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Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 142–147
Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap* J. Dabernig*, B. Shilov, O. Schumacher, C. Lenz, W. Dabernig, J. Schaff Department of Hand-, Micro- and Plastic Surgery, Amper Kliniken AG, Klinikum Dachau, 85221 Dachau, Germany Received 18 October 2004; accepted 1 July 2005
KEYWORDS Achilles tendon defect; Functional and soft tissue reconstruction; TFL; Free flap
Summary We present our experience in functional reconstruction of the Achilles tendon with large tissue defects following after trauma and infection. To cover the skin defect and to reconstruct the Achilles tendon we used the free tensor fasciae latae (TFL) flap. From 1997 to 2003 six males, ranging from 22 to 71 (average 38.6) years, underwent this reconstructive procedure. All of them had sustained a trauma with following loss of the tendon and of the overlying tissue. After initial debridements the reconstruction with a tensor fascia latae free flap was performed. To achieve a strong distal fascia lata attachment to the calcaneal bone, we developed a special method of fixation. After vertical osteotomy in the calcaneus the distal part of the fascia flap was introduced between the bone segments, which were fixed together with a spongiosa screw. For functional outcome, it was important to fix the foot in a 908 position with tension on the vascularised fascia lata. The range of motion of the ankle of the reconstructed foot showed 93.7% in comparison to the normal foot. No flap failure occurred in any of the six patients. Simultaneous soft-tissue and function restoration of the foot with TFL free flap is in our opinion an optimal one-stage reconstructive procedure. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Presented at the 120th Annual Congress of the German Society of Surgery, Munich, Germany, April 29–May 02, 2003. * Corresponding author. Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, Scotland. Tel.: C44 141 211 5600; fax: C44 141 211 5652. E-mail address: [email protected] (J. Dabernig).
In cases of Achilles tendon defects combined with defects of the overlaying skin and loss of a foot function it is very difficult to achieve satisfactory functional results. Necrosis of skin and tendon associated with wound infection is accompanied by two problems, (1) the skin defect and (2) the absence of the whole tendon in the axial expansion
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.07.011
Achilles tendon combined with overlaying skin defects using a free tensor fasciae latae flap with loss of plantar flexion. Refashioning is often rated as a challenge for the reconstructive surgeon.1–16 Such defects are a result of skin and tendon necrosis associated with wound infection after Achilles tendon rupture and failure of primary surgical repair, or caused by direct trauma with tendon and soft-tissue loss in the foot and ankle region when direct repair is impossible (Figures 1 and 2). In the case of elderly patients suffering from slight trauma complications can be caused by diabetes mellitus, venous insufficiency, peripheral arterial disease, macro- and microangiopathy and fasciitis. The TFL flap is often used for local tissue reconstruction,17–19 and is one of the most commonly employed flaps in this region. The utilisation of the TFL flap proved to be very good when reconstructing such types of defects, but clinical experience is limited and publications are rare.10 When one has to deal with associated loss of the calcaneal part of the Achilles tendon, the problem becomes more complicated, because of failure to achieve a strong junction between the fascia and the bone. We developed a surgical procedure to solve the problem by fixing the fascia in a new way.
Patients and methods Between 1998 and 2002, we treated six patients by covering the Achilles tendon and overlaying skin defect with the tensor fascia latae flap. All of them were male, ranging in age from 22 to 71 years (average 39 years). One patient sustained a slight trauma, three patients had closed Achilles tendon rupture and two patients an open traumatic injury. All patients had an extensive soft tissue and Achilles
143
Figure 2 Complete Achilles tendon loss. Stable and well granulated wound after radical programmied debridements and external fixation.
tendon necrosis and local infection when they were introduced to our department. In all cases we did an initial radical uncompromising debridement with following programmed debridements every 48 h, when the wound was excised and necrotic tissue was removed from the Achilles tendon with resection of parts of it, or the whole tendon if necessary was resected. In all patients broadspectrum antibiotics were initially administrated, which were followed by culture-specific antibiotics. With the wound in a clean condition, we reconstructed the skin and the underlying tendon defect with a TFL free flap from the contralateral side. Normally, the ankle joint was fixed in 908 flexion by external fixation for up to 6 weeks postoperatively and in most cases of primary healing we removed it early. We began the foot loading from the third week postoperatively, first as a simple floor contact and finally as full loading. As soon as the external fixation was removed the patient was provided with a special orthopaedic shoe set at 1108 ankle joint extension. The angle is continually decreased, thus increasing the loading of the foot. Rehabilitation and gymnastic activities are indicated up to the 12th week postoperatively.
