J Reconstr Microsurg 2017; 33(S 01): S40-S47
DOI: 10.1055/s-0037-1606554
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Achilles Region Soft-Tissue Defects: A Reconstructive Algorithm Based on a Series of 46 Cases

Marco Innocenti
1   Department of Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
,
Alessandro Innocenti
1   Department of Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
,
Serena Ghezzi
1   Department of Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
,
Luca Delcroix
1   Department of Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
› Institutsangaben
Weitere Informationen

Publikationsverlauf

24. Mai 2017

02. August 2017

Publikationsdatum:
06. Oktober 2017 (online)

Abstract

Background Several options have been described for soft-tissue reconstruction in Achilles tendon region (ATR). The best procedure should be customized according to any single case taking into account the number of structures involved, the quality of the neighboring skin, and patient's general condition. The aim of this article is to describe a simplified reconstructive algorithm based on personal experience and reviewing literature.

Methods Forty-four patients, who underwent ATR soft-tissue reconstruction between 1998 and 2016, have been retrospectively reviewed. Etiologies of the defect include the following: 18 posttraumatic, 10 postoncologic, 14 dehiscence/infection, and 2 chronic ulcers. Follow-up ranges between 12 and 96 months. Free flaps have been used in 30 cases (including two secondary surgeries due to propeller flap failure) and propeller flaps have been used in 16 cases.

Results Thirty-six flaps survived uneventfully (78.3%). Total flap necrosis occurred in three cases (6.5%), namely, two propeller flaps and one free flap. Partial necrosis of the flap was observed in seven cases (15, 2%): three in the free flap group and four in the propeller group. The functional recovery was very good in all the patients without involvement of the tendon and also all the patients who underwent a simultaneous reconstruction of the tendon with different techniques recovered a full weight bearing and a satisfactory range of motion.

Conclusion Propeller flaps are a valuable option for skin reconstruction in case of defects of small and medium size not involving the tendon. In case of larger defects and when a simultaneous ATR reconstruction is required, a free flap seems to be a better option.

Disclosure

The authors have no financial interest to declare in relation to the content of this article.


