Introduction: The open approach for releasing the A1 pulley shows high dissatisfaction rates. Percutaneous blind release is as an alternative achieving similar effectiveness and better results but the lack of visualization puts at risk the adjacent anatomy and its indicated only for the 3rd and 4th fingers. Recently, an effective percutaneous method for releasing A1 in every finger has been described assisted by the visualization with ultrasounds (US). Despite the reported safety, this US-technique poses a risk to the adjacent anatomy due the orientation of the blade. Our purposes were to develop a new percutaneous US-guided A1 release (USGAR) that lessens the risk to adjacent anatomic structures and to determine the precision, safety and efficacy of our USGAR.

Methods: To determine how to lessen the risk to adjacent structures, a descriptive study with a power-Doppler US (Logiq Book XP Pro 5–11 MHz, GE) was done in 100 fingers from 10 volunteers (3 females and 7 males; mean age 29,8 years, range 25–49 years). Measurements, on a transverse section of A1, included: lateral vascular angle (LVA), medial vascular angle (MVA), distance to lateral artery (DLA), distance to medial artery (DMA), lateral latitude (LL), medial latitude (ML), pulley thickness (PT) and synovial space width (SW).

A descriptive study was developed in 5 formaldehyde preserved cadavers, 50 fingers (3 men and 2 women, average age at time of death 60,6 years, range 52–81). US identification of topographic markings was followed by USGAR and open dissection. Measurements included real (RL) and US (UL) A1 length and distances from: markers to proximal (MP) and distal A1 edges (MD); markers to A2 (MA) and neurovascular (NV) bundles (MN); and from the surgical release to A2 (SA) and NV (SN). The length of any incomplete release (IR) and damage to adjacent structures were recorded. Mean values, Standard deviation and range were gathered. ANOVA was used to analyze differences (significant at p < 0.05).

Results: In our volunteers, we obtained the following values (degrees or mm): LVA, 20,9 +/− 14,03 (0/83,7); MVA, 23,3 +/−13,06 (0/61,5); DLA, 8,96 +/−3,08 (3,5/20,6); DMA, 7,59 +/−2,56 (3,7/16,8); LL, 2,38 +/−1,53 (−1/6,5); ML,: 2,56 +/−1,84 (0/10,8); PT, 0,79 +/−0,22 (0,2/1,5); SW, 0,33 +/−0,19 (0,1/0,9). Differences were not significant among fingers. In our group of cadavers our findings (mm) were: RL, 10,1 +/−1,36 (8/13); UL, 10,84 +/−1,38 (8/14); MP, −0,56 +/−1,3 (−5/2); MD, −0,19 +/−0,95 (−4/2); MA, 4,56 +/−1,64 (1/9); MN, 18,78 +/−4,11 (11/27); SA −1,08 +/−1,67 (−5/2); SN −13,17 +/−3,55 (−22/−6). There was a 1 mm IR in 2 fingers and minor puncture-like erosions in 6.

Conclussion: Our new method for USGAR minimizes the risk of accidental damage to adjacent anatomic structures. The method is precise, effective and safe in cadavers. This has set the bases for a clinical phase at our Institution.

We present in this work our experience with the sural fasciocutaneous flap to treat coverage defects following a lower limb posttraumatic lesion. This work is a review of the fasciocutaneous sural flaps carried out in different centres between 2000 and 2005. The series consist of 14 patients, 12 men and 2 women with an average age of 38 years (23–54) and with a medium follow-up time of 2 years (12–48 months). In all of the cases, aetiology was a lower limb injury being the most frequent the distal tibial fracture (eight patients), followed by sequelae from Achilles tendon reconstruction (two patients), fracture of the calcaneus (two patients) and osteomyelitis of the distal tibia (two patients) secondary to an open fracture. Associated risk factors in the patients for performing a fasciocutaneous flap were diabetes (1 case) and cigarette smoking (4 cases).

The technique is based on the use of a reverse-flow island sural flap with the superficial sural artery dependent on perforators of the peroneal arterial system. The anatomical structures which constitute the pedicle are the superficial and deep fascia, the sural nerve, external saphenous vein, superficial sural artery together with an islet of subcutaneous cellular tissue and skin.

The flap was viable in 13 of 14 patients. Only in one case, a diabetic patient, the graft failed. No patient showed signs of infection. Slight venous congestion of the flap occurred in two cases. No further surgical intervention of the donor site was required because of morbidity. In two cases partial necrosis of the skin edges occurred which resolved satisfactorily with conservative treatment.

The sural fasciocutaneous flap is useful for the treatment of complex injuries of the lower limbs. Its technical advantages are: easy dissection with preservation of more important vascular structures in the limb, complete coverage of the soft tissue defect in just one operation without the need of microsurgical anastomosis. All of that results in a well vascularised cutaneous islet and thus a reliable flap