Flap anatomy and operative technique
Figure 1 Necrotic Achilles tendon by bagatell trauma before the first debridement with soft tissue defect.
The flap is well described. It is based on the ascending branch of the lateral circumflex femoris artery, which brings three branches into the flap. The TFL flap is a type I flap as classified by Mathes and Nahai, with 6–9 perforating arteries through the muscle and the fascia into the skin (Figures 3 and 4). The main artery is the ascending branch of the lateral circumflex femoral artery, which provides one branch for the proximal muscle and the bone,
144
J. Dabernig et al. the proximal tarsus in the direction of the tuber calcanei (Figure 5). The foot was then positioned at 908 to mark the fixation points of the proximal part of the TFL flap on the remaining tissue of the triceps surae muscle. In plantar flexion the proximal part of the TFL flap was fixed under tension at the fixation points with absorbable sutures. We fixed the foot into a 908 position with joint overbridged external fixation. It was important for keeping the new tendon under permanent tension for preventing peronaeus position of the foot.
Figure 3 Flap in situ. Well blood supply of the skin by the perforating arteries through the muscle and the fascia into the skin. The broad fascia strip for tendon repair is shown.
one just for the muscle and a third branch for the whole fascia lata, which is very important for the Achilles tendon reconstruction. The perforating arteries are each accompanied by two concomitant veins.19 Employing TFL free flap transfer as a standard procedure we anastomosed the lateral circumflex femoris artery end-to-side to the posterior tibial artery with 9/0 monofilament suture. Two veins were anastomosed end-to-end to the concomitants veins. To achieve a strong junction between the distal fascia lata and calcaneal bone, we developed a method of special fixation to the bone. We performed a vertical osteotomy at least 3 cm deep at the origin of the Achilles tendon in the posterior part of the calcaneal bone. Then the fascia was located between the bone fragments and afterwards was fixed with a spongiosa screw from
Figure 4 TFL flap with muscle, skin and fascia lata for tendon repair. The strong fascia (left side) which will be fixed as described.
Results All six free tissue transfers were successful and all flaps survived completely. We have to do a revision in the case of one vein thromosis. One patient asked for debulking correction operation. All were able to wear shoes without prosthetic devices. Four patients returned to the same level of activity as before the injury. The other had not taken part in sports before the reconstruction.
Figure 5 Schema of our fixation of the fascia in between the calcaneus: (1) Screw for fixation, (2) fascia lata for tendon repair.
Achilles tendon combined with overlaying skin defects using a free tensor fasciae latae flap The donor site showed a satisfactory aesthetic scar, no complaints while moving, no instability and no subjective weakness. Two patients specify a sensitivity to changes in the weather. All donor site defects healed primarily. All showed good functional results in dorsal and plantarflexion of the reconstructed foot (Figure 6) The normal side showed an average of 618 range of motion of the ankle. The reconstructed side showed an average of 578 range of motion, that is 48 (93.7%) less than to the normal ankle motion (Figure 6 (a)–(d)). The dorsiflexion of the normal side showed 10.68 (average), dorsiflexion of the reconstructed foot was 9.68 average (90.5%). The plantarflexion showed 48.58 (average) normal, and 43.58 (89.7%) to the reconstructed foot. The tip-toe stance on both feet showed the normal foot to attain an average 9.1 cm (heel height) in comparison to the reconstructed Achilles tendons with 7.0 cm (heel height). That is 2.16 cm (76.9%) less than the normal side. Four of six patients are able to stand on tip toe just on the operated foot. All patients are satisfied with the functional, aesthetic and post operative
145
outcome, and all of them would repeat the same surgical procedure if necessary.
