Application of antibiotic bone cement combined with lobulated perforator flap based on descending branch of the lateral circumflex femoral artery in treatment of infected traumatic tissue defects of foot
Defects of the foot can arise from various causes, including trauma, ulceration, and thermal injuries, with trauma being the primary etiology . Soft tissue defects of the foot, associated with high-impact injuries and commonly accompanied by complicated infection, usually involve exposure of tendon, bone, and neurovascular structures, which pose significant challenges to orthopedic and plastic surgeons in determining an optimal treatment strategy for rapid infection control and wound healing . The main treatment method for these defects is skin flap repair. The anterolateral thigh flap (ALT) has become one of the most popular options due to its ease of harvesting, large cutaneous area with a long vascular pedicle, and acceptable donor site morbidity . For the reconstruction of extensive or irregular defects, the lobulated flap is an ideal choice because it allows flexible applications to match the contours and needs of the recipient site. The d-LCFA (Descending lateral circumflex femoral artery) lobulated perforator flap is a special type of ALT flap with two or more flap lobes, which are supplied by different branches of vessels originating from the descending lateral circumflex femoral artery. During the transplantation process, only one set of vessels requires anastomosis to reestablish blood circulation, thus reducing the operation time. Infection control and temporary coverage of wounds are both crucial procedures before flap transplantation. Vacuum sealing drainage (VSD) has been widely applied in dealing with open wounds . Zhang et al.  reported that the antibiotic bone cement offers similar clinical outcomes in the management of soft tissue defects, while providing the advantage of lower cost and reduced nursing requirements. Previous studies have shown that the antibiotic bone cement acts as a barrier between the wound and the external environment, maintaining an antibacterial environment by releasing a high concentration of antibiotics at the site of infection . And antibiotic bone cement has been commonly applied in the treatment of osteomyelitis and diabetic foot ulcers . However, by reviewing the literature, it has been found that there are relatively few studies on the sequential treatment of infected traumatic soft tissue defects in the foot with antibiotic bone cement followed by skin flap transplantation. The purpose of this study is to present our clinical experience in infection control and wound repair with the application of the d-LCFA lobulated perforator flap and antibiotic bone cement for reconstruction of infected traumatic defects in the foot. 

This study retrospectively analysed patients diagnosed with infected traumatic soft tissue defects of the foot in Liaocheng People’s Hospital from December 2019 to November 2022, with approval from the Medical Ethics Committee. All patients were informed of their condition and surgical plan, informed consent was signed prior to operation. Inclusion criteria: (a) Foot wounds with refractory infections unresponsive to conservative management with wound dressings and antibiotics. (b) Exposure of underlying vital structures including tendons, bones, nerves, or vessels in the foot, necessitating skin flap repair. (c) Patients consent to the surgical plan involving the application of the d-LCFA lobulated perforator flap and antibiotic bone cement. Exclusion criteria: (a) Patients with lower extremity arterial occlusive diseases in which no recipient vessel can be detected, or those who are unsuitable for free flap operation due to surgical contraindications. (b) Cases in which the width of the anterolateral thigh flap is estimated to be less than 8 cm, allowing direct suturing at the donor site. (c) Patients undergoing long-term steroid therapy for chronic diseases. A total of 10 patients were enrolled in this study, consisting of 6 males and 4 females. The ages ranged from 21 to 67 years, with a mean age of 32.6 years. The causes of injuries were motor vehicle accidents in 7 cases and machine crush injuries in 3 cases. The bacterial culture of the wound exudate or necrotic tissue confirmed the presence of bacteria, establishing the diagnosis of infection. There were 2 cases of Staphylococcus aureus infection, 2 cases of Pseudomonas aeruginosa infection, 1 case