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Tokumoto H, Akita S, Kosaka K, Nakamura R, Yamamoto N, Kubota Y, Mitsukawa N. Fascia turnover procedure at breast reconstruction using free TRAM flap for decreasing umbilical migration. J Plast Reconstr Aesthet Surg 2023; 85:120-126. [PMID: 37482025 DOI: 10.1016/j.bjps.2023.06.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/16/2023] [Accepted: 06/29/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The ideal umbilical position is midway between the two iliac crests. Some patients complained that the umbilicus position shifted from the midline after the breast reconstruction with a free muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flap. We considered that the fascia of the external oblique muscle could be applied to the rectus abdominis fascia defect. This study aimed to introduce this "fascia turnover procedure" and compare the umbilical position in this procedure with that in primary fascial closure for the MS-TRAM flap of breast reconstruction. METHODS A total of 152 patients were enrolled (80 patients with fascia turnover (+) vs. 72 patients (-)). The patients' demographics were compared. Horizontal distances (right side: a; left side: b) were measured bilaterally from the lateral abdominal wall to the center of the umbilicus. Frontal abdominal photographs were taken preoperatively (a1, b1) and postoperatively (a2, b2). The rate of umbilical migration (= | (a1 - b1) / (a1 + b1) - (a2 - b2) / (a2 + b2) | × 100%) was calculated. Because the aponeurosis of the external oblique muscle is confirmed in front of the lateral side of the anterior rectus sheath, this procedure could be performed in cases with a medial defect. RESULTS No significant differences in the patients' demographics, including abdominal bulging rates and abdominal wall defect widths were observed between the two groups. The rate of umbilical migration showed a significant difference (median 1.78% vs. 3.70%, P < 0.001). CONCLUSIONS This procedure could decrease the rate of umbilical migration.
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Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Japan.
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Japan
| | - Kentaro Kosaka
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Japan
| | - Rikiya Nakamura
- Department of Breast Surgery, Chiba Cancer Center Hospital, Japan
| | - Naohito Yamamoto
- Department of Breast Surgery, Chiba Cancer Center Hospital, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Japan
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Sayyed AA, Bekeny JC, Day J, Attinger CE, Fan KL, Evans KK. Composite Free Tissue Transfer for Reconstruction of Lower Extremity Tendon Injuries: A Systematic Review. J Reconstr Microsurg 2023; 39:9-19. [PMID: 35738298 DOI: 10.1055/s-0042-1748977] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Adaah A Sayyed
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Jonathan Day
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
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Rein S, Kremer T. [Reconstruction of Soft Tissue Defects of the Achilles Tendon Region: a Literature Review]. HANDCHIR MIKROCHIR P 2022; 54:464-474. [PMID: 35732189 DOI: 10.1055/a-1794-5449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Susanne Rein
- Städtisches Klinikum Sankt Georg Leipzig, Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum
| | - Thomas Kremer
- Städtisches Klinikum Sankt Georg Leipzig, Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum
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Imaizumi A, Toyota Y. One-stage reconstruction of the complex defects of the Achilles tendon and the adjoining calcaneus using the chimeric superolateral thigh flap: A case report. Microsurgery 2022; 42:611-616. [PMID: 35816008 DOI: 10.1002/micr.30937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 05/05/2022] [Accepted: 06/23/2022] [Indexed: 11/09/2022]
Abstract
Reconstruction of the composite defects of the Achilles tendon and the overlying skin is a great challenge. Should the tendon insertion and adjoining calcaneal defects coexist, such reconstruction becomes far more complicated. A chimeric superolateral thigh flap based on the ascending branch of the lateral circumflex femoral artery provides all the components for this complex defect. We aim to illustrate a case underwent one-stage reconstruction of such defects with this chimeric flap. A 55-year-old man presented with composite defects of Achilles tendon (11 cm), adjoining calcaneus (2 × 2 × 3 cm), and the overlying skin (15 × 3.5 cm) due to unsuccessful repair for his right chronic Achilles tendon rupture, which was complicated by infection. This complex defect was reconstructed using a chimeric superolateral thigh flap consisting of the superolateral thigh skin (8.5 × 17.5 cm), full-thickness iliac bone (4 × 3 cm), and the intervening iliotibial tract preserving the fascia-bone junction, which substituted for the lost insertion of the Achilles tendon. Bone union and full weight bearing were achieved by 11 and 24 weeks, respectively, after surgery. Two debulking procedures were performed. Isometric plantar flexion muscle strength was comparable to the healthy side, but isotonic strength was somewhat reduced at 18 months after reconstruction. This chimeric flap provided all the possible components necessary for the complex Achilles tendon defect, and led functional outcomes.
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Affiliation(s)
- Atsushi Imaizumi
- Department of Plastic Surgery, Okinawa Prefectural Chubu Hospital, Okinawa, Japan
| | - Yoshie Toyota
- Department of Plastic Surgery, Okinawa Prefectural Chubu Hospital, Okinawa, Japan
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唐 林, 周 鑫, 黄 波, 刘 安, 黄 宇, 邹 永. [Effectiveness of groin flap with external oblique aponeurosis for tendon and skin defects of dorsal foot]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:215-219. [PMID: 35172408 PMCID: PMC8863523 DOI: 10.7507/1002-1892.202108132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/27/2021] [Accepted: 12/01/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To investigate the effectiveness of groin flap with external oblique aponeurosis in repair of tendon and skin defects of dorsal foot. METHODS Between October 2016 and January 2020, 12 patients with compound tissue defects of the dorsal foot caused by trauma were treated. There were 9 males and 3 females, with a median age of 42 years (range, 32-65 years). The size of the skin defects ranged from 8 cm×5 cm to 12 cm×8 cm. All wounds were accompanied by extensor tendon injury, including 6 cases of extensor hallucis longus tendon defect, 5 cases of extensor digitalis longus tendon defect, and 3 cases of extensor digitalis longus tendon and extensor digitorum brevis defects. The interval between injury and admission was 1-6 hours (mean, 3 hours). After admission, the wounds were thoroughly debrided, and the groin flap with external oblique aponeurosis was used to repair the skin and tendon defects in the second stage. The size of skin flap ranged from 10 cm×6 cm to 13 cm×9 cm, and the size of the external oblique aponeurosis ranged from 5.5 cm×3.0 cm to 8.0 cm×5.0 cm. The wounds at donor sties were sutured directly. RESULTS All flaps survived completely without significant complications. All incisions of the recipient and donor sites healed by first intention. All patients were followed up 16-24 months (mean, 18 months). The flaps were satisfactory in appearance and soft in texture. At last follow-up, 9 cases were excellent and 3 cases were good according to the American Orthopaedic Foot and Ankle Society (AOFAS) metatarsophalangeal-interphalangeal joint scale criteria. The toe function was satisfactory. The line scar was left without hernia or other morbidity on the donor site. CONCLUSION The groin flap with the external oblique aponeurosis can repair the tendon and skin defects of the dorsal foot, with concealed donor site, easy dissection and adjustable thinness, as well as the enough tough aponeurosis.
