Double-Layer Reconstruction of the Achilles' Tendon Using a Modified Lindholm's Technique and Vascularized Fascia Lata

Composite Free Tissue Transfer for Reconstruction of Lower Extremity Tendon Injuries: A Systematic Review

BACKGROUND

 Tendon rupture with extensive soft tissue loss has few reconstructive options. Composite free tissue transfers including skin and tendon offer an attractive reconstructive approach. Unfortunately, most studies discussing them come from sparse case reports. We systematically assess evidence supporting composite flap use in single-stage reconstruction of lower extremity tendon and soft tissue defects.

METHODS

 A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. OvidMEDLINEqueried for records pertaining to the study question using Medical Subject Heading (MeSH) terms such as "lower extremity," "tendon," and "composite flap." No limitations were placed on the year of publication, country of origin, or study size. Study characteristics and patient demographics were collected. Primary outcomes included:(1) defect location, composite flap characteristics;(2) return to ambulation;(3) joint range of motion;(4) patient satisfaction, and (5) complications.

RESULTS

 In total, 29 articles examining 173 patients with lower extremity tendon defects and soft tissue loss were identified. Average age was 44.3 years (SD 17.5); most patients were male (n = 110, 66.3%). Achilles defect was mostly reported (n = 151, 86.8%), followed by patellar (n = 17, 9.8%) and other tendon defects (n = 6, 3.4%). Average tendon defect size was 8.4 cm (SD 4.0), average soft tissue loss was 80.2 cm² (SD 40.0). Most employed composite flap was anterolateral thigh and fascia lata (ALT + FL) (n = 101, 58.0%). Most patients (n = 134, 99.3%) returned to ambulation in an average 123.1 days (SD 78.3). Average reconstructive joint degree of motion was 62.1 degrees compared with normal degree of motion 62.3 degrees. Patient-reported outcomes demonstrated increased satisfaction after reconstruction.

CONCLUSION

 Composite flaps effectively reconstruct a variety of tendon and soft tissue defects; the most reported flap is ALT + FL, which provides large flap territories and rapid healing in Achilles, patellar, and other tendon defects. In this review, patients with composite flaps demonstrated return to ambulation, minimal impairment in range of motion, and notable postoperative satisfaction.

[Reconstruction of Soft Tissue Defects of the Achilles Tendon Region: a Literature Review]

BACKGROUND

Soft tissue defects in the achilles tendon region occur after trauma, but also as a complication after open recon- struction of the tendon with subsequent infection.

OBJECTIVES

Recommendations for the treatment of soft tissue injuries involving the Achilles tendon are presented.

MATERIALS AND METHODS

A search of the German, French and English literature on reconstruction of soft tissue defects of the Achilles tendon region was performed, which were differentiated into singular and combined tendocutaneous defects. Combined defects were further subdivided into three reconstructive principles: a simple soft tissue reconstruction without tendon repair or a combined reconstruction of the soft tissue as well as the tendon using either a vascularized tendon transplant or an avascular tendon graft.

RESULTS

Local and distally-based pedicled flaps include a relatively high risk or perioperative morbidity, whereas free flaps are described with significantly lower complications rates. Therefore, the authors prefer free flaps for reconstruction. Potential donor sites are the Medial Sural Artery (MSAP-) flap for smaller defects or free fasciocutaneous or muscle flaps in patients with large defects. The standard for tendocutaneousreconstructions is the free anterolateral thigh flap including vascularized fascia. Non-vascularized tendon grafts are frequently applied from the flexor hallucis longus- or peroneus brevis tendon.

CONCLUSIONS

Reconstructions over the Achilles tendon require thin and stable reconstructions that additionally allow slippage of soft tissues. Moreover, the use of normal shoes should be possible. The postoperative strength and range of motion of the ankle joint show comparable functional results after vascularized and non-vascularized tendon reconstruction.

Anterolateral Thigh and Vascularized-tensor Fascia Lata Flaps for Long-gap Achilles Tendon Reconstruction

We demonstrated our surgical technique of 8-cm segmental loss Achilles tendon reconstruction and repair of posterior heel skin and soft tissue defects with composite anterolateral thigh and 4-layer folding vascularized-tensor fasciae latae flaps of a 15-year-old adolescent boy's post-traumatic injury and infection after primary repair. This technique highlights the ease of harvesting the flap, short operative time, and facilitation of the strong and sustainable motion of the Achilles tendon after reconstruction.