of Enterococcus gallinarum infection, 2 cases of Enterobacter cloacae infection, and 3 cases of mixed infection. Operative technique Preoperative preparation: Empirical antibiotics were applied following a comprehensive evaluation of the injury etiology and the wound exudate characteristics . The wound exudates and necrotic tissues were detected with bacterial culture and drug susceptibility tests. Based on the results of drug susceptibility tests, antibiotics were selected for preparation and subsequent mixing with the bone cement intraoperatively. Additionally, inflammatory indicators, including routine blood tests, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin (PCT), were closely monitored. Patients were informed about the treatment plan and anticipated timeline, bolstering their confidence in conquering the disease. Debridement: A thorough surgical debridement was performed with complete resection of the necrotic tissue and inflammatory granulation. The clinical presentation and viability of exposed soft tissues must be carefully evaluated. In cases of bone infection, adequate bone debridement was deemed essential. Meticulous hemostasis was performed and the wounds were irrigated repeatedly with large volumes of normal saline. The irrigation volume should not be less than 9,000 ml . Preparation of antibiotic bone cement: Based on the results of preoperative bacterial culture and drug susceptibility tests, the appropriate antibiotic was selected. Current studies indicate that bone cement containing gentamicin offers a broader antibacterial spectrum and longer release duration, making it the preferred option for Gram-negative bacterial infections . Vancomycin has become the first-line antibiotic for Gram-positive bacterial infections due to its superior physicochemical properties, including a broad antibacterial spectrum, good thermal stability, and low incidence of adverse reactions . The ratio of vancomycin to bone cement was 1:10, that is, 4 g of vancomycin was mixed with 40 g of bone cement. The ratio of gentamicin to bone cement was 1:20, which means that 2 g of gentamicin was mixed with 40 g of bone cement. In case of mixed infections, 40 g of bone cement was mixed with 4 g of vancomycin and 2 g of gentamicin. In clinical practice, the latter two applications are more prevalent. After thoroughly mixing the bone cement and antibiotics, the antibiotic bone cement was applied to completely cover the wound with all deep cavities filled, including the medullary cavity and soft tissue gaps. A honeycomb-shaped structure can be constructed with a small curette to achieve effective drainage. It is imperative to frequently rinse the bone cement with saline to avoid thermal injury and the cement was sutured to the surrounding skin prior to solidification. The affected area was then covered with dry sterile dressings and secured with an elastic bandage to maintain the position of the bone cement. Treatment after debridement: Following the operation, intravenous antibiotics were prescribed according to drug susceptibility tests. Inflammatory indicators such as CRP, ESR, PCT, and routine blood tests were monitored within 48 to 72 h after surgery. Normalization of the CRP level indicated successful infection control, allowing discontinuation of antibiotics. The dressing changes were performed at intervals of 4 to 7 days to maintain the dressing in a clean and dry state, while adhesion of the bone cement and the presentation of redness or exudate around the wounds were observed. In case of increased wound exudate, a more frequent schedule of dressing changes is required. In the absence of abnormal signs in the wound, patients were encouraged to engage in weight-bearing activities with the assistance of crutches and forefoot or hindfoot offloading shoes. Pain management and prevention of complications such as deep vein thrombosis were also integral parts of postoperative management. When the inflammatory indicators returned to normal levels within 4 weeks, the infections were considered eradicated and the flap transplantation could be performed to close the wound. Among the 10 cases in this group, 9 cases achieved effective control with single debridement combined with antibiotic bone cement coverage and intravenous antibiotics for 5–6 days. One case required debridement twice due to the presentation of redness, swelling, and exudation around the wound. All 10 patients were discharged after infection control, and regular