Ankle

AIM Clinical determination of spasticity is confounded by the difficulty in distinguishing reflex from passive contributions to muscle stiffness. There is, therefore, a risk that children with cerebral palsy (CP) receive antispasticity treatment unnecessarily. To investigate this, we aimed to determine the contribution of reflex mechanisms to changes in the passive elastic properties of muscles and tendons in children with CP.

Charcot arthropathy of the rearfoot and ankle is a complex disorder. To date there are no evidence-based, universally agreed upon treatment protocols. As the number of patients who have these deformities continues to increase, surgeons' skill levels and experience grow as well. With increased technical skill, knowledge, and advances in fixation, these deformities are becoming more manageable. In the future this experience should afford the general community with evidenced-based protocols. This article discusses basic techniques in deformity planning and current uses of internal and external fixation techniques for rearfoot and ankle limb salvage.

Robotic technologies are being employed increasingly in the treatment of lower limb disabilities. Individuals suffering from stroke and other neurological disorders often experience inadequate dorsiflexion during swing phase of the gait cycle due to dorsiflexor muscle weakness. This type of pathological gait, mostly known as drop-foot gait, has two major complications, foot-slap during loading response and toe-drag during swing. Ankle foot orthotic (AFO) devices are mostly prescribed to resolve these complications. Existing AFOs are designed with or without articulated joint with various motion control elements like springs, dampers, four-bar mechanism, series elastic actuator, and so forth. This paper examines various AFO designs for drop-foot, discusses the mechanism, and identifies limitations and remaining design challenges. Along with two commercially available AFOs some designs possess promising prospective to be used as daily-wear device. However, the design and mechanism of ...

The lower extremity is a frequent site for malignant melanomas. However, skeletal metastases involving the foot and ankle are a rarity. Nearly all documented cases of secondary pedal bone metastasis have originated from a primary subungual melanoma. The following case study illustrates an unusual skeletal metastasis to the foot and ankle arising from a primary malignant melanoma of the torso.

Deficits in ankle muscle strength and ankle stiffness may be present in those subjects who underwent surgical treatment for an Achilles tendon rupture. The presence of these long-term deficits may contribute to a lower performance during daily activities and may be linked to future injuries. To compare the ankle passive stiffness and the plantar flexor muscle performance in patients who underwent unilateral surgical treatment of Achilles tendon rupture with nonsurgical subjects. Twenty patients who underwent unilateral surgical treatment of Achilles tendon rupture [surgical (SU) group], and twenty nonsurgical subjects [non-surgical (NS) group] participated in this study. The ankle passive stiffness was evaluated using a clinical test. The concentric and eccentric plantar flexors performance (i.e. peak torque and work) was evaluated using an isokinetic dynamometer at 30°/s. The surgical ankle of the surgical group presented lower stiffness compared to the non-surgical ankle (mean dif...

Los huesecillos accesorios del pie son variaciones anatómicas normales de infrecuente importancia clínica. Se sitúan en los sitios de los centros de osificación secundarios del tarso y metatarso. Desde su primera descripción en la literatura científica en 1804, el os trigonum ha sido un frecuente tema de debate por diversos aspectos, de la etiología al tratamiento. Presentamos un raro caso de un os trigonum doloroso con hallazgos clínicos más evidentes que lo habitual. El huesecillo fue extirpado mediante cirugía abierta con alivio completo de los síntomas. Se discuten brevemente algunas peculiaridades históricas, el diagnóstico, el diagnóstico diferencial, los hallazgos clínicos y las modalidades terapéuticas.

