows. A fibula osteocutaneous flap was harvested, and the mandible was reconstructed. However, the suture sites at the donor site began to demonstrate signs of necrosis, abscess formation, and widespread cellulitis beginning from postoperative day 9. Angiogram of the lower extremity on the 13th day demonstrated no flow in the right posterior tibial artery distal to the popliteal artery, whereas the anterior tibial artery had weak flow with collateral filling distally. An emergency bypass with a saphenous vein graft between the popliteal artery and the distal posterior tibial artery was performed. Repeated debridements, local wound care, and vacuum-assisted closure were applied. A skin graft was placed eventually. The extremity healed without severe functional disability. In conclusion, although the arterial anatomy is completely normal in preoperative evaluation, vascular complications may still ocur at the donor fibula free flap site. In addition, emergency cardiovascular bypass surgery, as we experienced, may be necessary for limb perfusion.

Fibula flap is widely used in reconstruction work, whereas the low extremity blood supply alteration was unclear. This study would observe the blood oxygen saturation change of foot after harvesting fibula flap. The regional tissue oxygen saturation (rSO2) of the lateral side and inner side of feet was measured using near-infrared spectroscopy oxygen monitoring system (NIRS) before operation and in postoperative day 1 to 7, and the foot of the control side was measured as control. The rSO2 of the donor side foot decreased less than 5% (P < 0.05) in the first 8 hours after operation and recovered to the level of the control side later. NIRS is ideal for measuring rSO2 of donor side foot after fibula flap. The rSO2 of the donor side foot decreased less than 5% after fibula flap harvesting.

Constipation is a common health problem that adversely affects quality of life and the prognosis of hospitalized patients with acute coronary syndromes (ACS). The purpose of this study was to develop and test the sweet potato/footbath/acupressure massage (SFA) intervention as a safe treatment for prevention of constipation and to increase satisfaction with bowel emptying in hospitalized patients with ACS. The study was a prospective, randomized controlled trial with a sample of 93 patients (SFA group, n = 44; usual care group, n = 49). Patients in the SFA group received SFA intervention combined with usual care. The results showed that there were statistical differences between the two groups in terms of (1) the incidence of constipation; (2) the use of laxatives and enemas; (3) patients' subjective satisfaction with their bowel emptying during hospitalization; and (4) sensation of incomplete evacuation and anorectal obstruction/blockade. The SFA intervention was more effective, economical, and practical than usual care alone in managing constipation and satisfaction with defecation in patients hospitalized with ACS.

Through-and-through facial defects can be the result of malignancy, malformations, or trauma and pose a challenge for reconstructive surgeons. An ideal reconstruction of such defects should restore both lining and external skin defects at the same time. In this report, we describe the use of combined anterior tibial flap and dorsalis pedis flap to reconstruct complex facial defects. Six patients who presented with through-and-through facial defects were included. The cause of defects were trauma, radiotherapy, or flap necrosis, and defect locations were the buccal (3 patients), oral region (2 patients), and frontal (1 patient). The outer defects were between 5 × 6 cm and 13 × 9 cm, whereas the inner defects were between 3 × 3 cm and 5 × 6 cm. The anterior tibial flaps that were used to cover the outer defects ranged from 5 × 8 cm to 10 × 15 cm, and the dorsalis pedis flaps that were used to reconstruct the lining ranged from 3 × 4 cm to 6 × 8 cm. Donor sites were covered with skin grafts. No flap failure was evident, and a good aesthetic outcome was obtained in all cases. In 1 patient, the skin graft on the dorsal pedis presented partial necrosis and ultimately healed by dressing change. Compared with other techniques, the combined anterior tibial flap and dorsalis pedis flap possesses the potential benefits of being thin and pliable and having reliable vascularity. It brings a new alternative method for complex facial defect reconstruction.