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Affiliation(s)
- 林 唐
- 西南医科大学附属中医医院手外科(四川泸州 646000)Department of Hand Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 鑫 周
- 西南医科大学附属中医医院手外科(四川泸州 646000)Department of Hand Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 波 黄
- 西南医科大学附属中医医院手外科(四川泸州 646000)Department of Hand Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 安铭 刘
- 西南医科大学附属中医医院手外科(四川泸州 646000)Department of Hand Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 宇 黄
- 西南医科大学附属中医医院手外科(四川泸州 646000)Department of Hand Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 永根 邹
- 西南医科大学附属中医医院手外科(四川泸州 646000)Department of Hand Surgery, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
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Long Term Follow-up of Composite Flaps for Single-stage Reconstruction of Concomitant Tendon and Soft Tissue Defects. Plast Reconstr Surg Glob Open 2022; 10:e4023. [PMID: 35047323 PMCID: PMC8757995 DOI: 10.1097/gox.0000000000004023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
Tendon rupture in the setting of significant soft tissue loss poses a challenging reconstructive situation, which requires (1) recreating a stable gait cycle, (2) reducing shear forces and re-rupture risk, and (3) providing adequate soft tissue coverage. In this study, we outline our experience with composite flaps in single-step reconstruction of various lower extremity tendinous injuries with soft tissue loss. Methods A retrospective review of all patients requiring free tissue transfer at our tertiary wound care center between 2011 and 2020 was performed. Patients undergoing single-stage free tissue transfer for both soft tissue coverage and tendon reconstruction were selected. Variables of interest included demographics, comorbid conditions, baseline functionality, reconstructive details, and wound characteristics. Outcomes of interest were flap success, return to ambulation, time to ambulation, and postoperative complications. Results Nineteen patients were included in this study. Patients were on average 48.0 years old (SD 16.5), with a median Charlson Comorbidity Index of 1.00 (IQR: 0.0-2.5). Defects were most often on the ankle (n = 1 3, 68.4%), with extension to the foot or leg in six of these cases. Median wound size was 68.0 cm2 (IQR: 48.0-120.0). The most common tendon requiring reconstruction was the Achilles (n = 13, 68.4%). An anterolateral thigh flap with attached fascia lata extension rolled into a neotendon was used in all 19 cases. At baseline, all patients were ambulatory. Only one patient (5.3%) required return to the operating room for suspected vascular compromise. At a median of 14.4 months (IQR: 8.5-40.5), all 19 patients were ambulatory. Conclusions Simultaneous reconstruction of tendinous injuries and soft tissue defects can be readily achieved via composite free flaps. Although other methods of reconstruction can be considered for smaller soft tissue and tendon loss, this approach has significant utility for patients with large defects and yields robust return to preinjury functionality.
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Eser C, Karagoz Ceylan OI, Gencel E, Tabakan I, Kokacya O, Yavuz M. Reconstruction of Achilles region defects: A single-centre experience. Int J Clin Pract 2021; 75:e14908. [PMID: 34547158 DOI: 10.1111/ijcp.14908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/11/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes. METHOD In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre. RESULTS Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting. CONCLUSION Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.
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Affiliation(s)
- Cengiz Eser
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ozgun Ilke Karagoz Ceylan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Eyuphan Gencel
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ibrahim Tabakan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Omer Kokacya
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Metin Yavuz
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
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Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap. Injury 2021; 52:1985-1992. [PMID: 33910686 DOI: 10.1016/j.injury.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/18/2021] [Accepted: 04/05/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Achilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue. METHODS 7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel. RESULTS The size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage. CONCLUSION Distally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.
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Anterolateral Thigh and Vascularized-tensor Fascia Lata Flaps for Long-gap Achilles Tendon Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3631. [PMID: 34123689 PMCID: PMC8191696 DOI: 10.1097/gox.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
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.
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Mohsin M, Zargar HR, Bhat TA, Bhat HA, Mir FA, Wani AH. Open tendoachilles injuries due to squatting type of toilet seats: Five-year prospective observational study from a tertiary care center in India. Injury 2020; 51:2316-2321. [PMID: 32620331 DOI: 10.1016/j.injury.2020.06.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/14/2020] [Accepted: 06/28/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Open traumatic tendoachilles injuries due to toilet seats are least reported. The exact mechanism of such injuries is debatable. None of the studies have reported associated neurovascular injuries and the need for microvascular tissue transfer. METHODS It is a 5-year prospective observational study from Sep 2013 - Aug 2018 at a tertiary care center on 26 patients who had sustained foot injuries due to squatting type toilet seats. All the patients were managed by thorough wound irrigation and debridement followed by repair of cut tendoachilles, other tendons and neurovascular structures. All the complications and secondary procedures required were recorded. Functional outcome was assessed by Boyden clinical outcome score. Follow up ranged from 1 to 5 years. RESULTS All the 26 patients reported a particular mechanism of injury. Complete transection of tendoachilles was seen in 23 (88.5%) patients and partial transection in three (11.5%) patients. Microvascular repair of cut posterior tibial artery was undertaken in three and posterior tibial nerve in two cases and microvascular parascapular flap in one case for soft tissue reconstruction. Twenty-three (88.5%) patients had good to excellent Boyden score while three patients (11.5%) had fair to poor score at 1 year. Such severe injuries due to toilet seats have never been reported in literature. CONCLUSIONS Squatting toilet seats can cause devastating foot injuries involving tendons and neurovascular structures and may require microvascular tissue transfer for definitive wound management. The risk of such injuries will continue unless some modifications are undertaken in the design of the seat.