Tourniquet use in foot and ankle surgery is common practice; however, the technique varies among foot and ankle surgeons and there are no standard guidelines. To analyze trends in foot and ankle tourniquet use, the authors conducted an e· mail sUlVey. One thousand six hundred sixty-five foot and ankle surgeons were sent a tourniquet-use survey via a-mail, across Canada and the United States. Nineteen percent of the recipients completed and returned the surveys. Eleven (3.4%) rarefy or never use a tourniquet and 8 (2.5%) use an Esmarch bandage toumiquet at the ankle. Most use pneumatic ankle cuffs (92% use, 27% use exclusively); many also use thigh cuffs (69%) and some a/so use calf cuffs (15 %). Most thigh-cuff users (62%) experience problems with cuff fit sometimes or often. All but 3 respondents exsanguinate the limb before tourniquet inflation. Specific devices used for exsanguination varied among surgeons. Most commonly used tourniquet pressures range from s 200 to 350 mm Hg at the ankle and s 200 to 2:.351 mm Hg for the thigh (64% use pressures between 301 and 350 mm Hg). Only 7% of respondents consider limb occlusion pressure when selecting tourniquet cuff pressure. Based on published studies of limb occlusion pressures, these ranges suggest that some of the more common pressure settings may be higher than necessary for many patients. Vascular disease or previous bypass (91 %) and deep vein thrombosis (83%) were the most commonly listed contraindications to tourniquet use. Approximately 10% of respondents have either experienced or learned of skin and nerve injuries secondary to lower extremity tourniquet use at any level. The varied responses show a lack of overall consensus on tourniquet pressure settings. Guidelines for optimizing cuff pressure and technique should be established to minimize the risk of complications.

Children with cerebral palsy (CP) have difficulty controlling and coordinating voluntary muscle, which results in poor selective control of muscle activity. Children with spastic CP completed ankle selective motor control exercises using a virtual reality (VR) exercise system and conventional (Conv) exercises. Ankle movements were recorded with an electrogoniometer. Children and their parents were asked to comment on their interest in the exercise programs. Greater fun and enjoyment were expressed during the VR exercises. Children completed more repetitions of the Conv exercises, but the range of motion and hold time in the stretched position were greater during VR exercises. These data suggest that using VR to elicit or guide exercise may improve exercise compliance and enhance exercise effectiveness.

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Squamous cell carcinoma (SCC) is a rare but well-documented complication of chronic osteomyelitis. Between February 1991 and March 1999, 13 cases (12 men and one woman) of SCC arising in chronic osteomyelitis were diagnosed and treated in our clinic. Mean age was 56.5 (38–70) years. Twelve patients underwent amputation and one underwent limb salvage. Average follow-up was 56 (24–121) months. Among the 13 patients two died of the disease. Treatment of choice for these tumours has been amputation. Carcinome cellulaire squameux est une complication d'ostéomyélite, peu fréquente, mais bien connue. Entre le février 91–mars 99, dans notre clinique, nous ont constate 13 malades (12 hommes et 1 femme) a qui nous ont vu la maladie développe a la base d'ostéomyélite chronique. L'age moyen était 56.5. (38–70) 12 malades ont subi une amputation et dans l'autre l'extrémité a été gardée. La surveillance a duré à peu près 56 (24–121) mois. Parmi ces 13 malades seulement deux sont morts. Pour ces tumeurs on peut dire que l'amputation est la méthode la plus efficace.

curve fit of the two parameters. Also included is the relation between the tube hematicrit and the feed hematcrit, upon which the data was based. Thus it is not necessary to consider such complicated effects for the two-fluid model. For in vivo experiments with blood vessels instead of glass tube, the experiments show higher apparent viscosity, probably due to the uneven glycocalyx wall. The curves however can be fitted similarly.

Background: Tendon transfers are commonly used for correction of pathology or deformity of the foot and ankle. Bioabsorbable implants have been developed as an alternative to metal interference screws. The purpose of this study was to document complications following tendon transfers of the foot and ankle using bioabsorbable poly-L-lactide interference screws. Methods: A retrospective chart review was used to identify patients in whom either of the 2 senior authors had performed a tendon transfer of the foot and ankle using a bioabsorbable interference screw between 1999 and 2005. A minimum of 6 months of follow-up was required for inclusion in the study. In all, 31 patients were identified who met the inclusion criteria with an average follow-up of 75 weeks. All screws were made of poly-L-lactide (PLLA). Results: Complications were identified in 12 (39%) of patients. All of the complications reported were known complications of the tendon transfer procedure itself, and were not directly related to the bioabsorbable screw. Conclusions: Based on these early results, PLLA implants appear safe and effective for tendon transfers of the foot and ankle. However, until long-term outcomes are available, judicious use of these implants is recommended. Level of Evidence: Level IV, retrospective case series.