Background: The sympathetic innervation of the hand was demonstrated using formaldehyde staining techniques in the 1990s and provides a basis for both medical (botulinum toxin type A) and surgical (sympathectomy) therapeutic approaches. This research investigates the sympathetic innervation of the human foot using tyrosine hydroxylase immunohistochemistry., Methods: With institutional review board approval, six freshly amputated lower extremities had arterial, venous, and peripheral nerve biopsies obtained at the distal leg, ankle, and forefoot levels. Tibial, peroneal, sural, and saphenous nerves were processed immediately for immunohistochemical staining using an anti-tyrosine hydroxylase antibody, for light and electron microscopy evaluation. Qualitative assessments noted the presence or absence of tyrosine hydroxylase-positive fibers in artery, vein, and peripheral nerve. Within the nerve, location of the tyrosine hydroxylase staining was noted., Results: The presence of tyrosine hydroxylase-positive material was identified in each artery, vein, and nerve examined at each level of the foot and ankle. For the artery, the staining was in the adventitia, and rarely in the media of the vessel wall. There were clear entry points into the artery from the connective tissue. For the vein, the staining was more evenly distributed but to a lesser intensity than in the artery. Within each nerve at the proximal levels, the staining was diffusely throughout the fascicles, with clear sites of fibers leaving the periphery., Conclusions: It is concluded that (1) sympathetic innervation of the foot arrives along each peripheral nerve, (2) the vessels already contain sympathetic innervation at the level of the ankle, and (3) the sympathetic innervation of the foot is extensive.

Objective: Many pediatric healthcare providers believe that capillary refill time is a measure of perfusion and cardiac output in children. Despite its widespread use, there are no studies examining the relationship of capillary refill time to cardiac output in noncritically ill children. This study examined the inter-rater reliability of capillary refill time and its relationship to hemoglobin and with cardiac output in pediatric patients undergoing cardiac catheterization., Design: Prospective observational study., Setting: Tertiary care pediatric hospital., Patients: A total of 58 children, ages 0.3-17 yrs, with congenital heart disease undergoing cardiac catheterization., Interventions: Two clinicians performed two measurements of capillary refill time in a standardized fashion on 58 children undergoing cardiac catheterization. Cardiac output was determined by the Fick method within 15 mins of the first assessment of capillary refill time (time 1)., Measurements and Main Results: Capillary refill time and cardiac output measurements were obtained in 44 children, and 108 paired measurements of capillary refill time were obtained to assess inter-rater reliability. The mean capillary refill time was 1.2 secs (±0.5 secs), and the mean cardiac output was 3.6 L/min/m (2.2-5.7 L/min/m). The inter-rater intraclass correlation coefficient was 0.12 (time 1) (95% confidence interval -0.15 to +0.37) and was 0.32 (95% confidence interval 0.058-0.54) at the end of the catheterization (time 2). A significant association was noted between average capillary refill time at time 1 and hemoglobin, with higher hemoglobin correlating with longer capillary refill time (p = .015). There was no significant correlation between the average capillary refill time taken at the time of cardiac output measurement (time 1) and measured cardiac output (r = .331, 95% confidence interval for r, .066-.552)., Conclusions: We found that the inter-rater reliability of capillary refill time was poor and variable under controlled conditions and capillary refill time was not correlated with cardiac output in anesthetized nonacutely ill pediatric patients undergoing cardiac catheterization. Caution should be used in inferring cardiac output from capillary refill time measurements alone.