Discussion The combination of large skin defects and total loss of the Achilles tendon after trauma, infection, or the combination of both means difficult problems for the reconstructive surgeon. The method of choice is a radical debridement, often more than twice, with an interval of 48 h, which results in a well granulated and stable wound, but with loss of the Achilles tendon and a large defect in the overlaying soft tissue.1,12,15 The problem is not merely skin cover but also the dynamic repair of the functioning tendon, which is the more far-reaching problem.6,7 Methods of reconstruction could be ordered according the reconstructive ladder. To cover defects like this, the use of skin craft is often limited to cases when the bone or remaining tendon is bare. Local flaps are often too small to cover a big defect and reconstruct the function of the tendon.9
Figure 6 Functional results after Achillestendon reconstruction: (a) Reconstructed side-dorsiflexion, (b) reconstructed side-palmarflexion, (c) contralateral side-palmarflexion, (d) contralateral side-dorsiflexion.
146 Other procedures like turned-over flaps20 or the distally based sural artery flap would be good for skin cover, but these surgical procedures are unsuitable for functional reconstruction of the Achilles tendon. Successful defect cover by using various microvascular free flaps,1–8 with nonvascularised marlex mesh16 or vascularised tendon, or temporo-fascial free flaps with skin cover3 are well known nowadays. The possibilities are almost unlimited. Reconstruction of the Achilles tendon with fascia lata, where the fascia lata was used as a free graft,14 with a composite flap in which a fascia lata strip was joined to a lateral thigh flap1 or the reconstruction with fascia lata graft and a medial plantar flap13 are described. We found one published study devoted to reconstruction of the Achilles tendon with overlaying skin defects, with combined functional reconstruction by using an tensor fascia latae (TFL) flap.10 The results of covering defects in the Achilles tendon region with free tissue transfer were, reported to be quite good in all published papers, especially for skin cover. However, we believe that without reconstructing the tendon, an extensive scar is formed under the flap after transplanting. A limited plantarflexion and dorsalflexion is possible in patients by using the scar under the flap for moving. The possibility of transmission of force onto the muscular system is certainly provided, but because of the presence of this scar is limited. For this reason, even patients, where the wounds are well granulated, who have undergone split skin graft transplantation are able to execute waggling movements. However, it is not possible to achieve quite the same range of motion as on the contralateral side. We would like to make a special reference to the distal and proximal fixation of the tensor fascia lata free flap. It is obviously very important for functional results. First it is suitable to fix the distal part of the flap in the calcaneal bone. Perfect fixation could be achieved only by using osteotomy and screw fixation. Then one has to bring the ankle into an almost 908 position and fix the proximal part of the flap in the definitive position with sutures. Very important is the following forced dorsi flexion to a 908 angle, to get tension on the fascia lata, and fixing with a fixateur externe. Nowadays, the standard method for reconstructing the Achilles tendon should include using tissue with good blood supply. Transplanting tendons and fascia without a specified level of blood supply should only be an exception. Any uncertainty that the transplants might not grow on and the possible ensuring necrosis and infections in previously
J. Dabernig et al. damaged tissues should be reduced to a minimum. In addition, tendons of insufficient strength are often integrated into a flap used as a substitute for an Achilles tendon. In the case of all reconstruction procedures it is necessary to introduce tissue with a good blood supply into a defect. This should also be the case when performing functional reconstructions of the Achilles tendon. The morphological similarity of the fascia lata to the Achilles tendon is an additional reason to consider the TFL for this special reconstructive procedure. Our functional results (Figure 6) and surgical procedure should show that it is worth while reconstructing the Achilles tendon if it is possible, and that this technique may be superior to other procedures. We are convinced we can show in our study, that the reconstruction of the skin and the dynamic and functioning repair with an TFL free flap is a good surgical procedure at this time. The reconstruction in one surgical procedure, with one free flap gives us the possibility of solving two problems, (1) the functional loss of the Achilles tendon and (2) covering a skin defect.
Acknowledgements We thank specially Mrs Renate Oswald and Ms Sabine Kornprotost for the Illustrations and the good photodocumentation of all our patients and difficult cases.