 
  • References

  • 1 Langer V. Management of major limb injuries. Sci World J 2014; 2014: 640430
  • 2 Hayafune N, Hayafune Y, Jacob HAC. Pressure and force distribution characteristics under the normal foot during the push-off phase in gait. The Foot 1999; 9: 88-92
  • 3 Murphy DF, Beynnon BD, Michelson JD, Vacek PM. Efficacy of plantar loading parameters during gait in terms of reliability, variability, effect of gender and relationship between contact area and plantar pressure. Foot Ankle Int 2005; 26 (02) 171-179
  • 4 Meyers-Rice B, Sugars L, McPoil T, Cornwall MW. Comparison of three methods for obtaining plantar pressures in nonpathologic subjects. J Am Podiatr Med Assoc 1994; 84 (10) 499-504
  • 5 Hughes J, Pratt L, Linge K, Clark P, Klenerman L. Reliability of pressure measurements: the EM ED F system. Clin Biomech (Bristol, Avon) 1991; 6 (01) 14-18
  • 6 Titianova EB, Mateev PS, Tarkka IM. Footprint analysis of gait using a pressure sensor system. J Electromyogr Kinesiol 2004; 14 (02) 275-281
  • 7 Innocenti M, Tani M, Carulli C, Ghezzi S, Raspanti A, Menichini G. Radial forearm flap plus flexor carpi radialis tendon in Achilles tendon reconstruction: surgical technique, functional results, and gait analysis. Microsurgery 2015; 35 (08) 608-614
  • 8 Hallock GG. Evidence based medicine: lower extremity acute trauma. Plast Reconstr Surg 2013; 132: 1733-1741
  • 9 Gehmert S, Geis S, Lamby P. , et al. Evaluation of hyperbaric oxygen therapy for free flaps using planar optical oxygen sensors. Preliminary results. Clin Hemorheol Microcirc 2011; 48 (01) 75-79
  • 10 Repta R, Ford R, Hoberman L, Rechner B. The use of negative-pressure therapy and skin grafting in the treatment of soft-tissue defects over the Achilles tendon. Ann Plast Surg 2005; 55 (04) 367-370
  • 11 Stannard JP, Volgas DA, McGwin III G, Steward RL, Obremskey W, Moore T. Incisional negative pressure wound therapy after high risk lower extremity fractures. J Orthop Trauma 2012; 26: 3742
  • 12 Vaienti L, Marchesi A, Palitta G, Gazzola R, Parodi PC, Leone F. Limb trauma: the use of an advanced wound care device in the treatment of full-thickness wounds. Strateg Trauma Limb Reconstr 2013; 8 (02) 111-115
  • 13 Attinger CE, Ducic I, Hess CL, Basil A, Abruzzesse 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 (07) 2460-2467
  • 14 Marchesi A, Brioschi M, Parodi PC, Marchesi M, Brambilla R, Vaienti L. Allogeneic epidermal substitutes in the treatment of chronic diabetic leg and foot ulcers. Plast Aesthet Res 2014; 1: 74-80
  • 15 Innocenti M, Menichini G, Baldrighi C, Delcroix L, Vignini L, Tos P. Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction?. Clin Orthop Relat Res 2014; 472 (07) 2276-2286
  • 16 Lee JW, Yu JC, Shieh SJ, Liu C, Pai JJ. Reconstruction of the Achilles tendon and overlying soft tissue using antero-lateral thigh free flap. Br J Plast Surg 2000; 53 (07) 574-577
  • 17 Jiga LP, Barac S, Taranu G. , et al. The versatility of propeller flaps for lower limb reconstruction in patients with peripheral arterial obstructive disease: initial experience. Ann Plast Surg 2010; 64 (02) 193-197
  • 18 Ignatiadis IA, Georgakopoulos GD, Tsiampa VA, Polyzois VD, Arapoglou DK, Papalois AE. Distal posterior tibial artery perforator flaps for the management of calcaneal and Achilles tendon injuries in diabetic and non-diabetic patients. Diabet Foot Ankle 2011; 2: 2
  • 19 Vaienti L, Calori GM, Leone F, Brioschi M, Parodi PC, Marchesi A. Posterior tibial artery perforator flaps for coverage of Achilles region defects. Injury 2014; 45 (Suppl. 06) S133-S137
  • 20 Raspanti A, Delcroix L, Ghezzi S, Innocenti M. Study of the tendinous vascularization for the compound radial forearm flap plus flexor carpi radialis tendon. Surg Radiol Anat 2016; 38 (04) 409-414
  • 21 Houtmeyers P, Opsomer D, Van Landuyt K, Monstrey S. Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata. J Reconstr Microsurg 2012; 28 (03) 205-209
  • 22 Smit JM, Darcy CM, Audolfsson T, Hartman EH, Acosta R. Multilayer reconstructions for defects overlying the Achilles tendon with the lateral-arm flap: long-term follow-up of 16 cases. Microsurgery 2012; 32 (06) 438-444
  • 23 Kim CH, Tark MS, Choi CY, Kang SG, Kim YB. A single-stage reconstruction of a complex Achilles wound with modified free composite lateral arm flap. J Reconstr Microsurg 2008; 24 (02) 127-130
  • 24 Huemer GM, Larcher L, Schoeller T, Bauer T. The free gracilis muscle flap in Achilles tendon coverage and reconstruction. Plast Reconstr Surg 2012; 129 (04) 910-919
  • 25 Kuo YR, Kuo MH, Chou WC, Liu YT, Lutz BS, Jeng SF. One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: clinical experience and functional assessment. Ann Plast Surg 2003; 50 (02) 149-155
  • 26 Michel G, Ho Quoc C, Assaf N, Delay E, Sinna R. Dynamic reconstruction of Achilles tendon by free composite perforator flap with functional assessment [in French]. Ann Chir Plast Esthet 2015; 60 (01) 78-83
  • 27 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 (02) 142-147
  • 28 DeFazio MV, Han KD, Evans KK. Functional reconstruction of a combined tendocutaneous defect of the Achilles using a segmental rectus femoris myofascial construct: a viable alternative. Arch Plast Surg 2014; 41 (03) 285-289
  • 29 Stamate T, Budurcă AR, Tamaş C, Lazăr AN. A free microsurgical transfer of a radial (Chinese) flap in reconstructing the lower limb [in Romanian]. Rev Med Chir Soc Med Nat Iasi 1998; 102 (3-4): 161-166
  • 30 Coşkunol E, Ozdemir O, Ozalp T. Free radial forearm flap transfer for the reconstruction of the Achilles tendon and soft tissue defect: a case report [in Turkish]. Ulus Travma Acil Cerrahi Derg 2005; 11 (03) 258-262
  • 31 Wei ZR, Sun GF, Wang DL, Tang XJ. Reconstruction of the Achilles tendon and overlying skin defect: 3 case reports. Ann Plast Surg 2014; 73 (03) 325-329
  • 32 D'Arpa S, Toia F, Pirrello R, Moschella F, Cordova A. Propeller flaps: a review of indications, technique, and results. BioMed Res Int 2014; 20 (14) 7
  • 33 Zheng L, Zhang XS, Dong ZG, Liu LH, Wei JW. One-staged reconstruction of Achilles tendon and overlying skin defects with suppuration: using peroneus brevis tendon transfer and reversed sural neurofasciocutaneous flap. Arch Orthop Trauma Surg 2011; 131 (09) 1267-1272
  • 34 Cavadas PC, Landin L. Reconstruction of chronic Achilles tendon defects with posterior tibial perforator flap and soleus tendon graft: clinical series. Plast Reconstr Surg 2006; 117 (01) 266-271
  • 35 Marchesi A, Parodi PC, Brioschi M. , et al. Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature. Injury 2016; 47 (Suppl. 04) S147-S153