Purpose: This study explores the vascular and morphologic anatomy of extensor digitorum brevis (EDB), which can be alternatives to donor muscles used in functional muscle transfer in long-standing facial paralysis reanimation., Methods: A total of 14 EDB muscles from 7 embalmed cadavers were dissected and examined. Diameters and lengths of major and minor arteries supplying the muscle, venous pedicle diameter, neural pedicle diameter and length, their entrances into the muscle, the extendibility of neurovascular pedicles, when necessary, and the morphology of muscles were evaluated., Results: Mean results obtained for EDB muscle in the study were as follows: the longest distance between the starting point and the area where the tendon started was a mean of 5.1 ± 0.1 cm (range, 4.8-5.4 cm), the distance between the widest points was 4.2 ± 0.3 cm (range, 3.7-4.9 cm), the thickest area was 1.4 ± 0.8 cm (range, 1-1.9 cm), and surface area was a mean of 32.1 ± 1.2 cm (range, 29.8-35.7 cm). The mean length of the major artery is type 2 according to Mahtnes-Nahai classification and was found to be 2.1 ± 0.03 cm (range, 1.6-3.2 cm), and its diameter was found to be 1.95 ± 0.15 mm (range, 1.7-2.1 mm). Mean length and diameter of the nerve providing motor innervation to the muscle were found to be 2.3 ± 0.03 cm (range, 2.1-2.6 cm) and 2.4 ± 0.08 mm (range, 2-2.9 mm), respectively., Conclusion: As a result of this preliminary study, we think that the morphologic and neurovascular structures of this muscle are suitable for use in long-standing facial paralysis reanimation.

Background: Ischemia-reperfusion (I/R) injuries consist of enhanced oxidative and inflammatory responses along with microvascular dysfunction after prolonged ischemia and reperfusion. Because I/R injuries induce chronic postischemia pain (CPIP) in laboratory animals, it is possible that surgical procedures using prolonged ischemia may result in chronic postoperative pain. Glycemic modulation during ischemia and reperfusion could affect pain after I/R injury because glucose triggers oxidative, inflammatory, and thrombotic reactions, whereas insulin has antioxidative, antiinflammatory, and vasodilatory properties., Methods: One hundred ten rats underwent a 3-h period of ischemia followed by reperfusion to produce CPIP. Rats with CPIP had previously been divided into six groups with differing glycemic modulation paradigms: normal feeding; fasting; fasting with normal saline administration; fasting with dextrose administration; normal feeding with insulin administration; and normal feeding with insulin and dextrose administration. Blood glucose concentration was assessed during I/R in these separate groups of rats, and these rats were tested for mechanical and cold allodynia over the 21 days afterward (on days 2, 5, 7, 9, 12, and 21 after I/R injury)., Results: I/R injury in rats with normoglycemia or relative hyperglycemia (normal feeding and fasting with dextrose administration groups) led to significant mechanical and cold allodynia; conversely, relative hypoglycemia associated with insulin treatment or fasting (fasting, fasting with normal saline administration, and normal feeding with insulin administration groups) reduced allodynia induced by I/R injury. Importantly, insulin treatment did not reduce allodynia when administered to fed rats given dextrose (normal feeding with dextrose and insulin administration group)., Conclusion: Study results suggest that glucose levels at the time of I/R injury significantly modulate postinjury pain thresholds in rats with CPIP. Strict glycemic control during I/R injury significantly reduces CPIP and, conversely, hyperglycemia significantly enhances it, which could have potential clinical applications especially in the surgical field.

Retinoblastoma is a common malignant intraocular tumor in childhood, and most patients require enucleation or exenteration even with irradiation. Severe anophthalmic orbits and atresic eye sockets are not rare. We conducted a retrospective study to evaluate the results of surgical management of reconstruction of severe anophthalmic orbits and atresic eye sockets with vascular anastomosed free dorsalis pedis flap transplantation. There were 5 patients (5 eyes) who underwent reconstructive surgery of severe anophthalmic orbits and atresic eye sockets after enucleation and irradiation of retinoblastoma in our hospital during the 3 years. All patients had enucleation and irradiation immediately after the retinoblastoma was diagnosed and had never worn artificial eyes because of the atresic eye sockets. Vascular anastomosed free dorsalis pedis flaps, whose dimensions were typically 6.5 × 5.5 cm(2), were transplanted to reconstruct the severe anophthalmic orbits and atresic eye sockets. The donor sites were covered by free abdominal skin flaps. All the vascular anastomosed free dorsalis pedis flaps were valid after more than 6 months of follow-up. And then all the 5 patients underwent secondary autogenous dermal fat implantation to augment the supraorbital area depression. After the 2-stage reconstruction surgery, the dimensions of the eye sockets were adequate, and all patients were able to wear their prosthesis and had a satisfactory cosmetic result. Implantation of alloplastic materials is not recommended because of insufficient blood supply of the irradiated orbital area.

