PMC8500390_01
Findings during the initial examination. (A) Initial soft tissue loss was an extensive defect at the lateral side of the lower leg. (B and C) Plain radiography and computed tomography demonstrate a fracture of the distal fibula. (D) Temporary fixation was performed using Kirschner wires at the initial debridement.
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The talus was visualized through the wound, and the ankle joint showed marked instability (Figure 1A). A comminuted fracture of the distal fibula was revealed by plain radiography and computed tomography (Figure 1B and C). Kirschner wires were inserted from the proximal tibia to the talus and calcaneus for temporary fixation (Figure 1D).
Appearance of the wound after initial debridement. The damaged skin area was resected, resulting in a 10x10-cm defect. The tip of the fibula is shown (white line). Both peroneus longus and brevis tendons were severely damaged and resected. The distal stump of the peroneus tendon is indicated (arrow).
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The damaged skin area was resected, resulting in a 10x10-cm defect (Figure 2).
Reconstruction of lateral ankle ligaments. (A) Two bone tunnels were made on the distal fibula, and the semitendinosus tendon graft (arrows) was passed through the tunnels. The proximal (*) and distal (**) stumps of the peroneus tendons are indicated. (B) Schematic diagram of anterior talofibular ligament and calcaneofibular ligament reconstruction using the semitendinosus tendon graft.
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The semitendinosus graft was passed through one bone tunnel in an anterior-to-posterior direction and through another tunnel in a posterior-to-anterior direction using a passing wire (Figure 3A and B). Then, two perpendicular bone tunnels, merging in the talar neck, were made at the anterior border of the talar body. The proximal portion of the graft (ATFL) was passed through the tunnels, posteriorly to anteriorly, and then overlaid on itself (Figure 3B).
Reconstruction of both peroneal tendons. Both the peroneus longus and brevis tendons were reconstructed using gracilis tendon grafts. The superior peroneal retinaculum was repaired (arrowhead) to prevent dislocation of the tendons. The bone tunnel on the calcaneus for calcaneofibular ligament reconstruction is shown (*). The arrow indicates suture tape augmentation overlaying a reconstructed anterior talofibular ligament.
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While maintaining the foot in a neutral position, additional Pulvertaft weave suturing was performed between the distal stumps and grafts (Figure 4).
Coverage of the wound with the anterolateral thigh flap at 5 months after surgery.
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The perforators were connected with anterior tibial vessels, and the wound was closed (Figure 5).