To compare the efficacy of free iliac bone flap combined with medial plantar flap and free anterolateral thigh flap combined with fibula flap in repair of tibial row defect of forefoot.

From January 2013 to December 2016, a total of 22 patients with tibial row defect of forefoot were admitted to Department of Hand Surgery Ⅱ of 521 Hospital of Norinco Group, Xi′an. Among them, 11 cases were repaired with free iliac bone flap combined with medial plantar flap and set as the observation group; the other 11 cases were repaired with anterolateral thigh flap and fibula flap and set as the control group. The fracture and dislocation were fixed with Kirschner wires or plates and screws after debridement in both groups in the first stage of operation, and the wounds were covered with vacuum sealing drain. In the second stage of operation for reconstruction of tibial row defect of forefoot, the observation group was reconstructed with free iliac bone flap combined with medial plantar flap, while the control group was reconstructed with free anterolateral thigh flap combined with fibular flap. The survival of the flap and the occurrence of vascular crisis and infection were observed, the patients were followed up by regular outpatient review, WeChat, telephone, etc. According to the American Orthopedic Foot and Ankle Society scoring standard, the patients′ foot function recovery was scored at 24 months after surgery, with excellent: 90-100 points; good: 75-89 points; acceptable: 50-74 points; poor: 50 points or less, the excellent rate of foot function recovery of patients were calculated and compared. According to the classification standard of sensory function restoration proposed by the British Medical Research Council, the sensory functional recovery of the two groups of flaps was scored and compared at 6, 12, and 24 months after surgery. Data were compared with Wilcoxon signed rank sum test.

All patients were followed up, with an average follow-up time of 31 months. All flaps survived after surgery. One patient in the control group developed venous crisis on the 1, 2 day after the operation, which was relieved after surgical exploration. One patient of superficial infection of flap wound in the observation group was relieved after dressing change and intravenous antibiotic infusion. According to the American Orthopedic Foot and Ankle Society scoring standard at 24 months after surgery, the observation group: excellent in 3 cases, good in 7 cases, acceptable in 1 case, the excellent and good rate was 90.9%; control group: excellent in 1 case, good in 3 cases, acceptable in 7 cases, the excellent and good rate was 36.4%, the difference of the excellent rate between the two groups was statistically significant (Z=-2.598, P=0.024). At 6, 12, and 24 months after operation, the scores of sensory function recovery in the observation group were 8.0 (4.0, 8.0), 12.0 (12.0, 16.0), and 16.0 (16.0, 16.0) points; the sensory function recovery scores in the control group were 4.0 (4.0, 4.0), 12.0 (8.0, 12.0) and 12.0 (12.0, 12.0) respectively. At the same time point comparison, the sensory function recovery score of the observation group was higher than that of the control group, the differences were statistically significant (Z=-2.165, -2.280, -3.031; P=0.030, 0.023, 0.002).

The vascularized iliac bone flap and fibula flap provide the ideal bone supply for the foot bone defect; the medial plantar flap is a good donor site for the repair of the plantar skin and soft tissue defect of foot. Good the weight-bearing and walking functions, satisfactory appearance, ideal sensory functional recovery and wear-resistant plantar skin can be achieved by it. Although the anterolateral thigh flap can also cover the skin and soft tissue defect of the foot, it has poor appearance, poor sensory recovery and is prone to slip and break.