outpatient follow-up visits were performed at 7-day intervals to monitor CRP, PCT, and ESR levels. In the absence of abnormalities, patients were readmitted at 4 weeks post-debridement for skin flap repair surgery. d-LCFA perforator flap repair surgery: The d-LCFA perforator flap technique entailed lower limb computed tomography angiography (CTA) to evaluate arterial patency and perforator vessel distribution. The perforating locations of the cutaneous branches from the descending branches of the lateral circumflex femoral artery were identified via color Doppler ultrasound, located approximately around the midpoint between the anterior superior iliac spine and the superolateral patellar corner . The maximum feasible flap size was assessed through a pinch test. A template was then designed to conform to the dimension and contour of the wound, divided into two sections, each with a width that allows for direct suturing of the donor site. The flap was delineated at the donor site based on the perforator location and the template. Considering the potential variability in perforator positions, the medial edge of the flap was incised initially. Multiple perforators were preserved in each lobe until the main perforator was identified. The deep fascia was then dissected and the perforators were traced back to the descending branch of the lateral circumflex femoral artery, which lies between the vastus lateralis and the rectus femoris. Subsequently the lateral edge of the flap was incised, and the dissection proceeded from lateral to medial at the superficial fascial plane. The lateral femoral cutaneous nerve in the flap was preserved. The flap leaves were dissected and spliced side by side to match the dimension of the recipient site. The pedicles of blood vessels in the flap were anastomosed end-to-end or end-to-side with vessels in the recipient site. Sensory perception was reestablished by cutaneous nerve anastomosis. Adequate hemostasis was achieved at the donor site before primary wound closure. Postoperatively, antispasmodics and anticoagulants were administered for one week, and the blood supply of the flap was monitored with symptomatic treatment as needed. At the final follow-up examination, pain intensity and functional outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. 

Preoperative preparation: Empirical antibiotics were applied following a comprehensive evaluation of the injury etiology and the wound exudate characteristics . The wound exudates and necrotic tissues were detected with bacterial culture and drug susceptibility tests. Based on the results of drug susceptibility tests, antibiotics were selected for preparation and subsequent mixing with the bone cement intraoperatively. Additionally, inflammatory indicators, including routine blood tests, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin (PCT), were closely monitored. Patients were informed about the treatment plan and anticipated timeline, bolstering their confidence in conquering the disease. Debridement: A thorough surgical debridement was performed with complete resection of the necrotic tissue and inflammatory granulation. The clinical presentation and viability of exposed soft tissues must be carefully evaluated. In cases of bone infection, adequate bone debridement was deemed essential. Meticulous hemostasis was performed and the wounds were irrigated repeatedly with large volumes of normal saline. The irrigation volume should not be less than 9,000 ml . Preparation of antibiotic bone cement: Based on the results of preoperative bacterial culture and drug susceptibility tests, the appropriate antibiotic was selected. Current studies indicate that bone cement containing gentamicin offers a broader antibacterial spectrum and longer release duration, making it the preferred option for Gram-negative bacterial infections . Vancomycin has become the first-line antibiotic for Gram-positive bacterial infections due to its superior physicochemical properties, including a broad antibacterial spectrum, good thermal stability, and low incidence of adverse reactions . The ratio of vancomycin to bone cement was 1:10, that is, 4 g of vancomycin was mixed with 40 g of bone cement. The ratio of gentamicin to bone cement was 1:20, which means that 2 g of gentamicin was mixed with 40 g of bone cement. In case of mixed infections, 40 g of bone cement was mixed with 4 g of vancomycin and 2 g of gentamicin. In clinical practice, the latter two applications are