Rekonstruktionen von Weichteildefekten der Achillessehnen region – eine Literaturübersicht

Zusammenfassung

Hintergrund Weichteildefekte der Regio tendinis achilleae treten nach Traumata und insbesondere als Komplikation nach offener Rekonstruktion der Sehne mit nachfolgendem Infekt auf.

Ziel der Arbeit Es werden Empfehlungen zur Therapie von Weichteilverletzungen mit Beteiligung der Achillessehne im Kontext der Literatur formuliert.

Material und Methoden Es wurde eine Recherche der deutsch-, französisch- und englischsprachigen Literatur zur Rekonstruktion von Hautweichteildefekten der Achillessehnenregion durchgeführt, welche in singuläre und kombinierte tendokutane Defekte differenziert wurden. Kombinierte Defekte wurden basierend auf drei rekonstruktiven Prinzipien weiter untergliedert in: ein alleiniger Verschluss der Haut ohne Sehnenrekonstruktion sowie eine Rekonstruktion der Haut zusammen mit einer Sehnenrekonstruktion als vaskularisiertes oder avaskuläres Transplantat.

Ergebnisse Lokale und distal gestielte Lappenplastiken sind für die Rekonstruktion über der Achillessehne mit einer hohen lokalen Morbidität behaftet, weshalb die Autoren freie Lappenplastiken aufgrund der geringeren Komplikationsrate favorisieren. Hier eignet sich für kleine Defekte die freie Medial Sural Artery (MSAP-)Lappenplastik, bei großen Defekten Muskeloder fasziokutane Lappenplastiken. Technik der Wahl für die kombinierte tendokutane Rekonstruktion ist die ALTLappenplastik mit vaskularisierter Fascia lata. Als nicht vaskuläre Sehnentransplantate werden häufig die Sehne des M. flexor hallucis longus oder des M. peroneus brevis verwendet.

Fazit Die Rekonstruktion der Achillessehnenregion erfordert dünne strapazier- und gleitfähige Lappen, die eine Schuhver- sorgung ermöglichen. Die postoperative Kraft und Beweglichkeit des Sprunggelenkes zeigen vergleichbare funktionelle Resultate nach vaskularisierter und nicht vaskularisierter Seh- nenrekonstruktion.

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.

Schlüsselwörter

Achillessehne - freie Lappenplastik - Fuß - Rekonstruktion - Weichteilverletzung;