A 58-year-old white woman with stasis dermatitis developed a solitary, slowly growing keratotic nodule of the dorsum of the foot. The excision biopsy specimen of this lesion showed a biphasic pattern of eccrine syringofibroadenoma and clear cell acanthoma. Such a previously unreported association is neither necessarily by chance nor necessarily a collision. Because a reactive histogenesis has been postulated for both eccrine syringofibroadenoma and clear cell acanthoma, this case could represent a morphologically biphasic pattern of epidermal and ductal hyperplasia as a consequence of the stasis-induced chronic inflammation coupled with the footwear-induced chronic trauma.

Background: Microvascular surgery plays a major role in the reconstructive process of limb salvage. However, microsurgery in the patient with renal disease is still considered a high-risk procedure. Some authors have even recommended immediate amputation because of poor long-term survival in patients with renal failure and lower limb ischemia., Methods: A retrospective review of all patients with end-stage renal disease on hemodialysis who underwent free flap surgery at Dalin Tzu Chi General Hospital was included in the study. Data were collected over a 5-year period, between June of 2005 and June of 2009., Results: A total of 20 patients were included in the study, of which 11 were men and nine were women. The average age of the patients was 63 years. All had a history of diabetes mellitus with peripheral vascular disease. Seven of the 20 patients had undergone prior vascular intervention. The total flap survival rate was 95 percent. Four patients eventually required major limb amputation because of progressive infection at the recipient site. There were no further major limb amputations in these patients during the long-term follow-up. The total limb salvage rate was 80 percent. The average follow-up was 30 months., Conclusions: The authors' present approach shows that the results of limb salvage in this particular group of patients are not as discouraging as previously reported. In the description of patients with renal disease, the authors suggest that they not be described as one entity but that they be divided into subgroups so that this better reflects the risk of surgery and the success of limb salvage.

We present a 44-year-old man who sustained a Lisfranc dislocation complicated by a dorsalis pedis pseudoaneurysm. This case represents a rare complication of a commonly performed orthopaedic procedure.

Volumetric computed tomography offers improved potential to perform perfusion analysis in peripheral musculoskeletal structures. Despite poor baseline tissue enhancement and artifacts from adjacent bone, reproducible perfusion estimates were attained using a volumetric en bloc technique in the plantar muscle compartment, Achilles tendon, and subcalcaneal adipose tissue of 16 feet in healthy male subjects. Inadequate enhancement prevented perfusion estimates in the second metatarsal head of all cases. Perfusion calculations succeeded in the calcaneus in 6 of the 16 examined feet.

Background: The use of pnuemoperitonium to create the working environment for laproscopic cholecystectomy results in an increase in intraabdominal pressure, which exceeds the pressure of the venous-return from the legs. The resulting venous stasis may increase the risk of thrombosis formation and deep vein thrombosis in the lower limbs. However, there is no information as to whether the venous stasis will also exacerbate the coagulabililty of blood flowing out of the lower limbs., Aim: The aim of the study is to find evidence of haemostatic activation in the blood draining the lower limbs, which experience venous stasis as a result of the laparoscopic cholecystectomy (LC) procedure., Materials and Methods: In this study, we prospectively studied 25 patients who underwent LC for uncomplicated cholelithiasis; 20 were female and 5 were male, aged between 17 to 65 years. LC was carried out according to a standard procedure. After general anesthesia, the patients were laid in a 30 degrees anti-Trendelenburg position, and pnuemoperitonium was maintained during the procedure with abdominal pressure of 12 mm Hg. The mean operating time was 55 minutes (range 25 to 118 min).Blood samples were collected simultaneously from the antecubetal fossa (the upper limb) and the dorsum of the foot (the lower limb), on 4 different occasions: i. preoperative; ii. after the induction of anesthesia, and before the inflation of the abdomen; iii. at the end of surgery, before deflation of the abdomen, and iv. 24 hours after surgery. LABORATORY ASSAYS: Prothrombin time, activated partial thromboplastin time, thrombin time, and plasma fibrinogen, Plasma Protein S (total and free), Protein C, Antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor (PAI-I). Platelet function was assessed by the platelet function analyser (PFA100)., Results: No significant differences were noted in all measured haemostatic parameters, including PFA100 closure times, when comparing the measurements that were taken simultaneously in the upper and lower limbs' blood. Plasma fibrinogen increased significantly 24 hours after surgery, and antithrombin levels dropped slightly, immediately after surgery, but recovered preoperative levels 24 hours after surgery. Coagulation inhibitors (total and free protein S and protein C), and fibrinolytic parameters did not show any significant fluctuations throughout the study intervals., Conclusion: The finding of this study is of no significant activation of coagulation in the blood flowing out of the lower limbs at the time of venous stasis, adds to the criteria of safety of the current surgical procedure used in LC, including reverse Trendelenburg position and pneumoperitoneum that unavoidably produce significant stasis in the lower limbs.

