Extract
Reconstruction of a segmental loss of the Achilles tendon combined with defects in soft-tissue coverage creates a challenge for the surgeon. We present the case of a patient who had combined loss of the Achilles tendon and overlying soft-tissue coverage. The patient was managed successfully with a single surgical procedure involving a composite anterolateral thigh free flap with vascularized fascia lata. The functional outcome of the reconstructed ankle and morbidity in the donor thigh were evaluated at one year with use of a kinetic dynamometer combined with magnetic resonance imaging.
Reconstruction of a segmental loss of the Achilles tendon combined with defects in soft-tissue coverage creates a challenge for the surgeon. We present the case of a patient who had combined loss of the Achilles tendon and overlying soft-tissue coverage. The patient was managed successfully with a single surgical procedure involving a composite anterolateral thigh free flap with vascularized fascia lata. The functional outcome of the reconstructed ankle and morbidity in the donor thigh were evaluated at one year with use of a kinetic dynamometer combined with magnetic resonance imaging.
The patient was informed that data concerning the case would be submitted for publication, and he consented.
A forty-eight-year-old man sustained a complete rupture of the left Achilles tendon during military service. Primary suture repair of the tendon was performed. Four months after that operation, a new rupture occurred when the patient returned to work, and a second tendon repair was performed to reconstruct the defect with the central part of the proximal part of the Achilles tendon (the Bosworth procedure). A large hematoma formed postoperatively, followed by skin necrosis, resulting in a 12-cm segmental tendon loss with an overlying soft-tissue defect measuring 8 × 3 cm.
The wound site was debrided of all fibrous and necrotic tissue (Fig. 1). Because of the lack of suitable local tissue, a composite anterolateral thigh flap with attached vascularized fascia lata was harvested after a preoperative Doppler ultrasound examination. The main cutaneous perforator was located in the middle portion of a line between the anterior superior iliac spine and the lateral edge of the patella (Fig. 2). The skin paddle of the anterolateral thigh flap (17 × 8 cm) was designed to be slightly larger than the soft-tissue defect. It was harvested along with its vascular pedicle and a portion of the fascia lata measuring 20 × 8 cm. An arterial end-to-side anastomosis and a venous end-to-end anastomosis were then performed under the microscope between the pedicle of the posterior tibialis artery and the flap pedicle vessels (Figs. 3-A and 3-B). The fascia lata was rolled up to recreate the missing segment of the Achilles tendon, and it was sutured to the end of the soleus musculocutaneous junction and the distal remnant of the Achilles tendon with the ankle in appropriate tension. The skin flap was then sutured in place. The donor site was closed over a suction drain. The overall duration of this two-team operation was approximately five and a half hours. Postoperative immobilization in a protective cast was maintained for six weeks with the ankle in 45° of plantar flexion and for six weeks with the foot in a neutral position. The patient was fully able to walk at sixteen weeks and followed an active rehabilitation program. A pressure stocking was used for six months to shrink the flap.
The patient returned to work six months after surgery. At the time of the latest follow-up, one year postoperatively, the patient was able to perform normal daily activities, was able to ride a bicycle, was able to walk without pain and without the need for support, and showed good plantar flexion strength and a normal gait. Nevertheless, the persistence of occasional pain and slight weakness after extreme activity were noted at the time of the one-year follow-up examination. The patient was satisfied with regard to pain, functional recovery, and cosmetic appearance, with only minor reservations related to the need to reduce the level of sports that he could practice. At the time of the one-year follow-up, the tendon healing was satisfactory on clinical and magnetic resonance imaging examinations, without scar adhesion. The active range of motion of the reconstructed ankle was about 50° (10° of dorsiflexion to 40° of plantar flexion), with only a deficit of 10° in dorsal flexion compared with the unaffected side. The circumference of the middle part of the calf was 3 cm smaller and the circumference of the ankle (5 cm proximal to the calcaneal insertion) was 2 cm larger on the reconstructed side than on the unaffected side. At the time of the latest follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) score was 82. Objective assessment of the reconstructed ankle and of donor thigh morbidity were investigated with use of isokinetic dynamometer measurements (Cybex, New York, NY). Testing showed 47% and 29% decreases in plantar flexion and dorsiflexion strength in comparison with the contralateral side. Nevertheless, the patient was able to stand and walk on the tips of the toes without pain and was able to perform a single-heel-rise test without fatigue (Figs. 4-A and 4-B). There was no deficiency of the quadriceps femoris muscle contraction forces compared with the other thigh.