The aims of the present study were to quantify the impairment in ankle coactivation on the paretic and non-paretic sides of subjects with hemiparesis and to examine the relationship of ankle coactivation with postural instability, motor deficit of the paretic lower extremity and locomotor performance. Electromyography of the medial gastrocnemius (MG) and tibialis anterior (TA) muscles were recorded bilaterally during gait in 30 subjects (62.1±9.9 years) who had suffered a recent stroke (Ͻ6 months) as well as on one side of 17 healthy controls (59.3±9.1 years) walking at very slow speed. Ankle muscle coactivation was calculated by dividing the time of overlap between MG and TA signals (threshold of 20 µV) by the duration of the gait phases of interest: stance, swing, first and second double support sub-phases and single support sub-phase. The time spent in single support and the peak plantarflexor moment of force on the paretic side were used to measure, respectively, postural stability and dynamic strength of the paretic plantarflexors. The subjects with hemiparesis demonstrated less coactivation on the paretic side during the single support sub-phase (pϽ0.01) and more coactivation during first and second double support sub-phases on the non-paretic side (pϽ0.001) compared to control values. The patients with coactivation patterns that differed the most from controls were the patients with the more severe impairments and disabilities. While the reduced coactivation on the paretic side may contribute to poor postural stability and poor locomotor performance, the presence of excessive coactivation on the non-paretic side when both limbs were in ground contact may be an adaptation to help maintain postural stability during gait.

Extracellular (ECW) and intracellular (ICW) volumes were measured using both segmental and wrist-ankle (W-A) bioimpedance spectroscopy (5-1000 kHz) in 15 healthy subjects (7 men, 8 women). In the 1st protocol, the subject, after sitting for 30 min, laid supine for at least 30 min. In the second protocol, the subject, who had been supine for 1 hr, sat up in bed for 10 min and returned to supine position for another hour. Segmental ECW and ICW resistances of legs, arms and trunk were measured by placing four voltage electrodes on wrist, shoulder, top of thigh and ankle and using Hanai's conductivity theory. W-A resistances were found to be very close to the sum of segmental resistances. When switching from sitting to supine (protocol 1), the mean ECW leg resistance increased by 18.2%, that of arm and W-A by 12.4%. Trunk resistance also increased but not significantly by 4.8%. Corresponding increases in ICW resistance were smaller for legs (3.7%) and arm ( 0.7%) but larger for the trunk (21.4%). Total body ECW volumes from segmental measurements were in good agreement with W-A and Watson anthropomorphic correlation. The decrease in total ECW volume (when supine) calculated from segmental resistances was at 0.79 l less than the W-A one (1.12 l). Total ICW volume reductions were 3.4% (segmental) and 3.8% (W-A). Tests of protocol 2 confirmed that resistance and fluid volume values were not affected by a temporary position change.

measurement. 7bepurpose of th & desc@tive study was to quantzfi the work that & accomplished by major muscle groups of the afected limb of 10 children with spasic herniplegia secondaty to cerebral palsy during walking. Cinematographic film and fmceplate data were used in a biomecbanical lid-segment model to calculate the positive Gait analysis of chldren with cerebral palsy (CP) has been used to study the basic biomechanics of their walking, which, in turn, has assisted in thera-peutic and surgical decision making.l-6 Recent developments in the technol-ogy used in gait analysis and the ready availability of high-speed com-puters at modest cost have made possible certain analyses that were known but not feasible. One of these analyses is the determination of instantaneous power and work accomplished by the muscle groups crossing major joints.

Doubt about the role of stretch reflexes in movement and posture control has remained in part because the questions of reflex "usefulness" and the postural "set" have not been adequately considered in the design of experimental paradigms. The intent of this study was to discover the stabilizing role of stretch reflexes acting upon the ankle musculature while human subjects performed stance tasks requiring several different postural "sets". Task specific differences of reflex function were investigated by experiments in which the role of stretch reflexes to stabilize sway during stance could be altered to be useful, of no use, or inappropriate.

A traditional knee-ankle-foot orthosis (KAFO) for myopathic patients has been studied for the assessment of loads and fatigue resistance. Starting from this basis a thermoplastic matrix carbon fibre reinforced plastic composite (CFRP) KAFO has been developed in order to reduce the weight. A finite-element simulation programme for deformation analysis was used to compare the behaviour of conventional and CFRP orthosis. There were no breakages either of the prototype or of its parts. The CFRP orthosis allows a weight reduction of more than 40 per cent.

