Reconstruction of Complicated Achilles Tendon Ruptures with Soft Tissue Defects – a Systematic Overview and Development of a Treatment Algorithm

Abstract

Achilles tendon ruptures are among the most common ruptures of large tendons. Due to the vulnerable soft tissue there is a high risk of soft tissue defects. The combination of Achilles tendon ruptures and soft-tissue defects remains a challenge for the surgeon. Despite different treatment options there is a lack of structured treatment recommendation. By means of a systematic literature review and experience from our own clinic standard, an overview of the stepwise treatment options is presented. A treatment algorithm for reconstructive measures of Achilles tendon ruptures accompanied by soft-tissue defects according to the length of defect of the Achilles tendon, the size of the soft-tissue defect and patient-individual factors is developed. This is intended to serve the surgeon as a basis for decision making prior to application of therapy.

Key words

Achilles tendon - rupture - soft tissue defect - reconstruction - flap

Publikationsverlauf

Artikel online veröffentlicht:
20. Januar 2020

• References/Literatur

• 1 Ho G, Tantigate D, Kirschenbaum J. et al. Increasing age in Achilles rupture patients over time. Injury 2017; 48: 1701-1709 doi:10.1016/j.injury.2017.04.007
• 2 Egger AC, Berkowitz MJ. Achilles tendon injuries. Curr Rev Musculoskelet Med 2017; 10: 72-80 doi:10.1007/s12178-017-9386-7
• 3 Gross CE, Nunley 2nd JA. Acute Achilles Tendon Ruptures. Foot Ankle Int 2016; 37: 233-239 doi:10.1177/1071100715619606
• 4 Costa ML, MacMillan K, Halliday D. et al. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br 2006; 88: 69-77 doi:10.1302/0301-620X.88B1.16549
• 5 Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999; 81: 1019-1036 doi:10.2106/00004623-199907000-00017
• 6 Wilkins R, Bisson LJ. Operative versus nonoperative management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. Am J Sports Med 2012; 40: 2154-2160 doi:10.1177/0363546512453293
• 7 Cetti R, Christensen SE, Ejsted R. et al. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 1993; 21: 791-799 doi:10.1177/036354659302100606
• 8 Mellor SJ, Patterson MH. Tendo Achillis rupture; surgical repair is a safe option. Injury 2000; 31: 489-491 doi:10.1016/s0020-1383(00)00028-0
• 9 Krueger-Franke M, Siebert CH, Scherzer S. Surgical treatment of ruptures of the Achilles tendon: a review of long-term results. Br J Sports Med 1995; 29: 121-125 doi:10.1136/bjsm.29.2.121
• 10 Bullocks JM, Hickey RM, Basu CB. et al. Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap. J Plast Reconstr Aesthet Surg 2008; 61: 566-572 doi:10.1016/j.bjps.2006.01.017
• 11 Agrawal NK, Bhattacharya V. V-Y gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: a simple solution. J Plast Reconstr Aesthet Surg 2010; 63: e406-e410 doi:10.1016/j.bjps.2009.09.017
• 12 Suda AJ, Thoele P, Heppert VG. [Flaps for soft tissue defect closure in the distal lower leg]. Unfallchirurg 2014; 117: 61-69 doi:10.1007/s00113-013-2528-5
• 13 Monnerie C, Le Nen D, Hu W. et al. [Treatment of necrosis of Achilles tendon without tendon reconstruction: About four cases]. Ann Chir Plast Esthet 2019; 64: 208-214 doi:10.1016/j.anplas.2019.01.004
• 14 Myerson MS. Achilles tendon ruptures. Instr Course Lect 1999; 48: 219-230
• 15 Den Hartog BD. Surgical strategies: delayed diagnosis or neglected Achillesʼ tendon ruptures. Foot Ankle Int 2008; 29: 456-463 doi:10.3113/FAI.2008.0456
• 16 Buda R, Castagnini F, Pagliazzi G. et al. Treatment algorithm for chronic Achilles tendon lesions. Review of the literature and proposal of a new classification. J Am Podiatr Med Assoc 2017; 107: 144-149 doi:10.7547/15-099