Objectives: To assess the feasibility of low-dose time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance (MR) angiography of the pedal vasculature at 3.0 Tesla (T) using a head coil., Materials and Methods: Eleven healthy volunteers were imaged using TRICKS MR angiography at 3.0 T with both feet positioned in a head coil. A dose of 7 mL was used for each of 3 acquisitions: images were obtained of each foot in the sagittal plane, and then both feet were imaged simultaneously in the transverse plane. The following parameters were used for acquisition: (TR/TE 4.7 milliseconds/ 1.3 milliseconds, field of view = 28 cm, Flip angle = 30 degrees, 384 x 256 matrix, section thickness = 1.6 mm, Bandwidth = 19.23). The dorsalis pedis, plantar arch, distal posterior tibial, lateral tarsal, and medial plantar arteries were graded for visualization, artifact, and overall image quality on a 4-point scale (1 = worst; 4 = best)., Results: Superior visualization trended towards separate sagittal acquisitions when compared with that of bilateral transverse acquisitions for most of the individual vessels of the foot. Overall, separate sagittal acquisitions (average score = 2.9) were superior to bilateral transverse acquisitions (average score = 2.6). The average image quality score reflecting the amount of artifact was 2.6 for studies obtained using bilateral transverse acquisitions and 3.1 for studies obtained using separate sagittal acquisitions., Conclusion: Low-dose gadolinium multi-injection TRICKS and bolus-chase MR angiography at 3.0 T provides an effective and easily reproducible technique for imaging of the pedal vasculature in volunteers and has great potential for clinical application.

Background: It is well known that venous drainage of the medial plantar flap is performed by two venous systems: cutaneous veins visible through the skin that drain into the great saphenous vein; and deep veins, namely, accompanying veins of the medial plantar artery. However, there are only a few illustrations of the cutaneous veins of the sole in anatomical textbooks. Further clarification of the cutaneous veins of the sole was considered to be useful information in elevating the medial plantar flap., Methods: Whole-body or local injection with contrast medium was performed in 10 fresh cadavers. The skin and subcutaneous tissue were elevated and radiographed with a soft x-ray system. In an embalmed cadaver, macroscopic observation was performed., Results: In the sole, an intimate venous network was formed by branches of the great saphenous vein, small saphenous vein, and dorsal venous arch. Vascular arrangement of the venous network was not random but characteristic in each region of the sole. In the medial plantar, vessels were arranged toward the anterior margin of the medial malleolus., Conclusion: In planning the medial plantar flap, taking the vascular arrangement into consideration is considered to help the flap to avoid venous congestion and to extend the skin portion.