This study aimed to examine player perceptions and biomechanical responses to tennis surfaces and to evaluate the influence of prior clay court experience. Two groups with different clay experiences (experience group, n = 5 and low-experience group, n = 5) performed a 180° turning movement. Three-dimensional ankle and knee movements (50 Hz), plantar pressure of the turning step (100 Hz) and perception data (visual analogue scale questionnaire) were collected for two tennis courts (acrylic and clay). Greater initial knee flexion (acrylic 20. 8 ± 11.2° and clay 32.5 ± 9.4°) and a more upright position were reported on the clay compared to the acrylic court (P < 0.05). This suggests adaptations to increase player stability on clay. Greater hallux pressures and lower midfoot pressures were observed on the clay court, allowing for sliding whilst providing grip at the forefoot. Players with prior clay court experience exhibited later peak knee flexion compared to those with low experie...

Objectives: Near-Infrared Spectroscopy (NIRS), suitable for dynamic measurements, is not routinely used for peripheral arterial disease (PAD). We propose a dynamic NIRS-based measurement to quantify variations in muscle metabolism in PAD. Method: Sixty-seven consecutive PAD patients (males Z 56, age 71.6 AE 8.7 years) and 28 healthy subjects (males Z 12, age 30.4 AE 11.9 years) were studied. An echo-colour Doppler (ECD) was performed and the ankleebrachial index (ABI) was calculated. Participants performed an incremental treadmill test with NIRS probes on the gastrocnemius. Variations in oxygenated (HbO 2 ), deoxygenated (HHb), total (tHb Z HbO 2 þ HHb), and differential (dHb Z HbO 2 À HHb) haemoglobin were recorded and quantified as area-under-curve (AUC) within the range 1.7e3.0 km h À1 . Heart rate was recorded, and the number of beats in the same interval was calculated (dHr). Results: O 2 Hb AUC , HHb AUC and dHb AUC differed between diseased and non-diseased legs (P < 0.0001) and exhibited different patterns related to PAD severity according to the ABI value. A compensatory heart rate increase was observed in PAD patients. Compared with the ECD positivity for occlusions/stenoses or multiple plaques, only the receiver-operating characteristic (ROC) analysis of dHb AUC (area Z 0.932, P < 0.0001) showed a sensitivity/specificity of 87.6/93.4 for values À197 (LR þ LRÀ: 13.36/0.13). Conclusion: The dynamic NIRS-based test, quantifying muscle metabolic response according to presence and degree of PAD, allows the evaluation of patients with walking disabilities. ª

The aim of the present study was to examine isokinetic and isometric strength of the knee and ankle muscles and to compare center of pressure (CoP) sway between blind and sighted women. A total of 20 women volunteered to participate in this study. Ten severe blind women (age 33.5 ± 7.9 years; height 163 ± 5 cm; mass 64.5 ± 12.2 kg) and 10 women with normal vision (age 33.5 ± 8.3 years; height 164 ± 6 cm; mass 61.9 ± 14.5 kg) performed 3 different tasks of increasing difficulty: Normal Quiet Stance (1 min), Tandem Stance (20 s), and One-Leg Stance (10 s). Participants stood barefoot on two adjacent force platforms and the CoP variations [peakto-peak amplitude (CoPmax) and SD of the CoP displacement (CoPsd)] were analyzed. Sighted participants performed the tests in eyes open and eyes closed conditions. Torque/angular velocity and torque/angular position relationships were also established using a Cybex dynamometer for knee extensors and flexors as well as for ankle plantar and dorsiflexors. The main finding of this study was that the ability to control balance in both anterior/posterior and medio/lateral directions was inferior in blind than in sighted women. However, when sighted participants performed the tests blindfolded, their CoP sway increased significantly in both directions. There were no differences in most isometric and concentric strength measurements of the lower limb muscles between the blind and sighted individuals. Our results demonstrate that vision is a more prominent indicator of performance during the postural tasks compared to strength of the lower limbs. Despite similar level of strength, blind individuals performed significantly worse in all balance tests compared to sighted individuals.