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Affiliation(s)
- Mir Mohsin
- Department of Plastic & Reconstructive Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, J&K, India.
| | - Haroon Rashid Zargar
- Department of Plastic & Reconstructive Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, J&K, India
| | - Tanveer Ahmed Bhat
- Department of Plastic & Reconstructive Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, J&K, India
| | - Hilal Ahmed Bhat
- Department of Plastic & Reconstructive Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, J&K, India
| | - Farooq Ahmed Mir
- Department of Plastic & Reconstructive Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, J&K, India
| | - Adil Hafeez Wani
- Department of Plastic & Reconstructive Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, J&K, India
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Cogswell L, McCulloch R. Extensor mechanism reconstruction in the setting of infected total knee arthroplasty. J Bone Jt Infect 2020; 5:184-186. [PMID: 32670772 PMCID: PMC7358970 DOI: 10.7150/jbji.47622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 11/05/2022] Open
Affiliation(s)
- Lucy Cogswell
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, UK
| | - Rob McCulloch
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, UK
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Maione L, Lisa A, Vinci V, Bandi V, Klinger F, Klinger M. AUtologous fat graft in foot calcaneal postsurgical chronic ulcer. Injury 2019; 50 Suppl 4:S64-S67. [PMID: 31526600 DOI: 10.1016/j.injury.2019.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Post-traumatic injury of talus's posterior area and ankle joint with consequent scar formation is often complicated by an unhealing trophic ulcer. Aim of this paper is to evaluate the autologous fat graft effectiveness in treating Achilles tendon area wounds. MATERIAL AND METHODS From October 2011 to March 2014 we treated with fat graft a total of 7 patients with post-surgical painful chronic ulcer of calcaneal area. Mean age was 38.6 years (range 22-64 years). One patient was a professional football player who was presenting a post-injury ulcer not respondant to advanced dressings. RESULTS Wound rehepitelization was observed in all cases treated within one month and fat grafting resolved pain related to the wound. All patient returned to their daily normal activities. In all cases treated we observed an increased softness of perilesional post-surgical scars. Our professional football player came back able to perform an usual training 5 days post-operation obtaining complete rehepitelization within 3 weeks. DISCUSSION Our surgical approach showed a therapeutic effect that relies on biological properties of adipose tissue; those properties are clear in both procedures of chronic ulcer's rehepitelization stimulation and perilesional tissue's enhancement obtaining pain control. The procedure is safe, with low rate of complication.
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Affiliation(s)
- Luca Maione
- Clinica San Carlo, Plastic Surgery Unit, Via Ospedale 21, 20037, Paderno Dugnano, Milan, Italy
| | - Andrea Lisa
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, Humanitas Clinical and Research Center, University of Milan, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Valeriano Vinci
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, Humanitas Clinical and Research Center, University of Milan, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Valeria Bandi
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, Humanitas Clinical and Research Center, University of Milan, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Francesco Klinger
- Reconstructive and Aesthetic Plastic Surgery School, MultiMedica Holding S.P.A., Plastic Surgery Unit, University of Milan, Sesto San Giovanni, Milan, Italy
| | - Marco Klinger
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, Humanitas Clinical and Research Center, University of Milan, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
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Iceman KL, Magnus MK, Roukis TS. Salvaging the Unsalvageable Severe Malunion Deformity After Displaced Intra-Articular Calcaneal Fractures: What Options Exist? Clin Podiatr Med Surg 2019; 36:339-347. [PMID: 30784541 DOI: 10.1016/j.cpm.2018.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A subset of calcaneal fractures is so severe that it may warrant primary conservative treatment. Unfortunately, nonoperative management of these fractures can lead to the development of a calcaneal malunion and cause significant patient morbidity. Surgical management of these deformities often requires increasingly complex reconstructive procedures. The goals of surgery include re-establishing calcaneal height, restoring the talocalcaneal relationship, and creating a stable, plantigrade foot. This article highlights the available surgical treatment options (including calcanectomy, calcaneal allograft transplantation, vascularized autografts, and calcaneal prostheses) for the management of severe calcaneal malunion deformities.
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Affiliation(s)
- Kelli L Iceman
- Gundersen Medical Foundation, Mail Stop CO3-006A, 1900 South Avenue, La Crosse, WI 54601, USA
| | - Mark K Magnus
- Gundersen Medical Foundation, Mail Stop CO3-006A, 1900 South Avenue, La Crosse, WI 54601, USA
| | - Thomas S Roukis
- Orthopaedic Center, Gundersen Health System, Mail Stop CO2-006, 1900 South Avenue, La Crosse, WI 54601, USA.
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Monnerie C, Le Nen D, Hu W, Letissier H, Kerfant N. [Treatment of necrosis of Achilles tendon without tendon reconstruction: About four cases]. ANN CHIR PLAST ESTH 2019; 64:208-214. [PMID: 30745022 DOI: 10.1016/j.anplas.2019.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/21/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Management of the combined loss of Achilles tendon and skin is difficult. However, these are not exceptional situations after Achilles tendon surgery. Data from the literature are extensive and there is currently no consensus on the technique of tendon reconstruction. CASE REPORTS We report four cases of purulent necrosis of the Achilles tendon complicating longitudinal incision or suturing of a tendon rupture. After debridement of necrotic tissue, the defect was covered either by a fasciocutaneous perforating flap or a thin skin graft without reconstruction of the underlying tendon. DISCUSSION AND CONCLUSION The functional results are very satisfactory with good joint mobilities and a resumption of walking without lameness for all patients. Fibrosis can reconstitute a true neo-tendon confirmed on MRI. The advantages are many compared to other methods: a single operating time is necessary, the postoperative management is simple and it avoids certain technical difficulties related to tendon reconstruction. A larger series would be needed to support these results.
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Affiliation(s)
- C Monnerie
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France.
| | - D Le Nen
- Service de chirurgie orthopédique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - W Hu
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - H Letissier
- Service de chirurgie orthopédique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
| | - N Kerfant
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France
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di Summa PG, Sapino G, Cherubino M, De Santis G, Durand S, Zaugg P, Bauquis O, Raffoul W. Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long term recovery and functional outcomes. Microsurgery 2019; 39:405-415. [PMID: 30672005 DOI: 10.1002/micr.30431] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 12/19/2018] [Accepted: 01/04/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND We evaluated composite anterolateral thigh (ALT) flaps including vascularized fascia lata (FL), for stable soft tissue coverage and tendons restoration at various joint levels in a one-stage procedure. METHODS We performed a retrospective investigation including 21 "functional" ALT flaps between November 2006 and December 2016. In all patients included, FL was shaped to anatomical reproduce a tendon structure. Functional analysis included range of motion and force assessment. Functional scores were established according to Chen classification, DASH, and LEFS score. Defects resulted from tumor excision, trauma, burn, or infection-debridement and were distributed in four main anatomical districts: knee (seven cases), ankle (six cases), forearm-elbow (four cases), and hand-wrist level (three cases). RESULTS Nineteen flaps were raised as free flaps, while two as distally-based propeller flaps. Average follow-up was 38 months. Major complication requiring the harvest of a second flap was seen in two patients, whereas three flaps presented superficial necrosis and was treated in an outpatient regimen. We observed 81% of total ROM recovery compared to contralateral sides with 89% recovered articular stability. Best articulation outcomes were present in elbow reconstruction, while ankle reconstructions showed less articularity. Hospital stay was significantly reduced in hand and wrist functional reconstruction when compared with reconstruction at the ankle level (P < 0.05). CONCLUSION The ALT flap extended to vascularized FL provides a particularly effective and resistant tissue that can be folded to reconstruct and support tendinous structures. This can restore functional and structural integrity after complex defects in a single stage procedure.