The reconstructed tendon morphology was evaluated with magnetic resonance imaging, which showed a normal homogeneous signal intensity, with well-defined margins and contours in both the axial and sagittal planes, without peritendinous fibrosis (Fig. 5).
To achieve acceptable rehabilitation for the combined loss of the Achilles tendon and overlying soft tissues in younger and athletic adults such as the one described here, both skin coverage and functional repair of the Achilles tendon are needed1,2.
Multiple surgical approaches have been used for the repair of Achilles tendon defects3,4. Conventionally, the soft-tissue defect of the exposed Achilles tendon is first covered with use of a local, regional, or distant flap as a free flap2,3. The extensor apparatus continuity is restored in a second-stage procedure with use of autologous tendon grafts, allografts, or manufactured mesh such as Marlex (Chevron Philips Chemical, The Woodlands, Texas) or equivalent3,5.
The use of vascularized tissues for tendon repair is probably better than the extensive use of a local flap and the incorporation of nonvascularized fascial grafts because vascularized tissues probably facilitate rapid wound and tendon healing, graft survival, and the prevention of infection6. Moreover, in this case of iterative rupture, reconstruction was a greater challenge because of the lack of locally available flaps.
Free-tissue transplantation allows for the reconstruction of multiple-tissue defects in a single surgical procedure with well-vascularized tissues7. Several free-tissue transfers have been reported to provide soft-tissue coverage and tendon reconstruction, including groin flaps, radial forearm and lateral arm flaps, extended temporoparietal-galeal flaps, latissimus dorsi flaps, tensor fasciae latae, rectus muscle flaps with vascularized abdominal wall fascia, and gracilis flaps8-15.
The free anterolateral thigh flap is a very versatile flap that has been used since the first description by Song et al. in 198416-18. Composite free flaps, such as an anterolateral thigh flap with vascularized fascia lata, allow simultaneous reconstruction of Achilles tendon and overlying soft-tissue defects in a single-step procedure with a two-team approach1,6,19. In the case described here, vascularized fascia lata was rolled up to serve as a vascularized tendon graft, which is also thought to promote rapid healing of the Achilles tendon as this tendon repair is well vascularized. The effectiveness of this procedure seems to be demonstrated by the good tendon healing on magnetic resonance imaging as indicated by normal signal intensity with well-defined margins in both the axial and sagittal planes, without peritendinous fibrosis. The posterior expansion of the fascia lata was used in order to prevent inadvertent injury to the flap vessels that were located closer to the front6. Furthermore, the harvesting of the anterolateral thigh composite flap needs to be performed with great care to avoid interruption of the vastus lateralis muscle innervation. In the case presented here, we only used an acoustic hand-held Doppler device for preoperative perforator mapping. To improve both surgical planning and flap harvesting, preoperative computed tomographic angiography is a noninvasive operator-independent tool that enables a precise vascular study of the donor site with accurate identification of septocutaneous or musculocutaneous perforator vessels before anterolateral thigh flap harvesting20.
The clinical outcome at the time of the one-year follow-up was good even though the persistence of occasional pain and slight weakness after extreme activities were noted. The AOFAS score that was obtained in this complicated case was satisfying in comparison with the functional assessments reported in the literature after reconstruction of acute or neglected Achilles tendon ruptures15,21,22. However, Cybex testing showed an incomplete recovery of strength at the time of the one-year follow-up.
Some authors have promoted the use of tendon transfers to reinforce the tendon repair22-25. Nevertheless, the case described here shows that such strengthening procedures are not essential when a vascularized tendon graft is used to preserve local tendons.
In the present case, the single-step reconstruction saved both time and expense, provided a functional tendon repair (enabling normal daily activities) with limited donor-site morbidity, and provided an acceptable cosmetic result without the need for a later debulking procedure. Composite microsurgical free-flap transfer, such as an anterolateral thigh flap with vascularized fascia lata, is a valid alternative in cases of combined loss of the Achilles tendon and overlying soft-tissue coverage6.
Reconstruction of segmental loss of the Achilles tendon combined with defects in soft-tissue coverage still remains a challenging issue, particularly after iterative ruptures.
In the case described here, a single surgical procedure involving the use of a composite free anterolateral thigh flap with attached vascularized fascia lata was successful for the treatment of this problem and provided a good functional outcome with cosmetic and stable soft-tissue coverage at the time of the one-year follow-up.
Note: The authors thank S. Fossat, MD (plastic surgeon), for his help, B. De Loynes, MD (orthopaedic surgeon), A. Thome (radiology), and the members of the Percy Military Hospital physical therapy service, including Pr. E. Lapeyre, who were involved in the management of this patient. They also thank Katherine Tyrka for proofreading.
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