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The incidence of postoperative surgical site infection (SSI) reported in the published data for foot and ankle surgery has been 1.0% to 5.3%. A variety of interventions have been used before, during, and after surgery to decrease the patient's risk of acquiring an infection at the surgical site. Foot and ankle surgeons often keep the incision site dry and covered until the sutures and pins have been removed, with the goal of preventing a SSI, despite the lack of available published evidence to support this practice. We undertook a prospective observation of 110 elective surgical patients to determine the rate of SSI when early surgical site exposure and showering were allowed. The risk factors for infection were recorded, and a series of logistic regression analyses was performed to determine the associations between the infection rate and early showering. The patients were evaluated at each postoperative appointment for signs of infection. For the present study, mild infection was defined as the subjective presence of erythema and/or swelling beyond that typically expected in the early postoperative period. These cases of presumed or mild SSI were managed with oral antibiotics until they had resolved. Major infection was defined as any infection altering the course of recovery or requiring admission or additional surgery. The overall infection rate was 4.5%, with all infections considered mild. Logistic regression analysis showed that none of the recorded risk factors significantly predicted infection. The results of the present study suggest that early daily showering of a surgical site after foot and ankle surgery will not be significantly associated with an increased risk of infection.

The deltoid ligament has both superficial and deep layers and consists of up to six ligamentous bands. The prevalence of the individual bands is variable, and no consensus as to which bands are constant or variable exists. Although other studies have looked at the variance in the deltoid anatomy, none have quantified the distance to relevant osseous landmarks.

During human walking, the center of pressure under the foot progresses forward smoothly during each step, creating a wheel-like motion between the leg and the ground. This rolling motion might appear to aid walking economy, but the mechanisms that may lead to such a benefit are unclear, as the leg is not literally a wheel. We propose that there is indeed a benefit, but less from rolling than from smoother transitions between pendulum-like stance legs. The velocity of the body center of mass (COM) must be redirected in that transition, and a longer foot reduces the work required for the redirection. Here we develop a dynamic walking model that predicts different effects from altering foot length as opposed to foot radius, and test it by attaching rigid, arc-like foot bottoms to humans walking with fixed ankles. The model suggests that smooth rolling is relatively insensitive to arc radius, whereas work for the step-to-step transition decreases approximately quadratically with foot length. We measured the separate effects of arc-foot length and radius on COM velocity fluctuations, work performed by the legs and metabolic cost. Experimental data (N=8) show that foot length indeed has much greater effect on both the mechanical work of the step-to-step transition (23% variation, P=0.04) and the overall energetic cost of walking (6%, P=0.03) than foot radius (no significant effect, P>0.05). We found the minimum metabolic energy cost for an arc foot length of approximately 29% of leg length, roughly comparable to human foot length. Our results suggest that the foot's apparently wheel-like action derives less benefit from rolling per se than from reduced work to redirect the body COM.

A 56-YEAR-OLD WOMAN presented with a 5-year history of a relapsing dermatitis confined to the ankles. Physical examination showed a bilateral, sharply demarcated eruption with erythema, edema, vesicles, and bullae limited to the area covered by her socks . The biopsy results were consistent with spongiotic dermatitis. Immunofluorescence study results were negative. Patch test studies included the standard, corticosteroid, and rubber additive trays. Patch tests were applied to the back using IQ chambers. Only the nickel sulfate patch test elicited a positive result that had a past relevance. Results of patch tests to 2 samples of the patient's socks were + + + positive .

This study examines the roles of somatosensory and vestibular information in the coordination of postural responses. The role of somatosensory information was examined by comparing postural responses of healthy control subjects prior to and following somatosensory loss due to hypoxic anesthesia of the feet and ankles. The role of vestibular information was evaluated by comparing the postural responses of control subjects and patients with bilateral vestibular loss. Postural responses were quantified by measuring 1) spatial and temporal characteristics of leg and trunk EMG activation; 2) ankle, knee, and hip joint kinematics, and 3) surface forces in response to anterior and posterior surface translations under different visual and surface conditions. Results showed that neither vestibular nor somatosensory loss resulted in delayed or disorganized postural responses. However, both types of sensory deficits altered the type of postural response selected under a given set of conditions. Somatosensory loss resulted in an increased hip strategy for postural correction, similar to the movement strategy used by control subjects while standing across a shortened surface. Vestibular loss resulted in a normal ankle strategy but lack of a hip strategy, even when required for the task of maintaining equilibrium on a shortened surface. Neither somatosensory nor vestibular loss resulted in difficulty in utilizing remaining sensory information for orientation during quiet stance. These results support the hypothesis that cutaneous and joint somatosensory information from the feet and ankles may play an important role in assuring that the form of postural movements are appropriate for the current biomechanical constraints of the surface and/or foot. The results also suggest that vestibular information is necessary in controlling equilibrium in a task requiring use of the hip strategy. Thus, both somatosensory and vestibular sensory information play important roles in the selection of postural movement strategies appropriate for their environmental contexts.