more prevalent. After thoroughly mixing the bone cement and antibiotics, the antibiotic bone cement was applied to completely cover the wound with all deep cavities filled, including the medullary cavity and soft tissue gaps. A honeycomb-shaped structure can be constructed with a small curette to achieve effective drainage. It is imperative to frequently rinse the bone cement with saline to avoid thermal injury and the cement was sutured to the surrounding skin prior to solidification. The affected area was then covered with dry sterile dressings and secured with an elastic bandage to maintain the position of the bone cement. Treatment after debridement: Following the operation, intravenous antibiotics were prescribed according to drug susceptibility tests. Inflammatory indicators such as CRP, ESR, PCT, and routine blood tests were monitored within 48 to 72 h after surgery. Normalization of the CRP level indicated successful infection control, allowing discontinuation of antibiotics. The dressing changes were performed at intervals of 4 to 7 days to maintain the dressing in a clean and dry state, while adhesion of the bone cement and the presentation of redness or exudate around the wounds were observed. In case of increased wound exudate, a more frequent schedule of dressing changes is required. In the absence of abnormal signs in the wound, patients were encouraged to engage in weight-bearing activities with the assistance of crutches and forefoot or hindfoot offloading shoes. Pain management and prevention of complications such as deep vein thrombosis were also integral parts of postoperative management. When the inflammatory indicators returned to normal levels within 4 weeks, the infections were considered eradicated and the flap transplantation could be performed to close the wound. Among the 10 cases in this group, 9 cases achieved effective control with single debridement combined with antibiotic bone cement coverage and intravenous antibiotics for 5–6 days. One case required debridement twice due to the presentation of redness, swelling, and exudation around the wound. All 10 patients were discharged after infection control, and regular outpatient follow-up visits were performed at 7-day intervals to monitor CRP, PCT, and ESR levels. In the absence of abnormalities, patients were readmitted at 4 weeks post-debridement for skin flap repair surgery. d-LCFA perforator flap repair surgery: The d-LCFA perforator flap technique entailed lower limb computed tomography angiography (CTA) to evaluate arterial patency and perforator vessel distribution. The perforating locations of the cutaneous branches from the descending branches of the lateral circumflex femoral artery were identified via color Doppler ultrasound, located approximately around the midpoint between the anterior superior iliac spine and the superolateral patellar corner . The maximum feasible flap size was assessed through a pinch test. A template was then designed to conform to the dimension and contour of the wound, divided into two sections, each with a width that allows for direct suturing of the donor site. The flap was delineated at the donor site based on the perforator location and the template. Considering the potential variability in perforator positions, the medial edge of the flap was incised initially. Multiple perforators were preserved in each lobe until the main perforator was identified. The deep fascia was then dissected and the perforators were traced back to the descending branch of the lateral circumflex femoral artery, which lies between the vastus lateralis and the rectus femoris. Subsequently the lateral edge of the flap was incised, and the dissection proceeded from lateral to medial at the superficial fascial plane. The lateral femoral cutaneous nerve in the flap was preserved. The flap leaves were dissected and spliced side by side to match the dimension of the recipient site. The pedicles of blood vessels in the flap were anastomosed end-to-end or end-to-side with vessels in the recipient site. Sensory perception was reestablished by cutaneous nerve anastomosis. Adequate hemostasis was achieved at the donor site before primary wound closure. Postoperatively, antispasmodics and anticoagulants were administered for one week, and the blood supply of the flap was monitored with symptomatic treatment as needed. At the final follow-up examination, pain intensity and functional outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. 