• 17 Saper D, Lybrand K, Creevy W. et al. Using a posterior compartment fasciotomy and paratenon closure in acute Achilles tendon repair. Orthopedics 2016; 39: e790-e793 doi:10.3928/01477447-20160503-04
• 18 Ozer H, Selek HY, Harput G. et al. Achilles Tendon open repair augmented with distal turndown tendon flap and posterior crural fasciotomy. J Foot Ankle Surg 2016; 55: 1180-1184 doi:10.1053/j.jfas.2016.07.005
• 19 Kuwada GT. Classification of tendo Achillis rupture with consideration of surgical repair techniques. J Foot Surg 1990; 29: 361-365
• 20 Maffulli N, Ajis A. Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am 2008; 90: 1348-1360 doi:10.2106/JBJS.G.01241
• 21 Schweitzer jr. KM, Dekker TJ, Adams SB. Chronic Achilles ruptures: reconstructive options. J Am Acad Orthop Surg 2018; 26: 753-763 doi:10.5435/JAAOS-D-17-00158
• 22 Dautry P, Isserlis G, Apoil A. et al. [Treatment of necrosis of the Achilles tendon (authorʼs transl)]. Ann Chir 1975; 29: 1093-1098
• 23 Fourniols E, Lazennec JY, Rousseau MA. Salvage technique for postoperative infection and necrosis of the Achilles tendon. Orthop Traumatol Surg Res 2012; 98: 915-920 doi:10.1016/j.otsr.2012.07.009
• 24 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 doi:10.1016/j.injury.2016.07.053
• 25 Wei ZR, Sun GF, Wang DL. et al. Reconstruction of the Achilles tendon and overlying skin defect: 3 case reports. Ann Plast Surg 2014; 73: 325-329 doi:10.1097/SAP.0b013e31827a3007
• 26 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: 266-271 doi:10.1097/01.prs.0000194905.25604.f8
• 27 Dumont CE, Kessler J. A composite medial plantar flap for the repair of an Achillesʼ tendon defect: a case report. Ann Plast Surg 2001; 47: 666-668 doi:10.1097/00000637-200112000-00015
• 28 Taniguchi Y, Tamaki T. Reconstruction of the Achilles tendon and overlying skin defect with a medical plantar flap and tensor fasciae latae graft. J Reconstr Microsurg 2000; 16: 423-425 doi:10.1055/s-2006-947148
• 29 Zheng L, Zhang XS, Dong ZG. et al. 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: 1267-1272 doi:10.1007/s00402-011-1298-1
• 30 Boopalan PR, Jepegnanam TS, Titus VT. et al. Open infected Achilles tendon injury–reconstruction of tendon with fascia lata graft and soft tissue cover with a reverse flow sural flap. Foot Ankle Surg 2008; 14: 96-99 doi:10.1016/j.fas.2007.11.002
• 31 Abhyankar SV, Kulkarni A, Agarwal NK. Single stage reconstruction of ruptured tendoachilles tendon with skin cover using distally based superficial sural artery flap. Ann Plast Surg 2009; 63: 425-427 doi:10.1097/SAP.0b013e31819516cc
• 32 Parodi PC, Moretti L, Saggin G. et al. Soft tissue and tendon reconstruction after Achilles tendon rupture: adipofascial sural turnover flap associated with cryopreserved gracilis tendon allograft for complicated soft tissue and Achilles tendon losses. A case report and literature review. Ann Ital Chir 2006; 77: 361-367
• 33 Babu V, Chittaranjan S, Abraham G. et al. Single-stage reconstruction of soft-tissue defects including the Achilles tendon using the dorsalis pedis arterialized flap along with the extensor digitorum brevis as bridge graft. Plast Reconstr Surg 1994; 93: 1090-1094 doi:10.1097/00006534-199404001-00033
• 34 Kim SW, Hong JP, Lee WJ. et al. Single-stage Achilles tendon reconstruction using a composite sensate free flap of dorsalis pedis and tendon strips of the extensor digitorum longus in a complex wound. Ann Plast Surg 2003; 50: 653-657 doi:10.1097/01.SAP.0000041479.79049.71
• 35 Koski EA, Kuokkanen HO, Tukiainen EJ. Distally-based peroneus brevis muscle flap: a successful way of reconstructing lateral soft tissue defects of the ankle. Scand J Plast Reconstr Surg Hand Surg 2005; 39: 299-301 doi:10.1080/0284431501006330
• 36 Michlits W, Gruber S, Windhofer C. et al. Reconstruction of soft tissue defects overlying the Achilles tendon using the super extended abductor hallucis muscle flap. J Trauma 2008; 65: 1459-1462 doi:10.1097/TA.0b013e31815ede2f