Background: The aim of this study was to describe the relationship between the deep peroneal nerve and the dorsalis pedis artery to help ensure a safer surgical approach in flap surgery., Methods: The dissection of 36 cadaver lower limbs was undertaken to describe the relationship of the deep peroneal nerve to the dorsalis pedis artery in the anterior tarsal tunnel and on the dorsum of the foot., Results: Four distinct relationships of the deep peroneal nerve to the dorsalis pedis artery were determined. In type 1 (36.1 percent), the artery was medial to the deep peroneal nerve in the tunnel and medial to the medial terminal branch below the tunnel on the dorsum of the foot. In type 2 (25.0 percent), the artery was medial to the deep peroneal nerve in the tunnel and lateral to the medial terminal branch below the tunnel on the dorsum of the foot. In type 3 (30.6 percent), the deep peroneal nerve and the artery were crossing over each other at multiple levels. In type 4 (8.3 percent), no medial terminal branch was observed. The artery was medial to the lateral terminal branch., Conclusions: The dorsalis pedis neurovascular island flap contains both the dorsalis pedis artery and the deep peroneal nerve. Because the design of a neurovascular free flap requires detailed knowledge of the nerve and vascular supply, the data presented here will help surgeons during the surgical approaches to the foot and ankle.

Objectives: To report normal values of skin perfusion in healthy subjects in three age groups using a laser Doppler imager; to determine differences attributable to gender, age, site, and use of red or near-infrared lasers; and to correlate transcutaneous oxygen with laser flux values., Design: Flux and transcutaneous oxygen were measured at ten sites in the lower extremity in 60 subjects from three age groups. Heated and unheated sites were scanned with red and near-infrared lasers., Results: Heat hyperemia was prominent at all sites. Small, statistically significant mean +/- SD differences were found between heated and nonheated sites for the red and near-infrared lasers (P = 0.02). All flux ratios were independent of gender but were higher in the oldest group. Plantar sites demonstrated higher flux in unheated areas and lower flux ratios compared with leg sites. Transcutaneous oxygen did not correlate significantly with flux for either laser type., Conclusions: Scanning laser-Doppler imaging flux values provide a reference for identifying patients at risk for tissue ischemia and poor healing potential caused by impaired circulatory reserve in the legs and distal feet. The lack of correlation between flux and transcutaneous oxygen in healthy individuals suggests that they measure different physiologic processes.

Background: Ian Taylor introduced the angiosome concept, separating the body into distinct three-dimensional blocks of tissue fed by source arteries. Understanding the angiosomes of the foot and ankle and the interaction among their source arteries is clinically useful in surgery of the foot and ankle, especially in the presence of peripheral vascular disease., Methods: In 50 cadaver dissections of the lower extremity, arteries were injected with methyl methacrylate in different colors and dissected. Preoperatively, each reconstructive patient's vascular anatomy was routinely analyzed using a Doppler instrument and the results were evaluated., Results: There are six angiosomes of the foot and ankle originating from the three main arteries and their branches to the foot and ankle. The three branches of the posterior tibial artery each supply distinct portions of the plantar foot. The two branches of the peroneal artery supply the anterolateral portion of the ankle and rear foot. The anterior tibial artery supplies the anterior ankle, and its continuation, the dorsalis pedis artery, supplies the dorsum of the foot. Blood flow to the foot and ankle is redundant, because the three major arteries feeding the foot have multiple arterial-arterial connections. By selectively performing a Doppler examination of these connections, it is possible to quickly map the existing vascular tree and the direction of flow., Conclusions: Detailed knowledge of the vascular anatomy of the foot and ankle allows the plastic surgeon to plan vascularly sound reconstructions, the foot and ankle surgeon to design safe exposures of the underlying skeleton, and the vascular surgeon to choose the most effective revascularization for a given wound.