The results are summarized in Table . Among the 10 patients, 9 cases underwent a single debridement procedure prior to the application of antibiotic bone cement, and one case underwent debridement procedures twice. Subsequently, all patients achieved normalization of C-reactive protein (CRP) levels within 15 days after debridement, with an average of 8.3 days. The bone cement was removed after 4 weeks and the wounds were repaired with the d-LCFA lobulated perforator flap. The size of the calculated flap surface ranged from 12 cm × 6 cm to 31 cm × 7 cm, and all donor sites were primarily closed. The average duration of intravenous antibiotic administration was 6.3 days, and the average duration of hospitalization was 7.2 days. Postoperative follow-up revealed no infection recurrence following flap surgery, and all flaps survived without signs of vascular crisis or pressure ulcers. The donor and recipient sites healed by first intention. All 10 flaps exhibited satisfactory texture and thickness, ranging from 4 to 9 mm, and 4 cases underwent flap revision surgery 12 months after the initial operation due to the bloated appearance. The abbreviated duration of intravenous antibiotic therapy, reduced hospital stay, facilitation of early ambulation, and satisfaction of patients reflected the principles of Enhanced Recovery After Surgery (ERAS). The 10 patients underwent follow-up for a duration ranging from 4 to 24 months, with an average of 14 months. At the final follow-up examination, the AOFAS ankle-hindfoot scores ranged from 72 to 94 points, with an average of 84.6 points. Three cases were deemed excellent, five cases were good, and two cases were moderate. Typical case A representative case involved a 33-year-old female patient suffered from infected tissue defects in the left foot due to a crush injury in a traffic accident. The patient underwent debridement and several dressing procedures in a local hospital and was transferred to our hospital on the 7th post-trauma day. The physical examination at admission revealed necrosis of the tendon and bone in the medial plantar region of the foot (Fig. (A) and (B)). The initial stage of treatment was radical debridement (Fig. (C) and (D)), and bacterial culture identified Pseudomonas aeruginosa as the pathogen, which was susceptible to gentamicin. The wound was then covered with antibiotic bone cement (Fig. (A) and (B)), and intravenous antibiotic was administered for 5 days. The short duration of systemic antibiotic therapy, coupled with the sustained coverage of the antibiotic bone cement, proved to be effective in controlling the infection. The inflammatory indicators decreased significantly by 4 weeks. After the removal of the bone cement, the induced membrane was formed (Fig. (C) and (D)). Computed tomography angiography (CTA) and Doppler ultrasound were utilized to delineate the location of the perforator vessels. During the flap transplantation procedure, a template was designed aligning with the dimension of the wound, which was dissected into two parts and subsequently arranged side-by-side (Fig. (A) and (B)). The contour of the lobulated perforator flap was then delineated at the donor site (Fig. (C)). After the flap was harvested, it was dissected into two lobes and combined to match the contour of the recipient site (Fig. (D), (E) and (F)), and then transplanted to the recipient site (Fig. (A)). The donor site was closed primarily and exhibited a linear scar (Fig. (B)). The patient was followed for 18 months after surgery and the flap survived completely with a satisfactory appearance (Fig. (C) and (D)). 

A representative case involved a 33-year-old female patient suffered from infected tissue defects in the left foot due to a crush injury in a traffic accident. The patient underwent debridement and several dressing procedures in a local hospital and was transferred to our hospital on the 7th post-trauma day. The physical examination at admission revealed necrosis of the tendon and bone in the medial plantar region of the foot (Fig. (A) and (B)). The initial stage of treatment was radical debridement (Fig. (C) and (D)), and bacterial culture identified Pseudomonas aeruginosa as the pathogen, which was susceptible to gentamicin. The wound was then covered with antibiotic bone cement (Fig. (A) and (B)), and intravenous antibiotic was administered for 5 days. The short duration of systemic antibiotic therapy, coupled with the sustained coverage of the antibiotic bone cement, proved to be effective in controlling the infection. The inflammatory indicators decreased significantly by 4 weeks. After the removal of the bone cement, the induced membrane was formed (Fig. (C) and (D)). Computed tomography angiography (CTA) and Doppler ultrasound were utilized to delineate the location of the perforator vessels. During the flap transplantation procedure, a template was designed aligning with the dimension of the wound, which was dissected into two parts and subsequently arranged side-by-side (Fig. (A) and (B)). The contour of the lobulated perforator flap was then delineated at the donor site (Fig. (C)). After the flap was harvested, it was dissected into two lobes and combined to match the contour of the recipient site (Fig. (D), (E) and (F)), and then transplanted to the recipient site (Fig. (A)). The donor site was closed primarily and exhibited a linear scar (Fig. (B)). The patient was followed for 18 months after surgery and the flap survived completely with a satisfactory appearance (Fig. (C) and (D)). 