We report a rare case of Kager's fat pad atrophy and fibrosis in a 60-year-old woman 1 year after a steroid injection for Achilles tendinopathy. There are few published reports of steroid-induced atrophy affecting deeper layers of fat tissue. To our knowledge, this case report is the first to illustrate its features using magnetic resonance imaging. A review of the scientific literature is also presented.

The purpose of this paper is to highlight the motor mechanisms involved in balance as the human, as a biped, continuously defends against gravitational and internal forces to maintain a safe posture. The search for these mechanisms needs precise and valid 3D measurements including both limbs plus valid biomechanical models. The literature shows the need for two force platforms to separate the mechanisms at the ankle and hip (load/unload mechanism). Also, precise measures (Ϸ0.03 mm) of markers on a multi-segment 3D bilateral model are required to record the minute trajectories of all segments and joints. The controlled variable, center-of-mass, is seen to be virtually in phase with the controlling variable, the center-of-pressure, which suggests a 0th order system where a simple series elastic spring could maintain balance. The first model involves a mass/spring/damper of medial/lateral balance: the stiffness was varied with stance width and the predicted sway from a spring controlled inverted pendulum closely matched the experimentally measured stiffness and sway. The second was a non-linear model of the plantarflexor series elastic elements which resulted in three closely validated predictions of anterior/posterior balance: the locus of the gravitational load line, the predicted ankle moment and the ankle stiffness at the operating point. 

Although several studies have demonstrated that motor imagery can enhance learning processes and improve motor performance, little is known about its effect on stretching and flexibility. The increased active and passive range of motion reported in preliminary research has not been shown to be elicited by motor imagery training alone. We thus compared flexibility scores in 21 synchronized swimmers before and after a 5-week mental practice programme that included five stretching exercises in active and passive conditions. The imagery training programme resulted in selective increased flexibility, independently of the stretching method. Overall, the improvement in flexibility was greater in the imagery group than in the control group for the front split (F 1,18 ¼ 4.9, P ¼ 0.04), the hamstrings (F 1,18 ¼ 5.2, P ¼ 0.035), and the ankle stretching exercises (F 1,18 ¼ 5.6, P ¼ 0.03). There was no difference in shoulders and side-split flexibility (F 1,18 ¼ 0.1, P ¼ 0.73 and F 1,18 ¼ 3.3, P ¼ 0.08 respectively). Finally, there was no correlation between individual imagery ability and improvement in flexibility. Psychological and physiological effects of motor imagery could explain the increase in range of motion, suggesting that imagery enhances joint flexibility during both active and passive stretching.

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Background: Soft tissue defects in the distal lower extremity present a formidable challenge due to the lack of reliable local flap options. Pedicled adipofasciocutaneous flaps provide the closest match to local tissues, but random pattern flaps are limited in reliability, size, reach, and arc-of-rotation. One hundred and eighty degree perforator-based propeller flaps are an innovative option because they provide robust axial perfusion to flaps with significantly greater surface area and ease of transposition versus that provided by their random pattern counterparts in these anatomic regions traditionally addressed with free tissue transfer. Case: We present a rare case of aggressive digital papillary carcinoma of the posteriolateral ankle and Achilles region. Wide local excision resulted in a defect with Achilles tendon exposure and denudation. A fasciocutaneous propeller flap based on a dominant peroneal artery perforator was raised and rotated 1808 to resurface the wound, providing a gliding surface for Achilles tendon function. The reconstruction was successful with no complications, excellent contour, and esthetic appearance. Conclusions: Peroneal perforator-based propeller flaps in the ankle region are useful local options providing unparalleled form and function, with excellent surface area and mobility, for dynamic areas of the lower extremity, without sacrificing any major vessels or nerves. This technique adds to the reconstructive microsurgeon's armamentarium for complex coverage of the ankle region.