References 1. Inoue T, Tanaka I, Imai K, et al. Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap. Br J Plast Surg 1990;43:728–31. 2. Shenaq SM, Dinh TA. Heel reconstruction with an iliac osteocutaneous free flap in a child. Microsurgery 1989;10: 9398. 3. Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal fascial free flap. Plast Reconstr Surg 1985; 76:177–88. 4. Feibel RJ, Jackson RL, Lineweaver WC, et al. Management of chronic Achilles tendon infection with musculotendinous gracilis interposition free-flap coverage. J Reconstr Microsurg 1993;9(5):321–5. 5. Babu V, Chittaranjan S, Abraham G, et al. Single-stage reconstruction of soft-tissue defects including the Achilles tendon using the doralis pedis arterialized flap along with the extensor digitorum brevis as bridge craft. Plast Reconstr Surg 1994;93(5):1090–3. ¨ zerkan F, Ada S, et al. Reconstruction of skin 6. Ademoglu Y, O and tendon defects from wound complications after Achilles tendon rupture. J Foot Ankle Surg 2001;40(3):158–65. 7. Leppilathi J, Kaarela O, Teerikangas H, et al. Free tissue coverage of wound complications following Achilles tendon rupture surgery. Clin Orthop Relat Res 1996;328:171–6.
Achilles tendon combined with overlaying skin defects using a free tensor fasciae latae flap 8. Wei FC, Chen HC, Chuang CC, et al. Reconstruction of Achilles tendon and calcaneus defect with skin-aponeurosisbone composite free tissue from the groin region. Plast Reconstr Surg 1988;81(4):579–87. 9. Hayashi A, Maruyama Y. Lateral calcaneal V–Y advencement flap for repair of posterior heel defects. Plast Reconstr Surg 1999;103(2):577–80. 10. Deiler S, Pfadenhauer A, Widmann J, et al. Tensor fasciae latae perforator flap for reconstruction of composite Achilles tendon defects with skin and vascularized fascia. Plast Reconstr Surg 2000;106(2):342–9. 11. Taylor I, Townsed P. Composite free flap and tendon transfer: An anatomical study and a clinical technique. Br J Plast Surg 1979;32:170–83. 12. Fumarola A. A one-stage reconstruction of a large defect of the tendo Achilles and the over lying skin. Br J Plast Surg 1985;38:403–6. 13. Tangiguchi Y, Tamaki T. Reconstruction of the Achilles tendon and overlying skin defect with a medial plantar flap and tensor fascia latae craft. J Reconstr Microsurg 2000; 16(6):423–5. 14. Lidman D, Nettelbad H, Berggren A, et al. Reconstruction of soft tissue defects including the Achilles tendon with free
15.
16.
17.
18.
19.
20.
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neurovascular tensor fascia lata flap and fascia lata. Scand J Plast Reconstr Surg 1987;21:213–8. Saunders DE, Hochberg J, Ittenborn W. Treatment of total loss of the Achilles tendon by skin flap cover without tendon repair. Plast Reconstr Surg 1978;5(62):708–12. Ozaki J, Fujiki J, Sugimoto K, et al. Reconstruction of neglected Achilles tendon rupture with marlex mesh. Clin Orthop Relat Res 1989;238:204–8. Nahai F, Love TR. Lower extremity reconstruction: Management of soft tissue defects. In: Cohen M, editor. Master of plastic and reconstructive surgery. New York: Little, Brown and Co.; 1994. p. 1779. McCraw J, Horton CE, Horton Jr CH. Basic techniques in genital reconstructive surgery. In: McCarthy J, editor. Plastic surgery. Philadelphia, PA: W.B. Saunders; 1990. p. 4136–7. Strauch B, Yu HL. Tensor fascia lata flap. Atlas of microvascular surgery. New York: Georg Thieme Verlag; 1993. p. 174–9. Hasse FM, Lo ¨hlein D. Der deepithelialisierte ‘turn-over-flap’ zur Defektdeckung im Bereich u ¨ber der Achillessehne und u ¨ber der lateralen Malleolarregion. Unfallchirurg 2000;103: 405–7.
Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap* J. Dabernig*, B. Shilov, O. Schumacher, C. Lenz, W. Dabernig, J. Schaff Department of Hand-, Micro- and Plastic Surgery, Amper Kliniken AG, Klinikum Dachau, 85221 Dachau, Germany Received 18 October 2004; accepted 1 July 2005
KEYWORDS Achilles tendon defect; Functional and soft tissue reconstruction; TFL; Free flap
Summary We present our experience in functional reconstruction of the Achilles tendon with large tissue defects following after trauma and infection. To cover the skin defect and to reconstruct the Achilles tendon we used the free tensor fasciae latae (TFL) flap. From 1997 to 2003 six males, ranging from 22 to 71 (average 38.6) years, underwent this reconstructive procedure. All of them had sustained a trauma with following loss of the tendon and of the overlying tissue. After initial debridements the reconstruction with a tensor fascia latae free flap was performed. To achieve a strong distal fascia lata attachment to the calcaneal bone, we developed a special method of fixation. After vertical osteotomy in the calcaneus the distal part of the fascia flap was introduced between the bone segments, which were fixed together with a spongiosa screw. For functional outcome, it was important to fix the foot in a 908 position with tension on the vascularised fascia lata. The range of motion of the ankle of the reconstructed foot showed 93.7% in comparison to the normal foot. No flap failure occurred in any of the six patients. Simultaneous soft-tissue and function restoration of the foot with TFL free flap is in our opinion an optimal one-stage reconstructive procedure. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Presented at the 120th Annual Congress of the German Society of Surgery, Munich, Germany, April 29–May 02, 2003. * Corresponding author. Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, Scotland. Tel.: C44 141 211 5600; fax: C44 141 211 5652. E-mail address: [email protected] (J. Dabernig).
In cases of Achilles tendon defects combined with defects of the overlaying skin and loss of a foot function it is very difficult to achieve satisfactory functional results. Necrosis of skin and tendon associated with wound infection is accompanied by two problems, (1) the skin defect and (2) the absence of the whole tendon in the axial expansion
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.07.011
Achilles tendon combined with overlaying skin defects using a free tensor fasciae latae flap with loss of plantar flexion. Refashioning is often rated as a challenge for the reconstructive surgeon.1–16 Such defects are a result of skin and tendon necrosis associated with wound infection after Achilles tendon rupture and failure of primary surgical repair, or caused by direct trauma with tendon and soft-tissue loss in the foot and ankle region when direct repair is impossible (Figures 1 and 2). In the case of elderly patients suffering from slight trauma complications can be caused by diabetes mellitus, venous insufficiency, peripheral arterial disease, macro- and microangiopathy and fasciitis. The TFL flap is often used for local tissue reconstruction,17–19 and is one of the most commonly employed flaps in this region. The utilisation of the TFL flap proved to be very good when reconstructing such types of defects, but clinical experience is limited and publications are rare.10 When one has to deal with associated loss of the calcaneal part of the Achilles tendon, the problem becomes more complicated, because of failure to achieve a strong junction between the fascia and the bone. We developed a surgical procedure to solve the problem by fixing the fascia in a new way.
Patients and methods Between 1998 and 2002, we treated six patients by covering the Achilles tendon and overlaying skin defect with the tensor fascia latae flap. All of them were male, ranging in age from 22 to 71 years (average 39 years). One patient sustained a slight trauma, three patients had closed Achilles tendon rupture and two patients an open traumatic injury. All patients had an extensive soft tissue and Achilles
143
Figure 2 Complete Achilles tendon loss. Stable and well granulated wound after radical programmied debridements and external fixation.
tendon necrosis and local infection when they were introduced to our department. In all cases we did an initial radical uncompromising debridement with following programmed debridements every 48 h, when the wound was excised and necrotic tissue was removed from the Achilles tendon with resection of parts of it, or the whole tendon if necessary was resected. In all patients broadspectrum antibiotics were initially administrated, which were followed by culture-specific antibiotics. With the wound in a clean condition, we reconstructed the skin and the underlying tendon defect with a TFL free flap from the contralateral side. Normally, the ankle joint was fixed in 908 flexion by external fixation for up to 6 weeks postoperatively and in most cases of primary healing we removed it early. We began the foot loading from the third week postoperatively, first as a simple floor contact and finally as full loading. As soon as the external fixation was removed the patient was provided with a special orthopaedic shoe set at 1108 ankle joint extension. The angle is continually decreased, thus increasing the loading of the foot. Rehabilitation and gymnastic activities are indicated up to the 12th week postoperatively.
Flap anatomy and operative technique
Figure 1 Necrotic Achilles tendon by bagatell trauma before the first debridement with soft tissue defect.