The concept of Enhanced Recovery after Surgery (ERAS) was originally proposed in the 1990s  and has been advocated in various medical disciplines. The ERAS philosophy involves adopting evidence-based practices to optimize perioperative management and mitigate the stress response of patients, ultimately achieving the goal of accelerating recovery, shortening hospitalization time, reducing medical expenditures, and improving patient satisfaction . Skin and soft tissue defects complicated by infection, which are frequently attributable to severe trauma, are notoriously refractory with protracted therapeutic procedures. Under the guidance of the ERAS concept, perioperative treatment procedures are improved to achieve the purpose of accelerating recovery. Infection control is the preliminary step in the treatment of foot wounds with complicated infection, and thorough debridement represents a crucial step . Before debridement, the following considerations should be taken into account in the course of bacterial culture: (1) Collecting specimens prior to antibiotic administration. (2) Prioritizing deep tissue specimens over swabs or pus specimens when sampling . (3) Attaching importance to anaerobic bacterial culture as well as aerobic bacterial culture. Identifying the pathogen and susceptible antibiotics plays a key role in infection control and achieving the purpose of ERAS. Antibiotics mixed with bone cement should be available in powder form, as liquid antibiotics could interfere with the polymerization process of the cement. They should also have broad-spectrum antimicrobial activity and possess good thermal stability due to the exothermic polymerization process of bone cement formation. The antibiotics typically utilized in bone cement include gentamicin, tobramycin, vancomycin, and cefuroxime . In our study, gentamicin and vancomycin are selected because of their thermostability and broad antibiotic coverage. Commercially prepared antibiotic-loaded cement offers a viable alternative with the advantage of predictable elution kinetics, while this convenience comes with certain limitations, such as the inability to modify the concentration or type of antibiotic included in the preparation. Frew et al.  have demonstrated that manually prepared antibiotic-loaded bone cement exhibits a higher elution rate at a significantly lower cost compared to commercially prepared antibiotic-loaded cement. Consequently, manual addition of antibiotics to bone cement in the operating theatre is recommended. The antibiotic bone cement has been extensively investigated for its application in treating osteomyelitis and preventing bone infections associated with artificial hip and knee replacements . Ehya et al. and Dong et al.  have reported that antibiotic bone cement improves the outcomes of surgical treatment for diabetic foot osteomyelitis. The research by Dai et al.  has found similar results that the antibiotic bone cement can shorten the healing duration in patients with infected diabetic foot ulcers. However, a limited number of studies have elucidated the advantages of antibiotic bone cement in the treatment of infected tissue defects prior to flap transplantation. Following the coverage of the wound with antibiotic bone cement, high local antibiotic concentrations, resulting from antibiotic elution, can be achieved at the infected site. Infection control is achieved, and both the inflammatory reaction and edema are significantly reduced by 4 weeks . The tissue response to the bone cement leads to the development of a highly vascularized pseudosynovial membrane known as the induced membrane . Biochemical analysis demonstrated a high concentration of growth factors within the induced membrane, particularly vascular endothelial growth factor and transforming growth factor beta-1 . The antibiotic bone cement enhances vascularization of exposed tissues at the wound site, thus preventing secondary necrosis of bones or tendons and providing an ideal bed for flap transplantation. Vacuum sealing drainage (VSD), a pivotal component of negative pressure wound therapy (NPWT), is extensively utilized for the treatment of various acute and chronic wounds. Notably, previous research has demonstrated that antibiotic bone cement can achieve comparable clinical outcomes to those of VSD in the management of infected soft tissue defects . In comparison, antibiotic bone cement offers distinctive advantages in dealing with infected tissue defects: (1) It yields high concentrations of susceptible antibiotics within the infected lesion, while effectively inhibiting and eliminating residual bacteria after debridement. This reduces the duration and dosage of systemic antibiotic administration, minimizes the risk of toxic side effects, shortens hospitalization time, and reduces medical expenses, all in line with the ERAS concept. (2) Continuous and sufficient drainage