Background: Toe-to-hand transfer is an accepted procedure for reconstruction of thumbs and fingers. Although the vascular anatomy of the toe has been well studied, its symmetry on both feet has not previously been reported., Methods: A retrospective review of 85 cases of simultaneous bilateral toe-to-hand transfers, performed between 1984 and 2002, was carried out. All of the pedicles were dissected in a retrograde fashion., Results: A symmetric vascular pedicle anatomy was found in 78.8 percent of the patients, whereas 21.2 percent of the patients had an asymmetric vascular pattern., Conclusions: This result cautions surgeons about the possibility of vascular pedicle asymmetry between two feet in bilateral toe harvest. It proves once more the advantage of a retrograde pedicle dissection technique, which allows for a safe and straightforward toe harvest regardless of the vascular pedicle course variations.

Ischemic necrosis, which develops rarely after clubfoot surgery, may have a vascular etiology, since many idiopathic and neurogenic clubfeet have congenital deficiency of the anterior tibial and dorsalis pedis arteries. Dorsalis pedis deficiency is demonstrated more frequently in those clubfeet showing greater deformity. Substantial hypoplasia of the profunda femoris and posterior and anterior tibial arteries was evident in the affected limb of a patient in this series who underwent postoperative arteriography. Herein, we report massive necrosis in seven limbs of six patients after clubfoot surgery and have combined this series with seven previously published cases. Additional cases support our hypothesis that arterial deficiencies put some postoperative clubfeet at risk of perioperative ischemic necrosis. Necrosis occurs in those regions supplied by the congenitally diminished anterior tibial and dorsalis pedis arteries. Knowing that children with congenital vascular deficiency are at risk for ischemic necrosis, surgeons should be alert to the subtle, early signs of ischemia and be prepared to prevent or ameliorate the consequences of this condition. Since hypoperfusion in these postoperative feet is a surgical emergency, we propose clinical guidelines for treatment for this phenomenon, which we have named the purple hallux sign.

Twenty children are presented after undergoing a distally based superficial sural flap for coverage of defects at the lower leg and foot. The age of the patients was between 1 and 12 years. Fifteen patients had trauma to the lower leg, with eight of them having associated injuries. Three had postburn contracture and two had pressure sore. In 14 cases, the flap was used as a fasciocutaneous flap, whereas in six cases it was used as a fascial flap covered with a skin graft. The flaps were used to cover the defects from the dorsum of the foot distally up to the mid third of tibia proximally. The mean follow-up was for a period of 2 years. Even though free tissue transfer is reliable and safe for the reconstruction of major leg injuries in children, the distally based superficial sural flap has the advantage of being easy to perform, with short operating time, minimal donor side morbidity, and preservation of major arteries of the leg.

Objective: To evaluate the role of the C-nociceptive nerve fibers in nerve axon reflex-related vasodilation., Methods: Skin vascular reactivity, in response to iontophoresis of acetylcholine and sodium nitroprusside, was evaluated at both the forearm and the foot levels in 13 diabetic neuropathic (DN),11 nonneuropathic (D), and 9 healthy control (C) subjects. The total and nerve axon reflex-related vasodilation were measured by two single-point laser probes. A topical anesthetic was applied on the contralateral forearm and foot, and all the measurements were repeated., Results: Dermal anesthesia resulted in a reduction of the nerve axon reflex-related vasodilation at the forearm in all three groups (C 70.7 +/- 12%, D 59.7 +/- 7%, and DN 73.5 +/- 14%; percentage of reduction over preanesthesia response, mean +/- SEM; p < 0.001) and at the foot in the two nonneuropathic groups (C 74 +/- 10% and D 68.9 +/- 9%; p < 0.001 versus before anesthesia). This reduction was absent at the foot of the neuropathic patients (DN -4 +/- 21%; p = NS versus before anesthesia). A correlation was found between the nerve axon reflex-related response and measurements of nerve function (neuropathy disability score, r = -0.425, p < 0.017; vibration perception threshold, r = -0.527, p < 0.002; Semmes-Weinstein monofilament perception, r = -0.619, p < 0.001)., Conclusion: The nerve axon reflex-related vasodilation is directly related to the function of the C-nociceptive fibers and is significantly associated with other nerve function measurements. As this is an objective measurement, it has the potential to be used as an alternative to currently employed techniques to evaluate small-fiber function.