The flap is well described. It is based on the ascending branch of the lateral circumflex femoris artery, which brings three branches into the flap. The TFL flap is a type I flap as classified by Mathes and Nahai, with 6–9 perforating arteries through the muscle and the fascia into the skin (Figures 3 and 4). The main artery is the ascending branch of the lateral circumflex femoral artery, which provides one branch for the proximal muscle and the bone,
144
J. Dabernig et al. the proximal tarsus in the direction of the tuber calcanei (Figure 5). The foot was then positioned at 908 to mark the fixation points of the proximal part of the TFL flap on the remaining tissue of the triceps surae muscle. In plantar flexion the proximal part of the TFL flap was fixed under tension at the fixation points with absorbable sutures. We fixed the foot into a 908 position with joint overbridged external fixation. It was important for keeping the new tendon under permanent tension for preventing peronaeus position of the foot.
Figure 3 Flap in situ. Well blood supply of the skin by the perforating arteries through the muscle and the fascia into the skin. The broad fascia strip for tendon repair is shown.
one just for the muscle and a third branch for the whole fascia lata, which is very important for the Achilles tendon reconstruction. The perforating arteries are each accompanied by two concomitant veins.19 Employing TFL free flap transfer as a standard procedure we anastomosed the lateral circumflex femoris artery end-to-side to the posterior tibial artery with 9/0 monofilament suture. Two veins were anastomosed end-to-end to the concomitants veins. To achieve a strong junction between the distal fascia lata and calcaneal bone, we developed a method of special fixation to the bone. We performed a vertical osteotomy at least 3 cm deep at the origin of the Achilles tendon in the posterior part of the calcaneal bone. Then the fascia was located between the bone fragments and afterwards was fixed with a spongiosa screw from
Figure 4 TFL flap with muscle, skin and fascia lata for tendon repair. The strong fascia (left side) which will be fixed as described.
Results All six free tissue transfers were successful and all flaps survived completely. We have to do a revision in the case of one vein thromosis. One patient asked for debulking correction operation. All were able to wear shoes without prosthetic devices. Four patients returned to the same level of activity as before the injury. The other had not taken part in sports before the reconstruction.
Figure 5 Schema of our fixation of the fascia in between the calcaneus: (1) Screw for fixation, (2) fascia lata for tendon repair.
Achilles tendon combined with overlaying skin defects using a free tensor fasciae latae flap The donor site showed a satisfactory aesthetic scar, no complaints while moving, no instability and no subjective weakness. Two patients specify a sensitivity to changes in the weather. All donor site defects healed primarily. All showed good functional results in dorsal and plantarflexion of the reconstructed foot (Figure 6) The normal side showed an average of 618 range of motion of the ankle. The reconstructed side showed an average of 578 range of motion, that is 48 (93.7%) less than to the normal ankle motion (Figure 6 (a)–(d)). The dorsiflexion of the normal side showed 10.68 (average), dorsiflexion of the reconstructed foot was 9.68 average (90.5%). The plantarflexion showed 48.58 (average) normal, and 43.58 (89.7%) to the reconstructed foot. The tip-toe stance on both feet showed the normal foot to attain an average 9.1 cm (heel height) in comparison to the reconstructed Achilles tendons with 7.0 cm (heel height). That is 2.16 cm (76.9%) less than the normal side. Four of six patients are able to stand on tip toe just on the operated foot. All patients are satisfied with the functional, aesthetic and post operative
145
outcome, and all of them would repeat the same surgical procedure if necessary.
Discussion The combination of large skin defects and total loss of the Achilles tendon after trauma, infection, or the combination of both means difficult problems for the reconstructive surgeon. The method of choice is a radical debridement, often more than twice, with an interval of 48 h, which results in a well granulated and stable wound, but with loss of the Achilles tendon and a large defect in the overlaying soft tissue.1,12,15 The problem is not merely skin cover but also the dynamic repair of the functioning tendon, which is the more far-reaching problem.6,7 Methods of reconstruction could be ordered according the reconstructive ladder. To cover defects like this, the use of skin craft is often limited to cases when the bone or remaining tendon is bare. Local flaps are often too small to cover a big defect and reconstruct the function of the tendon.9
Figure 6 Functional results after Achillestendon reconstruction: (a) Reconstructed side-dorsiflexion, (b) reconstructed side-palmarflexion, (c) contralateral side-palmarflexion, (d) contralateral side-dorsiflexion.