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Affiliation(s)
- Pietro G di Summa
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Gianluca Sapino
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,Department of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
| | - Mario Cherubino
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Varese, Varese, Italy
| | - Giorgio De Santis
- Department of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
| | - Sebastien Durand
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Patrice Zaugg
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Olivier Bauquis
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Wassim Raffoul
- Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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Lee YK, Lee M. Treatment of infected Achilles tendinitis and overlying soft tissue defect using an anterolateral thigh free flap in an elderly patient: A case report. Medicine (Baltimore) 2018; 97:e11995. [PMID: 30170404 PMCID: PMC6392569 DOI: 10.1097/md.0000000000011995] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Infected segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a more complex reconstructive challenge. Here, we present a functional reconstruction of infected Achilles tendinitis with combined soft tissue defects using a free composite anterolateral thigh (ALT) flap with vascularized fascia lata in an elderly patient. CASE PRESENTATION A 71-year-old male patient was transferred to our department due to soft tissue defect of the left lower leg and infected Achilles tendinitis. The patient underwent incision and drainage of both lower legs with necrotizing fasciitis in another hospital 2 months ago. Physical examination revealed a 12 × 5 cm wound with exposed Achilles tendon over the posteromedial aspect of lower one-third of the leg. His wound culture grew methicillin-resistant Staphylococcus aureus (MRSA). All infected necrotic Achilles tendon with proximal muscle tissue was excised. The patient underwent successful Achilles tendon reconstruction and soft tissue coverage procedure with a 14 × 7 cm ALT flap with the fascia lata. At the 12-month follow-up, the patient resumed full daily activities, was able to squat, showed a range of motion at the ankle in the 15° dorsiflexion and 45° plantar flexion, and the American Orthopaedic Foot and Ankle Society (AOFAS) score was 94. CONCLUSION A free ALT composite flap with the vascularized fascia lata, was successfully used for the treatment of infected Achilles tendinitis with overlying soft tissue defect even in an elderly patient. Furthermore, it provided satisfactory functional and cosmetic outcomes. Hence, the use of free ALT composite flap is highly recommended in such patients.
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Affiliation(s)
- Young-Keun Lee
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital
| | - Malrey Lee
- The Research Center for Advanced Image and Information Technology, School of Electronics and Information Engineering, Chonbuk National University, Jeonju, Chonbuk, Republic of Korea
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Okochi M, Momiyama M, Okochi H, Ueda K. Early mobilizing and dangling of the lower leg after one-stage reconstruction of Achilles tendon and overlying tissue defect using an anterolateral thigh flap with vascularized fascia lata. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2017; 4:89-95. [PMID: 29152539 PMCID: PMC5678446 DOI: 10.1080/23320885.2017.1396902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 10/23/2017] [Indexed: 11/15/2022]
Abstract
We have treated two patients who had an Achilles tendon and overlying tissue defect using an anterolateral thigh flap with fascia lata. Postoperatively, skeletal suspension of the affected leg and intra-arterial heparin infusion were performed for seven days. Six weeks postoperatively, the patients could walk again.
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Affiliation(s)
- Masayuki Okochi
- Department of Plastic and Reconstructive Surgery, Fukushima Medical UniversityFukushimaJapan
| | - Masanori Momiyama
- Department of Plastic and Reconstructive Surgery, Fukushima Medical UniversityFukushimaJapan
| | - Hiromi Okochi
- Department of Plastic and Reconstructive Surgery, Fukushima Medical UniversityFukushimaJapan
| | - Kazuki Ueda
- Department of Plastic and Reconstructive Surgery, Fukushima Medical UniversityFukushimaJapan
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Abstract
BACKGROUND Amputation has been most commonly considered the only option to achieve local tumor control for calcaneal malignancies. Advances in oncologic treatment modalities and wide resection have made limb salvage increasingly possible. We retrospectively reviewed nine patients with calcaneal malignancies treated with different surgical options. METHODS The diagnoses included chondrosarcoma in three patients, Ewing's sarcoma in three, osteosarcoma in two, and small round cell sarcoma in one. Four patients were managed by below-the-knee amputation owing to neurovascular invasion. Five patients were managed by limb salvage procedures. Pedicled osteomyocutaneous fibular grafts were used to reconstruct the defects created after total calcanectomy in limb salvage procedures. Clinical and radiographic evaluations were performed, and functional outcomes were assessed using the Musculoskeletal Tumor Society score. RESULTS The patients were followed up for a mean of 42.3 months. Wide resection margins were achieved in all of the patients with limb salvage surgery. At the final follow-up, two patients had died of disease. Lung metastasis was found in two patients who were alive with disease. Five patients had no evidence of disease. No local recurrence occurred in this series. All of the fibular flaps survived, and fibula hypertrophies were observed in three patients. Average Musculoskeletal Tumor Society scores were 74.6% and 83.2% in patients with amputation and limb salvage, respectively. CONCLUSIONS After wide resection of a calcaneal malignancy, biological reconstruction using pedicled osteocutaneous fibular flaps has proved to be a successful limb salvage procedure, offering a satisfactory oncologic and functional outcome alternative to amputation in selected patients.
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Affiliation(s)
- Jing Li
- Department of Orthopaedic Oncology, Xijing Hospital Affiliated to the Fourth Military Medical University, Xi'an, China
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Marchesi A, Parodi PC, Brioschi M, Riccio M, Perrotta RE, Colombo M, Calori GM, Vaienti L. Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature. Injury 2016; 47 Suppl 4:S147-S153. [PMID: 27492062 DOI: 10.1016/j.injury.2016.07.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Defects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed. MATERIALS AND METHODS An extensive review of the English literature was performed on PubMed using the following key-words: "Achilles region", "heel", "soft-tissue reconstruction", "flaps", "grafts" and "dermal substitutes". RESULTS A total of 69 complete papers were selected, covering the last thirty years' literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review. CONCLUSIONS The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally-based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.