is required in VSD therapy, which is achieved by the drainage tube to specialized equipment. The drainage tube must be monitored in case of obstruction, which can prolong the hospital stay. Meanwhile, VSD should be repeatedly changed, which significantly increases the average costs of treatment . Wound coverage with antibiotic bone cement eliminates the constraint of drainage tubes during VSD use and reduces nursing requirements. Patients can perform early activities with crutches, allowing personalized use of forefoot or hindfoot offloading shoes to encourage partial weight-bearing in the affected limbs, effectively preventing joint stiffness and lower extremity deep venous thrombosis, achieving the purpose of accelerating recovery. However, the bone cement was placed on the surface of the wound and sutured to the skin, subsequently reinforced with an elastic bandage. This method was employed to maintain the position of the bone cement, which did not constitute a stable fixation technique. Therefore, patients should refrain from strenuous activities and excessive weight-bearing to reduce the risks of soft tissue friction, shearing, or dislocation of the cement. Close monitoring should be implemented during the follow-up period. (3) Shaped or beaded antibiotic bone cement can be placed in dead spaces and sinus tracts, optimizing contact with the infected wound and ensuring rapid and effective control of the infection. Whether the infection has been effectively controlled is mainly based on the local manifestation around the wound. Additionally, inflammatory biomarkers such as CRP, PCT, and ESR serve as auxiliary diagnostic tools . Among these, CRP exhibits the highest sensitivity . A continuously increasing or persistently high level of CRP indicates ongoing infection, and a return to normal CRP levels indicates that the infection has been effectively controlled. An ESR greater than 60 mm/h, in conjunction with a CRP level greater than 7.9 mg/L, may suggest the possibility of bone infection . In the course of treatment, as the wound area gradually dries out and inflammatory markers trend toward normal levels, intravenous antibiotic use can be discontinued, and the patient may be discharged for home-based rehabilitation. Throughout outpatient care, the adhesion status of bone cement to the wound surface should be monitored. Based on adhesion status and inflammatory indicators, they can be classified into three types: Type I: Characterized by tight adhesion between bone cement and wound surface, with the wound area remaining dry and free of redness or swelling. Type II: There is no adhesion between bone cement and the wound surface, with no significant redness or swelling around the wound. The induced membrane can be seen in the gap, and CRP levels are normal. In this case, the dressing can be continued without surgical intervention. Type II: There is no adhesion between bone cement and the wound surface with obvious redness and swelling, and CRP levels are significantly abnormal. In this case, increasing the frequency of dressing or surgical intervention may be considered. Another important component of ERAS is to reduce the stress response of patients, including physical and psychological stress. There is ample evidence to support the notion that psychological factors influence the course and prognosis of treatment. During the home recovery stage, active rehabilitation and self-care are encouraged. When patients witness that the infection is under control in a short period and can independently manage their follow-up dressing without assistance, this virtually builds up the confidence to conquer the disease, which is conducive to subsequent treatment. There is currently no consensus on the optimal time for bone cement removal. Our experience suggests that removal of bone cement and subsequent flap repair surgery around 3–4 weeks after debridement is favorable. If the patient is still experiencing posttraumatic psychological stress, the bone cement removal time may be postponed for psychological construction to accept skin flap repair surgery. This is in line with the ERAS principle of “better first, faster later”, which conforms to the trend of development from “disease-centered” to “patient-centered” . As the weight-bearing organ, the foot plays an important role in daily activities such as walking, running, and jumping. The complex soft tissue defect of the foot, especially on the plantar side, necessitates a flap for reconstruction to maintain mechanical resistance to the pressure and shear forces and achieve a satisfactory functional and aesthetically pleasing outcome. In general, the selection of the flap may depend on the surgeon’s preference and experience. Over the past decades, various methods have been reported for the reconstruction of foot defects, which can be broadly divided into muscle and fasciocutaneous flaps , including local pedicle flaps, muscle/musculocutaneous flaps , island flaps, pedicled fasciocutaneous flaps, and microsurgical free flaps [ , – ]. The muscle flaps have gained extensive utilization in lower limb defect reconstruction, offering benefits such as minimal anatomical variation, constant vascular support, and straightforward harvesting. However, the necessity for coverage of split-thickness skin grafts and the lack of sensitivity which may result in ulceration remain a concern . The fasciocutaneous flaps have become a more popular option with the advantages of a lower postoperative complications rate, better aesthetical and sensory outcomes, and lower donor-site morbidity . The anterolateral thigh flap, first introduced by Song et al. in 1984 , is the most commonly utilized fasciocutaneous flap. It has become a versatile option due to its large cutaneous area, long vascular pedicle, acceptable donor site morbidity, and adjustable thickness, making it a popular choice in clinical practice . Research has indicated that the anterolateral thigh flap exceeding 8 cm in width may prove challenging to suture primarily at the donor site, often necessitating skin grafting and creating an additional donor site . In reconstruction surgery, consideration should also be given to minimizing damage at the donor site and primary closure, which may improve patient satisfaction notably. In our study, the lobulated perforator flap pedicled with the descending branch of the lateral circumflex femoral artery (d-LCFA) has been selected with significant advantages over the conventional anterolateral thigh flap: (1) Ingenious design based on wound area converts the width of the flap into length, facilitating primary closure of the donor site with residual linear scars, avoiding skin grafts and minimizing donor site morbidity, further improving the visual presentation. (2) The lobulated perforator flap leaves are recombined side by side to extend the width of the flap that suits the recipient site precisely, allowing for the reconstruction of extensive defects. (3) The surgery is performed in the supine position without position alternation, and only a single set of vessels needs to be anastomosed, thus shortening the operation time. Nevertheless, the d-LCFA lobulated perforator flap shares common disadvantages with other lobulated flaps: (1) The lateral circumflex femoral artery must have two or more branches to ensure that separate branches can supply each lobe of the flap. In the case of the d-LCFA lobulated perforator flap, the perforators can be identified at the midpoint between the anterior superior iliac spine and the superolateral portion of the patella . The number of perforator arteries that branch off from the descending branch of the lateral circumflex femoral artery has been reported to range from 2 to 3, with an average diameter of 1.58 mm [ – ]. These attributes render the d-LCFA lobulated perforator flap an ideal option. (2) The length of the perforator vessels must be sufficient to exceed the sum of the widths of the flap lobes, allowing for free assembly of the lobulated flaps. (3) The introduction of an additional scar to the recipient site. In this study, we reviewed our experience in the management of infected traumatic tissue defects of the foot. The application of antibiotic bone cement combined with the d-LCFA lobulated perforator flap yielded a satisfactory clinical outcome. However, the current outcomes should be interpreted with an understanding of some limitations, primarily stemming from its retrospective nature. The small sample size inherent to this investigation limits the generalizability of the results to a broader population. To strengthen the validity, future research is required in a larger prospective cohort with a randomized controlled design. Such a study would allow for a more rigorous evaluation of the impact of our treatment protocol on patient outcomes. 

The application of antibiotic bone cement combined with d-LCFA lobulated perforator flaps represents an effective approach for the treatment of infected traumatic tissue defects. It offers rapid control of infection with high reproducibility and a definite curative effect. The utilization of lobulated perforator flaps minimizes donor site morbidity, shortens hospital stay, and reduces medical expenses, which is consistent with the ERAS concept. However, this study has some limitations: (1) A key limitation was the retrospective design with a small number of samples. Randomized controlled trials with a large sample size are required to verify the effectiveness of the treatment measures in this study. (2) Several aspects of the application of antibiotic bone cement require further exploration, including ascertaining the optimal timing for the removal of the bone cement and establishing the ideal concentration of antibiotics within the cement. 