• 37 Jastrzebski J, Huber P. [Reconstruction in Achilles tendon rupture and simultaneous covering of a skin and soft tissue defect using the myocutaneous gastrocnemius sliding flap]. Handchir Mikrochir Plast Chir 1987; 19: 281-283
• 38 Zhu YL, Xu YQ, Yang J. et al. One-stage reconstruction of Achilles tendon and skin defects by the sliding gastrocnemius musculocutaneous flap without anastomosis. J Trauma 2009; 66: 1129-1134 doi:10.1097/TA.0b013e31817dac20
• 39 Youn SK, Kim SW, Kim YH. et al. 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: 615-621 doi:10.1002/micr.22490
• 40 DeFazio MV, Han KD, Iorio ML. et al. Combined free tissue transfer for the management of composite Achilles defects: functional outcomes and patient satisfaction following thigh-based vascularized reconstruction with a neotendon construct. J Reconstr Microsurg 2014; 30: 431-440 doi:10.1055/s-0034-1370339
• 41 Ando J, Sakuraba M, Sugawara A. et al. Free flap reconstruction of Achilles tendon and overlying skin defect using ALT and TFL fabricated chimeric flap. Case Reports Plast Surg Hand Surg 2019; 6: 82-85 doi:10.1080/23320885.2019.1635023
• 42 Michel G, Ho Quoc C, Assaf N. et al. [Dynamic reconstruction of Achilles tendon by free composite perforator flap with functional assessment]. Ann Chir Plast Esthet 2015; 60: 78-83 doi:10.1016/j.anplas.2014.05.004
• 43 Soons J, Rakhorst HA, Ruettermann M. et al. Reconstruction of defects involving the Achilles tendon and local soft tissues: a quick solution for a lingering problem. Bone Joint J 2015; 97-B: 215-220 doi:10.1302/0301-620X.97B2.34521
• 44 Duhamel P, Mathieu L, Brachet M. et al. 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: 2598-2603 doi:10.2106/JBJS.I.01578
• 45 Houtmeyers P, Opsomer D, Van Landuyt K. et al. Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata. J Reconstr Microsurg 2012; 28: 205-209 doi:10.1055/s-0032-1306367
• 46 Sato R, Hibino N, Yamano M. et al. One-stage reconstruction for re-rupture of Achilles tendon with soft tissue infection: using an anterolateral thigh flap incorporating a vascularized muscle flap and a strip of iliotibial tract. J Hand Microsurg 2018; 10: 105-108 doi:10.1055/s-0038-1630141
• 47 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 doi:10.1097/MD.0000000000011995
• 48 Inoue T, Tanaka I, Imai K. et al. Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap. Br J Plast Surg 1990; 43: 728-731 doi:10.1016/0007-1226(90)90199-a
• 49 Kuo YR, Kuo MH, Chou WC. et al. 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: 149-155 doi:10.1097/01.SAP.0000037270.95257.B9
• 50 Lee JW, Yu JC, Shieh SJ. et al. Reconstruction of the Achilles tendon and overlying soft tissue using antero-lateral thigh free flap. Br J Plast Surg 2000; 53: 574-577 doi:10.1054/bjps.2000.3407
• 51 Smit JM, Darcy CM, Audolfsson T. et al. Multilayer reconstructions for defects overlying the Achilles tendon with the lateral-arm flap: long-term follow-up of 16 cases. Microsurgery 2012; 32: 438-444 doi:10.1002/micr.21972
• 52 Berthe JV, Toussaint D, Coessens BC. One-stage reconstruction of an infected skin and Achilles tendon defect with a composite distally planned lateral arm flap. Plast Reconstr Surg 1998; 102: 1618-1622 doi:10.1097/00006534-199810000-00044
• 53 Kim CH, Tark MS, Choi CY. et al. A single-stage reconstruction of a complex Achilles wound with modified free composite lateral arm flap. J Reconstr Microsurg 2008; 24: 127-130 doi:10.1055/s-2008-1076090
• 54 Haas F, Seibert FJ, Koch H. et al. Reconstruction of combined defects of the Achilles tendon and the overlying soft tissue with a fascia lata graft and a free fasciocutaneous lateral arm flap. Ann Plast Surg 2003; 51: 376-382 doi:10.1097/01.sap.0000068080.76814.D7