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Affiliation(s)
- A Marchesi
- Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato, Università degli Studi di Milano, San Donato Milanese, Via Morandi, 30 - 20097, Milan, Italy.
| | - P C Parodi
- Department of Plastic and Reconstructive Surgery, University of Udine, Udine, Italy
| | - M Brioschi
- Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato. Università degli Studi di Milano, San Donato Milanese, Milan, Italy
| | - M Riccio
- Department of Reconstructive Plastic Surgery-Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy
| | - R E Perrotta
- Department of Medical and Surgery Specialties, Section of Plastic Surgery, University of Catania, Catania, Italy
| | - M Colombo
- Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy
| | - G M Calori
- Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy
| | - L Vaienti
- Department of Plastic and Reconstructive Surgery. I.R.C.C.S. Policlinico San Donato, Università degli Studi di Milano, San Donato Milanese, Milan, Italy
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Single-Stage Reconstruction of Achilles Tendon and Overlying Tissue With the Extended Temporoparietal Fasciagaleal Flap—23-Year Follow-Up and the Review of the Literature. Ann Plast Surg 2016; 76 Suppl 3:S165-70. [DOI: 10.1097/sap.0000000000000789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Youn SK, Kim SW, Kim YH, Hwang KT. The composite anterolateral thigh flap for achilles tendon and soft tissue defect reconstruction with tendon repair by fascia with double or triple folding technique. Microsurgery 2015; 35:615-21. [DOI: 10.1002/micr.22490] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 08/17/2015] [Accepted: 08/21/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Seung Ki Youn
- Department of Plastic and Reconstructive Surgery, College of Medicine; Hanyang University; Seoul Korea
| | - Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine; Seoul National University, Seoul National University Hospital; Seoul Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine; Hanyang University; Seoul Korea
| | - Kyu Tae Hwang
- Department of Orthopaedic Surgery, College of Medicine; Hanyang University; Seoul Korea
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22
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Kane JM, Raikin SM. Treatment of Catastrophic Infection After Surgery for Insertional Achilles Enthesopathy: A Case Report and Review of the Literature. Foot Ankle Spec 2015; 8:324-9. [PMID: 25142918 DOI: 10.1177/1938640014546864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED Wound complications after surgical treatment of insertional Achilles enthesopathy are well documented. Skin and tendon necroses pose a significant dilemma with the potential for catastrophic outcomes. Numerous treatment algorithms have been described to treat the resultant skin and tendon defects after catastrophic infection; however, to date, there is no consensus as to the optimal treatment modality. We report our experience in the management of deep infection of 2 patients who had previously undergone surgical treatment for insertional Achilles enthesopathy. A comprehensive review of the literature was undertaken with a focus on described treatment options. LEVELS OF EVIDENCE Therapeutic, Level IV: Case report.
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Affiliation(s)
- Justin M Kane
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (JMK)Rothman Institute, Philadelphia, Pennsylvania (SMR)
| | - Steven M Raikin
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (JMK)Rothman Institute, Philadelphia, Pennsylvania (SMR)
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23
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Bipedicled Flap for the Reconstruction of Soft Tissue Defects of the Achilles Tendon. Ann Plast Surg 2015; 74:484-7. [DOI: 10.1097/sap.0b013e3182a1e508] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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End-to-patch anastomosis for microvascular transfer of free flaps with small pedicle. J Plast Reconstr Aesthet Surg 2015; 68:559-64. [DOI: 10.1016/j.bjps.2014.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 11/22/2014] [Accepted: 11/28/2014] [Indexed: 11/21/2022]
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25
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Michel G, Ho Quoc C, Assaf N, Delay E, Sinna R. Reconstruction dynamique de tendon d’Achille par lambeau perforant composite avec évaluation fonctionnelle. ANN CHIR PLAST ESTH 2015; 60:78-83. [DOI: 10.1016/j.anplas.2014.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 05/18/2014] [Indexed: 10/25/2022]
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27
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Uchikawa Y, Yazawa M, Kishi K. A vascularised gracilis flap with tibial bone for the reconstruction of the Achilles tendon. J Plast Reconstr Aesthet Surg 2013; 66:e281-3. [DOI: 10.1016/j.bjps.2013.03.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 03/16/2013] [Indexed: 11/29/2022]
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Upadhyaya DN, Khanna V, Kohli R, Tulsi SPS, Garg S. Functional reconstruction of complex tendo Achilles defect by free latissimus dorsi muscle flap. Indian J Plast Surg 2013; 45:572-5. [PMID: 23450740 PMCID: PMC3580366 DOI: 10.4103/0970-0358.105983] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Managing the complex tendo Achilles defect involves reconstructing the Achilles tendon as well as providing soft tissue cover to the heel area. The advent of microsurgery has revolutionised the reconstruction of this difficult defect providing a number of options to the reconstructive surgeon. We present a case of complex tendo Achilles defect reconstructed by the latissimus dorsi free flap.
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Affiliation(s)
- Divya N Upadhyaya
- Department of Plastic, Craniofacial and Microsurgery, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Duhamel P, Fossat S, Brachet M, Mathieu L, Rigal S, Bey E. Simultaneous Reconstruction of Achilles Tendon and Soft-Tissue Defects with a Composite Anterolateral Thigh Free Flap with Vascularized Fascia Lata. JBJS Essent Surg Tech 2011; 1:e8. [PMID: 34377585 DOI: 10.2106/jbjs.st.k.00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction Reconstruction to treat segmental loss of the Achilles tendon combined with soft-tissue defects can be challenging, particularly after the recurrent ruptures that may occur during intense physical activity. Step 1 Preoperative Planning Design flap and use Doppler ultrasound for perforator mapping. Step 2 Debride Wound and Prepare Recipient Vessels Use a two-team approach, one for the affected side and one for the unaffected side. Step 3 Harvest the Composite ALT Flap Take care to include one or two perforator vessels in the flap and to avoid vessel damage throughout the dissection. Step 4 Perform Vascular Anastomosis Use the posterior tibial vessel as the recipient site for the microvascular anastomosis. Step 5 Reconstruct the Achilles Tendon Suture the rolled up vascularized fascia lata sheet; then check for tension. Step 6 Postoperative Care Gradual, protected weight-bearing begins at twelve weeks. Results & Preop/Postop Images For recurrent tendon rupture, this single-step reconstruction saves both time and expense and it provides a functional tendon reconstruction (enabling normal daily activities) with limited donor-site morbidity and an acceptable cosmetic result without the need for a later debulking procedure. What to Watch For IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Patrick Duhamel
