Trauma to the heel is easy to cause the Achilles tendon or ankle joint exposure, as well as post-traumatic scar contracture of the heel has become a difficult point of clinical repair and plastic treatment, with the development of microsurgical technology and the depth of human anatomy research, the clinical often use flap transposition or flap transplantation to repair plastic wounds. Usually used flap, there is a bloated tip, sacrificing the more important blood vessels, nerves, and postoperative impact on the activities of the main muscle groups of the calf. In contrast, the posterior tibial artery medial superior ankle branch flap can better solve the above problems and minimize the damage. I. Clinical data and methods 1. General data 12 cases in this group, 7 males and 5 females, age 23-36 years old. Reasons for surgery: 5 cases of motorcycle wire strangulation, 4 cases of traffic accidents, 1 case of chronic ulcer, 2 cases of scar contracture. All cases were combined with Achilles fracture or Achilles tendon exposure after debridement or scar excision, 7 cases were combined with Achilles tendon injury, 2 cases were combined with Achilles fracture, and 2 cases were combined with wound infection. All of them were repaired by elective surgery in this group. 2.Surgical methods (1) Wound preparation Thoroughly remove wound infection and unhealthy scar tissue, preoperative routine wound bacterial culture plus drug sensitivity to guide the postoperative medication, Achilles fracture was fixed with Kirschner’s pin or dowel pin to repair the Achilles tendon. (2) Flap design Points: the point of penetration of all the skin branches of the posterior tibial artery on the inner ankle was detected by ultrasound Doppler flow detector before surgery, and usually 5cm or 7cm on the inner ankle was selected as the point of rotation; line: the line connecting the back of the inner ankle and the medial condyle of the femur was the axis; surface: between the lower edge of the patella and the upper edge of the inner ankle, and the anterior and posterior sides did not exceed the median line. After determining the points, lines and surfaces, the nearest distance from the point of rotation to the trauma was measured as the length of the vascular tip, the trauma-sized cloth sample was cut out, and the boundary of the flap was drawn in methylene blue. General vascular tip enlargement 1,0cm ~ 1,5cm, the flap put about 1,0cm, the vascular tip is designed as a tennis racket shape, the width of the tip in 1,5cm ~ 2,0cm or so. (3) Flap cutting Firstly, cut the vascular tip and the posterior edge of the flap, dissect to the deep fascia, find the posterior tibial artery between the flounder muscle and the toe flexor muscle, determine the point of penetration of the dermatomal branch, and then cut the anterior edge of the flap, dissect the flap under the deep fascia, and then ligate the proximal end of the saphenous vein, and carry the appropriate length of saphenous nerve in case of a larger cutting range. If conditions permit, the saphenous vein can be anastomosed with the subcutaneous co-current vein. The flap donor area was packed with tough and thick skin implantation and pressure, and the donor area with a diameter less than 5.0cm could be sutured directly. The 12 cases of flaps in the whole group all survived, of which 3 cases anastomosed the saphenous vein with the subcutaneous coexisting vein, 5 cases ligated the distal and proximal ends of the saphenous vein, and 6 cases ligated only the proximal end of the saphenous vein. The postoperative swelling of those who performed anastomosis of saphenous vein was less serious than those who didn’t perform anastomosis, and the swelling of flaps ligated at the distal and proximal ends of the saphenous vein was less serious than that of those who ligated the proximal end of the saphenous vein. The donor area grafts all healed in one stage. The postoperative follow-up was 6 to 12 months, and the flap had good blood circulation, soft texture, wear-resistant, non-bulky appearance, and satisfactory functional recovery. Typical case: Tang Mou, female, 36 years old. Motorcycle wire strangulation of the right heel after skin blackening necrosis for 34 days, the heel area can be seen in the size of about 3cm × 4cm skin blackening necrosis, and a little oozing, preoperative trauma bacterial culture sent to the test, after expanding the wound, the heel head is exposed, the skin and soft tissue defects of about 4cm × 6cm, the design of the area of 5cm × 7cm posterior tibial artery supra-ankle flap repair, the rotational point is located in the inner ankle at the top of the 5cm, the donor area direct The donor area was sutured directly. After surgery, the flap survived, the wound healed in one stage, and the foot shape and function recovered satisfactorily. Anatomical basis of posterior tibial artery supraspinatus flap Huang Jifeng et al. found that the posterior tibial artery was penetrated by the musculocutaneous artery in the medial aspect of the calf at a distance of 5cm-12cm, 15cm-18cm, and 