• 55 Innocenti M, Tani M, Carulli C. et al. Radial forearm flap plus Flexor Carpi Radialis tendon in Achilles tendon reconstruction: surgical technique, functional results, and gait analysis. Microsurgery 2015; 35: 608-614 doi:10.1002/micr.22481
• 56 Nazerali RS, Hakimi M, Giza E. et al. Single-stage reconstruction of Achilles tendon rupture with flexor hallucis longus tendon transfer and simultaneous free radial fasciocutaneous forearm flap. Ann Plast Surg 2013; 70: 416-418 doi:10.1097/SAP.0b013e3182853d6c
• 57 Stanec S, Stanec Z, Delimar D. et al. A composite forearm free flap for the secondary repair of the ruptured Achilles tendon. Plast Reconstr Surg 1999; 104: 1409-1412 doi:10.1097/00006534-199910000-00026
• 58 Papp C, Todoroff BP, Windhofer C. et al. Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap. Plast Reconstr Surg 2003; 112: 777-783 doi:10.1097/01.PRS.0000073975.01321.8B
• 59 Coskunfirat OK, Sheu TJ, Jeng SF. et al. Reconstruction of Achilles tendon and overlying skin with composite groin-fascial free flap: a case report of 14-year follow-up. Plast Reconstr Surg 2003; 112: 215-219 doi:10.1097/01.PRS.0000066338.08871.A5
• 60 Deiler S, Pfadenhauer A, Widmann J. et al. Tensor fasciae latae perforator flap for reconstruction of composite Achilles tendon defects with skin and vascularized fascia. Plast Reconstr Surg 2000; 106: 342-349 doi:10.1097/00006534-200008000-00016
• 61 Dabernig J, Shilov B, Schumacher O. et al. 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: 142-147
• 62 Lee HB, Lew DH, Oh SH. et al. Simultaneous reconstruction of the Achilles tendon and soft-tissue defect using only a latissimus dorsi muscle free flap. Plast Reconstr Surg 1999; 104: 111-119
• 63 Sauerbier M, Erdmann D, Bruner S. et al. [Covering soft tissue defects and unstable scars over the Achilles tendon by free microsurgical flap-plasty]. Chirurg 2000; 71: 1161-1166 doi:10.1007/s001040051195
• 64 Upadhyaya DN, Khanna V, Kohli R. et al. Functional reconstruction of complex tendo Achilles defect by free latissimus dorsi muscle flap. Indian J Plast Surg 2012; 45: 572-575 doi:10.4103/0970-0358.105983
• 65 Zhu L, Wei J, Daluvoy S. et al. Free partial latissimus dorsi myocutaneous flap for coverage of severe Achilles contracture in children. J Plast Reconstr Aesthet Surg 2013; 66: 113-119 doi:10.1016/j.bjps.2012.08.010
• 66 Kim SW, Kwon YH, Kim JT. et al. Foot reconstruction using a serratus anterior muscle flap from the same donor site after failure of a thoracodorsal artery perforator flap. Microsurgery 2014; 34: 153-156 doi:10.1002/micr.22181
• 67 Wurzer P, Eberl R, Kamolz LP. et al. Aesthetically and functionally satisfying reconstruction of an Achilles tendon and overlying skin defect in a 15 year old girl: a case report. Burns 2015; 41: e1-e3 doi:10.1016/j.burns.2014.06.004
• 68 Dobke M, Suliman A, Mackert GA. et al. 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. 03) S165-S170 doi:10.1097/SAP.0000000000000789
• 69 Lykoudis EG, Contodimos GV, Ristanis S. et al. One-stage complex Achilles tendon defect reconstruction with an Achilles tendon allograft and a gracilis free flap. Foot Ankle Int 2010; 31: 634-638 doi:10.3113/FAI.2010.0634
• 70 Feibel RJ, Jackson RL, Lineaweaver WC. et al. Management of chronic Achilles tendon infection with musculotendinous gracilis interposition free-flap coverage. J Reconstr Microsurg 1993; 9: 321-325 doi:10.1055/s-2007-1006737
• 71 Huemer GM, Larcher L, Schoeller T. et al. The free gracilis muscle flap in Achilles tendon coverage and reconstruction. Plast Reconstr Surg 2012; 129: 910-919 doi:10.1097/PRS.0b013e31824422da
• 72 Yuen JC, Nicholas R. Reconstruction of a total Achilles tendon and soft-tissue defect using an Achilles allograft combined with a rectus muscle free flap. Plast Reconstr Surg 2001; 107: 1807-1811 doi:10.1097/00006534-200106000-00028