- Plastic and Maxillofacial Surgery Service (P.D., S.F., M.B., and E.B.) and Orthopaedic Surgery and Trauma Service (L.M. and S.R.), HIA Percy, 101 Avenue Henri Barbusse, BP 406-92141 Clamart, France. E-mail address for P. Duhamel: . E-mail address for S. Fossat: . E-mail address for M. Brachet: . E-mail address for L. Mathieu: . E-mail address for S. Rigal: . E-mail address for E. Bey:
| | - Sébastien Fossat
- Plastic and Maxillofacial Surgery Service (P.D., S.F., M.B., and E.B.) and Orthopaedic Surgery and Trauma Service (L.M. and S.R.), HIA Percy, 101 Avenue Henri Barbusse, BP 406-92141 Clamart, France. E-mail address for P. Duhamel: . E-mail address for S. Fossat: . E-mail address for M. Brachet: . E-mail address for L. Mathieu: . E-mail address for S. Rigal: . E-mail address for E. Bey:
| | - Michel Brachet
- Plastic and Maxillofacial Surgery Service (P.D., S.F., M.B., and E.B.) and Orthopaedic Surgery and Trauma Service (L.M. and S.R.), HIA Percy, 101 Avenue Henri Barbusse, BP 406-92141 Clamart, France. E-mail address for P. Duhamel: . E-mail address for S. Fossat: . E-mail address for M. Brachet: . E-mail address for L. Mathieu: . E-mail address for S. Rigal: . E-mail address for E. Bey:
| | - Laurent Mathieu
- Plastic and Maxillofacial Surgery Service (P.D., S.F., M.B., and E.B.) and Orthopaedic Surgery and Trauma Service (L.M. and S.R.), HIA Percy, 101 Avenue Henri Barbusse, BP 406-92141 Clamart, France. E-mail address for P. Duhamel: . E-mail address for S. Fossat: . E-mail address for M. Brachet: . E-mail address for L. Mathieu: . E-mail address for S. Rigal: . E-mail address for E. Bey:
| | - Sylvain Rigal
- Plastic and Maxillofacial Surgery Service (P.D., S.F., M.B., and E.B.) and Orthopaedic Surgery and Trauma Service (L.M. and S.R.), HIA Percy, 101 Avenue Henri Barbusse, BP 406-92141 Clamart, France. E-mail address for P. Duhamel: . E-mail address for S. Fossat: . E-mail address for M. Brachet: . E-mail address for L. Mathieu: . E-mail address for S. Rigal: . E-mail address for E. Bey:
| | - Eric Bey
- Plastic and Maxillofacial Surgery Service (P.D., S.F., M.B., and E.B.) and Orthopaedic Surgery and Trauma Service (L.M. and S.R.), HIA Percy, 101 Avenue Henri Barbusse, BP 406-92141 Clamart, France. E-mail address for P. Duhamel: . E-mail address for S. Fossat: . E-mail address for M. Brachet: . E-mail address for L. Mathieu: . E-mail address for S. Rigal: . E-mail address for E. Bey:
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Baden JM, Warr RP, Khan U. Immediate free tissue transfer for coverage of Achilles tendon injury or reconstruction. Foot Ankle Surg 2010; 16:164-9. [PMID: 21047603 DOI: 10.1016/j.fas.2009.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 08/25/2009] [Accepted: 10/13/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND The restoration of function and contour to the Achilles region is a complex problem. This is reflected in the variety of reconstructive options described in the literature. The aim however remains to normalise the range of movement at the ankle joint and restore the power of plantar flexion. Few techniques have demonstrated this. METHODS Six patients underwent soft tissue reconstruction over the Achilles tendon with a free scapular flap. Two ruptured Achilles tendons were reconstructed with FHL transfers. RESULTS All six flaps remained viable and achieved stable coverage over the Achilles tendon. Five of the six required thinning for use of normal foot wear. Those that had FHL transfer normalised their range of movement. CONCLUSIONS It has previously been shown that FHL transfer provides optimum results in terms of functional outcome while here the scapular flap has fulfilled the requirement to restore the contour of this region.
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Affiliation(s)
- James Martin Baden
- Department of Plastic Surgery, Frenchay Hospital, Frenchay Park Rd, Frenchay, Bristol BS16 1LE, United Kingdom.
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31
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Duhamel P, Mathieu L, Brachet M, Compere S, Rigal S, Bey E. Reconstruction of the Achilles tendon with a composite anterolateral thigh free flap with vascularized fascia lata: a case report. J Bone Joint Surg Am 2010; 92:2598-603. [PMID: 21048179 DOI: 10.2106/jbjs.i.01578] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Patrick Duhamel
- Plastic and Maxillofacial Surgery Service, HIA Percy, 101 Avenue Henri Barbusse, BP 406-92141 Clamart, France.
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Huang D, Wang HW, Xu DC, Wang HG, Wu WZ, Zhang HR. An anatomic and clinical study of the adductor magnus tendon-descending genicular artery bone flap. Clin Anat 2010; 24:77-83. [DOI: 10.1002/ca.21060] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Li J, Guo Z, Pei GX, Wang Z, Chen GJ, Wu ZG. Limb salvage surgery for calcaneal malignancy. J Surg Oncol 2010; 102:48-53. [PMID: 20578078 DOI: 10.1002/jso.21564] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy increasingly possible. However, reconstructions of the calcaneal remain a major surgical challenge because of the rarity and specific anatomy of this condition. METHODS we retrospectively reviewed five patients who had primary calcaneal malignancy and underwent total calcanectomy and reconstructions with the distally pedicled osteocutaneous folded fibular flap between 2001 and 2007. The diagnoses included chondrosarcoma in 2, Ewing's sarcoma in 2 and osteosarcoma in 1. Three tumors were classified as stage-II B lesions, one as I A and one as II A. Wide resection margins were achieved in all patients. The patients were followed up for a mean of 50.4 months (range, 32-76 months). Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society (MSTS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score. RESULTS Four patients had no evidence of disease, and lung metastasis was found in one patient who was alive with disease. No local recurrence occurred in this series. At latest evaluation four patients had no evident limp or limitation of daily activities and one patient had mild limp. The average MSTS 93 score and AOFAS score were 83.2% and 86.4% at the last follow-up, respectively. All fibular flaps survived and bone unions achieved successfully. Fibula hypertrophies were seen in three patients. The overall mean time for bone union was 6.2 months. The mean time to full weight-bearing was 8.6 months. The average two-point discrimination was 2.3 cm at the time of final follow-up. Two patients had surgery-related complications including hematoma in 1 and skin margin necrosis in 1. CONCLUSIONS Following the wide resection of calcaneal malignancy, biological reconstruction using distally pedicled osteocutaneous fibular has proven to be a successful limb salvage procedure, offering satisfactory local tumor control and functional restoration of the lower extremity function.
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Affiliation(s)
- Jing Li
- Orthopaedic Oncology Department, Xijing Hospital Affiliated to the Fourth Military Medical University, Xi'an, People's Republic of China
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Lykoudis EG, Contodimos GV, Ristanis S, Georgoulis AD, Lazarou SA. One-stage complex Achilles tendon defect reconstruction with an Achilles tendon allograft and a gracilis free flap. Foot Ankle Int 2010; 31:634-8. [PMID: 20663433 DOI: 10.3113/fai.2010.0634] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level of Evidence: V, Expert Opinion
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Affiliation(s)
- Efstathios G Lykoudis
- Department of Plastic Surgery and Burns, Ioannina University School of Medicine, University Campus, 45110 Ioannina, Greece.