146 Other procedures like turned-over flaps20 or the distally based sural artery flap would be good for skin cover, but these surgical procedures are unsuitable for functional reconstruction of the Achilles tendon. Successful defect cover by using various microvascular free flaps,1–8 with nonvascularised marlex mesh16 or vascularised tendon, or temporo-fascial free flaps with skin cover3 are well known nowadays. The possibilities are almost unlimited. Reconstruction of the Achilles tendon with fascia lata, where the fascia lata was used as a free graft,14 with a composite flap in which a fascia lata strip was joined to a lateral thigh flap1 or the reconstruction with fascia lata graft and a medial plantar flap13 are described. We found one published study devoted to reconstruction of the Achilles tendon with overlaying skin defects, with combined functional reconstruction by using an tensor fascia latae (TFL) flap.10 The results of covering defects in the Achilles tendon region with free tissue transfer were, reported to be quite good in all published papers, especially for skin cover. However, we believe that without reconstructing the tendon, an extensive scar is formed under the flap after transplanting. A limited plantarflexion and dorsalflexion is possible in patients by using the scar under the flap for moving. The possibility of transmission of force onto the muscular system is certainly provided, but because of the presence of this scar is limited. For this reason, even patients, where the wounds are well granulated, who have undergone split skin graft transplantation are able to execute waggling movements. However, it is not possible to achieve quite the same range of motion as on the contralateral side. We would like to make a special reference to the distal and proximal fixation of the tensor fascia lata free flap. It is obviously very important for functional results. First it is suitable to fix the distal part of the flap in the calcaneal bone. Perfect fixation could be achieved only by using osteotomy and screw fixation. Then one has to bring the ankle into an almost 908 position and fix the proximal part of the flap in the definitive position with sutures. Very important is the following forced dorsi flexion to a 908 angle, to get tension on the fascia lata, and fixing with a fixateur externe. Nowadays, the standard method for reconstructing the Achilles tendon should include using tissue with good blood supply. Transplanting tendons and fascia without a specified level of blood supply should only be an exception. Any uncertainty that the transplants might not grow on and the possible ensuring necrosis and infections in previously
J. Dabernig et al. damaged tissues should be reduced to a minimum. In addition, tendons of insufficient strength are often integrated into a flap used as a substitute for an Achilles tendon. In the case of all reconstruction procedures it is necessary to introduce tissue with a good blood supply into a defect. This should also be the case when performing functional reconstructions of the Achilles tendon. The morphological similarity of the fascia lata to the Achilles tendon is an additional reason to consider the TFL for this special reconstructive procedure. Our functional results (Figure 6) and surgical procedure should show that it is worth while reconstructing the Achilles tendon if it is possible, and that this technique may be superior to other procedures. We are convinced we can show in our study, that the reconstruction of the skin and the dynamic and functioning repair with an TFL free flap is a good surgical procedure at this time. The reconstruction in one surgical procedure, with one free flap gives us the possibility of solving two problems, (1) the functional loss of the Achilles tendon and (2) covering a skin defect.
Acknowledgements We thank specially Mrs Renate Oswald and Ms Sabine Kornprotost for the Illustrations and the good photodocumentation of all our patients and difficult cases.
References 1. Inoue T, Tanaka I, Imai K, et al. Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap. Br J Plast Surg 1990;43:728–31. 2. Shenaq SM, Dinh TA. Heel reconstruction with an iliac osteocutaneous free flap in a child. Microsurgery 1989;10: 9398. 3. Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal fascial free flap. Plast Reconstr Surg 1985; 76:177–88. 4. Feibel RJ, Jackson RL, Lineweaver WC, et al. Management of chronic Achilles tendon infection with musculotendinous gracilis interposition free-flap coverage. J Reconstr Microsurg 1993;9(5):321–5. 5. Babu V, Chittaranjan S, Abraham G, et al. Single-stage reconstruction of soft-tissue defects including the Achilles tendon using the doralis pedis arterialized flap along with the extensor digitorum brevis as bridge craft. Plast Reconstr Surg 1994;93(5):1090–3. ¨ zerkan F, Ada S, et al. Reconstruction of skin 6. Ademoglu Y, O and tendon defects from wound complications after Achilles tendon rupture. J Foot Ankle Surg 2001;40(3):158–65. 7. Leppilathi J, Kaarela O, Teerikangas H, et al. Free tissue coverage of wound complications following Achilles tendon rupture surgery. Clin Orthop Relat Res 1996;328:171–6.
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