Key words

achilles tendon - foot - free flap - reconstruction - soft tissue injury

Publikationsverlauf

Eingereicht: 04. Juni 2021

Angenommen: 03. März 2022

Artikel online veröffentlicht:
22. Juni 2022

• Literatur

• 1 Baden JM, Warr RP, Khan U. Immediate free tissue transfer for co- verage of Achilles tendon injury or reconstruction. Foot Ankle Surg 2010; 16: 164-169
• 2 Wei FC, Chen HC, Chuang CC. et al. Reconstruction of achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region. Plast Reconstr Surg 1988; 81: 579-587
• 3 Poynton AR, O’Rourke K. An analysis of skin perfusion over the Achilles tendon in varying degrees of plantarflexion. Foot Ankle Int 2001; 22: 572-574
• 4 Reda Y, Farouk A, Abdelmonem I. et al. Surgical versus non-surgical treatment for acute Achilles’ tendon rupture. A systematic review of literature and meta-analysis. Foot Ankle Surg 2019; S1268-7731(19)30053–0: Im Internet:
• 5 Stavenuiter XJR, Lubberts B, Prince RM. et al. Postoperative complica- tions following repair of acute Achilles tendon rupture. Foot Ankle Int 2019; 40: 679-686
• 6 Gatz M, Driessen A, Eschweiler J. et al. Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study. Arch Orthop Trauma Surg 2020; Im Internet:
• 7 Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of Achilles tendon ruptures. Am J Sports Med 2002; 30: 565-575
• 8 Pajala A, Kangas J, Ohtonen P. et al. Rerupture and deep infection follo- wing treatment of total Achilles tendon rupture. J Bone Jt Surg – Ser A 2002; 84: 2016-2021
• 9 Nilsson-Helander K, Grävare Silbernagel K. et al. Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med 2010; 38: 2186-2193
• 10 Marican MM, Fook-Chong SMC, Rikhraj IS. Incidence of postoperative wound infections after open tendo achilles repairs. Singapore Med J 2015; 56: 549-554
• 11 Khan RJK, Fick D, Keogh A. et al. Treatment of acute Achilles tendon ruptures: A meta-analysis of randomized, controlled trials. J Bone Jt Surg – Ser A 2005; 87: 2202-2210
• 12 Jildeh TR, Okoroha KR, Marshall NE. et al. Infection and rerupture after surgical repair of achilles tendons. Orthop J Sport Med 2018; 6: 1-5
• 13 Highlander P, Greenhagen RM. Wound complications with posterior midline and posterior medial leg incisions: a systematic review. Foot Ankle Spec 2011; 4: 361-369
• 14 Grabb WC, Argenta LC. The lateral calcaneal artery skin flap (the lateral calcaneal artery, lesser saphenous vein, and sural nerve skin flap). Plast Reconstr Surg 1981; 68: 723-730
• 15 Rein S, Kremer T. Systematik der plastischen Defektrekonstruktion am Fuß. Unfallchirurg 2021; 124: 797-806
• 16 Vaienti L, Calori GM, Leone F. et al. Posterior tibial artery perforator flaps for coverage of Achilles region defects. Injury 2014; 45: 133-137 Im Internet:
• 17 Attinger CE, Ducic I, Hess CL. et al. Outcome of skin graft versus flap surgery in the salvage of the exposed Achilles tendon in diabetics versus nondiabetics. Plast Reconstr Surg 2006; 117: 2460-2467
• 18 Lin CT, Chen SG, Chen TM. et al. Bipedicled flap for the reconstruction of soft tissue defects of the Achilles tendon. Ann Plast Surg 2015; 74: 484-487
• 19 Koski A, Tukiainen E, Suominen S. et al. Reconstruction of iatrogenic skin defects of the Achilles tendon region: An analysis of 25 consecuti- ve patients. Eur J Plast Surg 2003; 26: 298-303
• 20 Fumarola A. A one-stage reconstruction of a large defect of the tendo Achilles and the overlying skin. Br J Plast Surg 1985; 38: 403-406
• 21 Zhu YL, Xu YQ, Mei LB. et al. Open Achilles tendon defects: A 12-year study on the injury mechanisms, reconstructions, and late complicati- ons. J Reconstr Microsurg 2014; 30: 569-580
• 22 Vaienti L, Cottone G, Zaccaria G. et al. One-Step Approach for Infec- tions After Achilles Tendon Open Repair: The Distally Based Peroneus Brevis Muscle Flap. Int J Low Extrem Wounds 2020; 1-7
• 23 Fansa H, Frerichs O, Schneider W. Der distal gestielte M. peroneus brevis-Lappen zur Defektdeckung am Unterschenkel. Unfallchirurg 2006; 109: 453-456
• 24 Baumeister SP, Spierer R, Erdmann D. et al. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003; 112: 129-140
• 25 Kumta SM, Maffulli N. Local flap coverage for soft tissue defects following open repair of achilles tendon rupture. Acta Orthop Belg 2003; 69: 59-66
• 26 Masquelet AC, Beveridge J, Romana C. et al. The lateral supramalleolar flap. Plast Reconstr Surg 1988; 81: 74-84
• 27 Demiri E, Foroglou P, Dionyssiou D. et al. Our experience with the lateral supramalleolar island flap for reconstruction of the distal leg and foot: A review of 20 cases. Scand J Plast Reconstr Surg Hand Surg 2006; 40: 106-110