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Parkar AAH, Taylor M, Patel N, Ramakrishnan V. Regeneration of tendo Achillis. THE JOURNAL OF BONE AND JOINT SURGERY. BRITISH VOLUME 2010; 92:885-887. [PMID: 20513890 DOI: 10.1302/0301-620x.92b6.23323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A child with traumatic laceration of the tendo Achillis developed secondary infection after primary repair. This resulted in the loss of 5 cm of the distal part of the tendon and overlying soft tissue. The patient was treated with a free skin flap to cover the wound and to control the infection leaving reconstruction for a second-stage procedure. However, when he was assessed two years after the skin-flap, delayed reconstruction proved to be unnecessary since he had regained normal ankle function spontaneously and could demonstrate equal function in both tendons.
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Abstract
The most suitable free flap alternative in upper extremity reconstruction has adequate and quality of tissue with consistent vascular pedicle. Free flap must provide convenient tissue texture to reconstruct aesthetic and functional units of upper extremity. Furthermore, minimal donor site morbidity is preferred features in free flap election. In our efforts to obtain the best possible outcome for patients, we chose, as a first priority, the free superficial circumflex inferior artery (SCIA)/superficial inferior epigastric artery (SIEA) flap over other free flap options for the soft-tissue reconstruction of upper extremities. The authors retrospectively report the results of 20 free SCIA/SIEA flaps for upper extremity reconstruction during the past 3 years. Nineteen of 20 flaps were successful (95%): three required emergent postoperative reexploration of the anastomosis and one failed. Flap thinning (n = 4) was performed during the flap harvest, whereas some flaps were thinned with secondary debulking (n = 4). The functional and aesthetic results were evaluated as acceptable by all patients. Based on our results, a free SCIA/SIEA flap has the following advantages in soft-tissue reconstruction of the upper extremity: (1) if necessary, flap thinning may be performed safely at the time of flap elevation and (2) flaps are harvested using a lower abdominal incision so that it causes minimal donor site scar.
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Affiliation(s)
- Serdar Nasir
- Department of Plastic and Reconstructive Surgery, Hacettepe University, School of Medicine, Ankara, Turkey.
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Strategies for managing massive defects of the foot in high-energy combat injuries of the lower extremity. Foot Ankle Clin 2010; 15:139-49. [PMID: 20189121 DOI: 10.1016/j.fcl.2009.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Blast-related lower extremity trauma presents many challenges in its management that are not frequently experienced in high-energy civilian trauma. Because many of the blasts experienced in the current conflicts are ground based, the foot and ankle have sustained considerable severity and extent of injury because of the proximity of the blast. The high functional demands required of active service members create several reconstructive challenges. The authors' experience in the current conflicts has shown a similar trend, with the magnitude of soft tissue injury usually dictating whether or not salvage may be possible. Several reconstructive options for bone defect management are outlined and discussed.
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Chalmers R, Tare M, Niranjan N. Vascularised Achilles tendon graft reconstruction – By the tendon for the tendon. J Plast Reconstr Aesthet Surg 2010; 63:e273-6. [DOI: 10.1016/j.bjps.2009.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 07/04/2009] [Accepted: 07/08/2009] [Indexed: 10/20/2022]
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Scoccianti G, Campanacci DA, Innocenti M, Beltrami G, Capanna R. Total calcanectomy and reconstruction with vascularized iliac bone graft for osteoblastoma: a report of two cases. Foot Ankle Int 2009; 30:716-20. [PMID: 19589324 DOI: 10.3113/fai.2009.0716] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Guido Scoccianti
- Orthopedic Oncology Unit, Azienda Ospedaliero-Universitaria Careggi, C.T.O., Largo Palagi 1, Firenze, 50139, Italy.
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Abstract
We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.
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Affiliation(s)
- M. R. Brinker
- Center for Problem Fractures and Limb Restoration Fondren Orthopedic Group, 7401 S. Main Street, Houston, Texas 77030, USA
| | - D. P. Loncarich
- Center for Problem Fractures and Limb Restoration Fondren Orthopedic Group, 7401 S. Main Street, Houston, Texas 77030, USA
| | - E. G. Melissinos
- University of Texas Medical School-Houston, 6410 Fannin St Ste 1220, Houston, Texas 77030, USA
| | - D. P. O’Connor
- University of Houston, 3855 Holman GAR 104, Houston, Texas 77204-6015, USA
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Zhu YL, Xu YQ, Yang J, Li J. One-Stage Reconstruction of Achilles Tendon and Skin Defects by the Sliding Gastrocnemius Musculocutaneous Flap Without Anastomosis. ACTA ACUST UNITED AC 2009; 66:1129-34. [DOI: 10.1097/ta.0b013e31817dac20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Reconstruction of Soft Tissue Defects Overlying the Achilles Tendon Using the Super Extended Abductor Hallucis Muscle Flap. ACTA ACUST UNITED AC 2008; 65:1459-62. [DOI: 10.1097/ta.0b013e31815ede2f] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gruber S, Michlits W, Papp C. The new distal soleus adiposal pull-through composite flap for reconstruction of defects overlying the Achilles tendon: The anatomy and clinical experience. Surgery 2008; 143:441-6. [DOI: 10.1016/j.surg.2007.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 10/24/2007] [Accepted: 10/25/2007] [Indexed: 10/22/2022]
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Newman C, Molnar JA. Achilles tendon reconstruction after electrical injury with a neurotized cross-leg fillet flap. Ann Plast Surg 2007; 59:447-50. [PMID: 17901740 DOI: 10.1097/sap.0b013e31802e32d1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors present a case where a cross-leg fillet flap from an amputated limb allowed reconstruction of the contralateral disrupted Achilles tendon and provided neurotized soft tissue. Achilles tendon reconstruction of the left leg was achieved by utilizing vascularized extensor tendons from the dorsum of the right foot based on the dorsalis pedis circulation. Neurotization was accomplished end to side between a cutaneous nerve from the dorsum of the foot and the recipient sural nerve. Healing was complete and without complication. Cross-leg flaps including tendon and nerve may be used to reconstruct complex lower-extremity injuries, even when free flaps are not feasible.