22cm-24cm from the tip of the medial ankle. Zhang Huifa et al. studied 30 cases of adult lower limb specimens with intra-arterial infusion of red latex and found that there was stable perforation of the interosseous cutaneous branch of the posterior tibial artery at 3,0±1,1cm, 6,2±1,4cm, and 8,6±+1,4cm above the most prominent point of the medial ankle with the rate of occurrence of the three branches reaching 86.6%, and that the outer diameter was 0,5mm-2,5mm, and there were osteocutaneous perforating branches emanating from the medial side of the calf at about 5,0cm, 9,0cm, which is the most prominent point of the medial ankle. There were osteocutaneous perforating branches emanating, which provided a reliable anatomical basis for the posterior tibial artery supra-ankle cutaneous branch flap. In this group of cases, ultrasound Doppler flow detector was used to detect the perforation points of all the percutaneous branches of the posterior tibial artery on the medial malleolus before surgery, and it was confirmed that the perforation points were basically 5 cm to 7 cm above the medial malleolus, and the flap area was the largest at 14 cm×8 cm, and the flaps had good blood flow after surgery. The treatment of the saphenous vein in the posterior tibial artery epithelial branch flap The treatment of the saphenous vein in the posterior tibial artery epithelial branch flap varies, but the anastomosis of the saphenous vein with the subcutaneous co-current vein of the affected area can maintain the flap in a benign state of “perfusion and flow,” take away the hazardous substances in the flap, and reduce the edema of the flap, which is certainly a good idea. It is certain that the saphenous vein is in a “perfused and flowing” state. As for whether the saphenous vein is ligated at the tip of the vessel, it is generally believed that the saphenous vein is the main refluxing vein of the foot, and ligation can reduce the venous perfusion of the flap and alleviate the pressure of venous reflux of the flap. However, Sasa found that arterial blood oxygen is generally only 25%-30% utilized in tissue cells, while venous blood oxygen can meet the needs of tissue cells, so retaining the saphenous vein at the tip is conducive to the survival of the flap. The results of blood gas analysis in the experiments of Song Jianxing et al. showed that there was an exchange of nutrients between the venous blood and the flap tissue. In this group, only the proximal end of the saphenous vein was ligated in 6 cases, and the postoperative flap had good blood flow. Although the swelling of the flap was more serious than that of the distal and proximal ligated ones, the authors believed that it would not affect the survival of the flap, and on the contrary, it might help to nourish the flap and improve the survival rate of the flap in the first 3-4 d after surgery. Advantages and disadvantages of posterior tibial artery epithelial branch flap in the repair of heel skin and soft tissue defects Tang Juyu et al. found that, among the various surgical methods for the repair of heel skin and soft tissue defects, the posterior tibial artery epithelial branch flap has a better texture, is more resistant to abrasion, and can be used to partially repair sensation, and the shape of the flap is not bulky after surgery, so that it does not affect the ability to wear shoes; the vascular outlet is more stable, and the outer diameter is more stable. The flap has a stable point of exit, large outer diameter, reliable blood supply, without sacrificing important blood vessels, safe and easy surgery; more importantly, in the repair of small heel defects, the donor area can be sutured directly; and does not affect the activities of the main calf muscles. However, for large defects, the donor area needs a phase of skin grafting, which affects the aesthetics after surgery. Surgical considerations The following aspects should be noted in the repair of heel skin and soft tissue defects: ① Preoperative ultrasound Doppler flow detector to detect all the skin branches of the posterior tibial artery on the ankle, in order to prevent the emergence of a high level of the skin branch penetration point during the operation. Intraoperatively, all intermuscular skin-penetrating branches of the posterior tibial artery were preserved as much as possible, and the free or retrograde island flap of the posterior tibial artery could be carried instead for repair if necessary. ② Dissecting the flap usually starts from the vascular tip first, and the posterior edge of the flap is incised to clarify the position of the posterior tibial artery skin perforating branch, which is conducive to better cutting of the flap. ③ Because of the short vascular tip of the flap, the flap is designed to be as racket-shaped as possible when the tip is designed, and the open channel transfer is used. ④ The condition of the recipient area allows anastomosis of the saphenous vein and saphenous nerve as much as possible, which is conducive to postoperative flap management and flap sensation recovery.