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Affiliation(s)
- Chad Newman
- Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157, USA
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Lepow GM, Green JB. Reconstruction of a neglected achilles tendon rupture with an achilles tendon allograft: A case report. J Foot Ankle Surg 2006; 45:351-5. [PMID: 16949535 DOI: 10.1053/j.jfas.2006.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Multiple surgical techniques for repair of neglected Achilles tendon ruptures have been described in the literature. The authors present a case using a freeze-dried Achilles tendon allograft for repair of a neglected rupture of the Achilles tendon with a defect of 10 cm. At 1-year follow-up, the patient achieved pre-injury functional use of the affected limb.
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Affiliation(s)
- Gary M Lepow
- American Board of Podiatric Surgery, Houston Podiatric Foundation Surgical Residency, Kingwood, TX, USA
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Lin CH, Mardini S, Wei FC, Lin YT, Chen CT. Free Flap Reconstruction of Foot and Ankle Defects in Pediatric Patients: Long-Term Outcome in 91 Cases. Plast Reconstr Surg 2006; 117:2478-87. [PMID: 16772960 DOI: 10.1097/01.prs.0000219133.72059.71] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Free tissue transfer has not been fully adopted as the primary mode of treating foot and ankle defects in potentially indicated patients, partly because of the lack of sizable vessels and the potential in the long term of differential growth in the flap and the recipient site. Also lacking are long-term outcome studies in these growing patients. METHODS Between 1989 and 2002, 91 children with 93 foot and ankle defects underwent microsurgical reconstructions. The patients underwent reconstruction with flaps with a cutaneous component or with muscle flaps (skin-grafted). RESULTS Fifty-eight defects were reconstructed with cutaneous/musculocutaneous flaps (37 fasciocutaneous and 21 musculocutaneous flaps), and 35 were reconstructed with skin-grafted muscle flaps. Thirteen patients underwent secondary free flap surgery, for a total of 106 flaps used to complete the reconstructions. Twelve cases underwent reexploration, and overall survival was 95.3 percent (101 of 106). Secondary deformities were present in 37.9 percent of skin/musculocutaneous flaps and 58.9 percent of skin-grafted muscle flaps (p = 0.029). More resurfacing procedures were performed in skin-grafted muscle flaps than in skin/musculocutaneous flaps (32.4 percent versus 12.1 percent; p = 0.0386). CONCLUSIONS Free tissue transfer in pediatric patients is a viable and reliable option. Skin/musculocutaneous flaps and skin-grafted muscle flaps both had equal survival rates; however, flaps with a skin component required fewer secondary procedures to correct deformities. Whenever a skin component was present, it provided useful tissue during the secondary procedure and minimized complications. For plantar foot reconstructions, skin-grafted muscle flaps demonstrated a higher incidence of trophic ulcers and a higher need for resurfacing procedures than flaps with a skin component. Reconstructions of tendons in the immediate setting led to fewer secondary operations than staged tendon reconstructions.
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Affiliation(s)
- Chih-Hung Lin
- Trauma Center, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kweishan, Taoyuan 33333, Taiwan.
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Attinger CE, Ducic I, Hess CL, Basil A, Abbruzzesse M, Cooper P. Outcome of Skin Graft versus Flap Surgery in the Salvage of the Exposed Achilles Tendon in Diabetics versus Nondiabetics. Plast Reconstr Surg 2006; 117:2460-7. [PMID: 16772957 DOI: 10.1097/01.prs.0000219345.73727.f5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Achilles tendon wounds pose a reconstructive dilemma because of the tendon's functional importance and the paucity of soft tissue surrounding the ankle. The currently accepted treatment is to repair the wound with a flap (local, pedicled, or free). In this article, the authors examine whether skin graft coverage of the exposed Achilles tendon is a viable option for reconstruction and whether the comorbidity of diabetes affects the outcome. METHODS Forty-five consecutive patients presenting with wounds involving the Achilles tendon in 49 limbs were retrospectively evaluated from the authors' limb salvage registry from 1990 to 1999. RESULTS After initial debridement, the method of reconstruction consisted of closure by secondary intention (n = 6), skin grafting (n = 27), and reconstruction with a flap (n = 10) or free flaps (n = 6). The primary success rate of each procedure was not significantly different: secondary intention, 83 percent; skin graft, 83 percent; local flap, 80 percent; and free flap, 83 percent. The overall wound-healing rate was 96 percent and the limb salvage rate was 98 percent. Six wounds eventually recurred in patients who had undergone skin grafting. All but one went on to heal with conservative therapy. There was no difference in any of the result parameters between diabetics and nondiabetics. CONCLUSIONS This study demonstrates that, with a properly prepared wound bed, skin grafting can be as effective as local or free flaps in successfully healing Achilles tendon wounds. Diabetes should not be used as a contraindication to limb salvage in patients who present with Achilles tendon ulceration or gangrene.
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Peek A, Giessler GA. Functional Total and Subtotal Heel Reconstruction With Free Composite Osteofasciocutaneous Groin Flaps of the Deep Circumflex Iliac Vessels. Ann Plast Surg 2006; 56:628-34. [PMID: 16721075 DOI: 10.1097/01.sap.0000205768.96705.1e] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Functional and esthetic reconstruction of the bony and tendinous structures with a stable, sensate soft tissue integument after complex posttraumatic defects of the heel is demanding. Cases are rare in the literature and hardly comparable due to their heterogeneity. The reconstructive approach has to consider both patient profile and the reconstructive tree, with free microvascular flaps playing a primary role. The goals are the reconstruction of both osteotendinous structures and slender soft tissue lining for proper shoe fitting for ambulation and mechanical and thermal protection. The flap should be sensate in weightbearing areas to optimize gait and to prevent long-term complications by ulcers. The osteofasciocutaneous deep inferior circumflex artery (DCIA) flap is especially suitable for complex heel defects with subtotal or total loss of the calcaneal bone as all components (iliac bone, groin skin, and fascia lata) can have a wide range of size and shape. We operated on 2 cases with this variable composite flap. One patient had a complete heel defect by war shrapnel. The complete calcaneus, soft heel, and Achilles tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and a lateral crush-induced soft tissue defect. In both patients, a stable wound closure, osseous integration, and weightbearing ambulation could be achieved.
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Affiliation(s)
- Alberto Peek
- Department for Plastic and Hand Surgery, Breast Center, Behandlungszentrum Vogtareuth, Germany
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Dabernig J, Shilov B, Schumacher O, Lenz C, Dabernig W, Schaff J. Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap. J Plast Reconstr Aesthet Surg 2006; 59:142-7. [PMID: 16703858 DOI: 10.1016/j.bjps.2005.07.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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 90 degrees 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.
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Affiliation(s)
- J Dabernig
- Department of Hand-, Micro- and Plastic Surgery, Amper Kliniken AG, Klinikum Dachau, 85221 Dachau, Germany.
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