• 28 Hamdi MF, Khlifi A. Lateral supramalleolar flap for coverage of ankle and foot defects in children. J Foot Ankle Surg 2012; 51: 106-109
• 29 Omokawa S, Yajima H, Tanaka Y. et al. Long-term results of lateral calcaneal artery flap for hindfoot reconstruction. J Reconstr Microsurg 2008; 24: 239-245
• 30 Jakubietz RG, Jakubietz DF, Grünert JG. et al. Reconstruction of soft tissue defects of the achilles tendon with rotation flaps, pedicled pro- peller flaps and free perforator flaps. Microsurgery 2010; 30: 608-613
• 31 Feng K-M, Sudirman SR, Shih H-S. et al. Experience on primary closure of fibular flap donor sites and development of an algorithm for closure based on different flap designs. Microsurgery 2020; 40: 741-749
• 32 Innocenti M, Innocenti A, Ghezzi S. et al. Achilles region soft-tissue defects: a reconstructive algorithm based on a series of 46 cases. J Reconstr Microsurg 2017; 33: S40-S47
• 33 Sauerbier M, Erdmann D, Brüner S. et al. Die Deckung von Weich- teildefekten und instabilen Narben über der Achillessehne durch freie mikrochirurgische Lappenplastiken. Chirurg 2000; 71: 1161-1166
• 34 Baden JM, Warr RP, Khan U. Immediate free tissue transfer for coverage of Achilles tendon injury or reconstruction. Foot Ankle Surg 2010; 16: 164-169 Im Internet:
• 35 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
• 36 Yuan W, Satkunanantham M, Sechachalam S. Results of Achilles tendon excision for purpose of wound closure: case series. J Foot Ankle Surg 2019; 58: 184-186 Im Internet:
• 37 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 Im Internet:
• 38 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
• 39 Saunders ED, Hochberg J, Wittenborn W. Treatment of total loss of the achilles tendon by skin flap cover without tendon repair. Plast Reconstr Surg 1978; 62: 708-712
• 40 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
• 41 Boorboor P, Lahoda LU, Spies M. et al. Resektion der infizierten Achillessehne: Ergebnisse nach plastischer Defektdeckung ohne Achillessehnenersatz. Chirurg 2006; 77: 1144-1151
• 42 Finni T, Hodgson JA, Lai AM. et al. Muscle synergism during isometric plantarflexion in achilles tendon rupture patients and in normal subjects revealed by velocity-encoded cine phase-contrast MRI. Clin Biomech 2006; 21: 67-74
• 43 Benetazzo L, Bizzego A, De Caro R. et al. 3 D reconstruction of the crural and thoracolumbar fasciae. Surg Radiol Anat 2011; 33: 855-862
• 44 Kumka M. Fascia: a morphological description and classification system based on a literature review. J Can Chiropr Assoc 2012; 56: 179-191
• 45 Gelse K, Pöschl E, Aigner T. Collagens – structure, function, and biosynthesis. Adv Drug Deliv Rev 2003; 55: 1531-1546
• 46 Gordon MK, Hahn RA. Collagens. Cell Tissue Res 2011; 339: 247-257
• 47 Engler AJ, Sen S, Sweeney HL. et al. Matrix elasticity directs stem cell lineage specification. 2006; 126: 677-689
• 48 Fede C, Porzionato A, Petrelli L. et al. Fascia and soft tissues innervation in the human hip and their possible role in post-surgical pain. J Orthop Res 2020; 38: 1646-1654
• 49 Federative Committee of Anatomical Terminology. Terminologica Anatomica: international anatomical terminology. Stuttgart-New York: Thieme; 1998
• 50 Fourie W. Fascia lata: Merely a thigh stocking, or a coordinator of com-plex thigh muscular activity?. J Bodyw Mov Ther 2008; 12: 265
• 51 Youn SKI, Kim SWHA, 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
• 52 Okochi M, Momiyama M, Okochi H. et al. 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 Plast Surg Hand Surg 2017; 4: 89-95 Im Internet:
• 53 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 Im Internet:
• 54 Jandali Z, Lam MC, Merwart B. et al. Predictors of clinical outcome after reconstruction of complex soft tissue defects involving the Achilles tendon with the composite anterolateral thigh flap with vascularized fascia lata. J Reconstr Microsurg 2018; 34: 632-641
• 55 Andreu-Sola V, Aguilera-Sáez J, Rivas-Nicolls D. et al. Reconstruction fonctionnelle d’une brûlure du tendon d’achille dans la phase aigue par un lambeau composite antero latéral de cuisse avec fascia lata: À propos d’une observation. Ann Burns Fire Disasters 2017; 30: 309-312
• 56 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 Jt Surg – Ser A 2010; 92: 2598-2603
• 57 Ehrl D, Heidekrueger PI, Schmitt A. et al. The anterolateral thigh flap for Achilles tendon reconstruction: functional outcomes. Plast Re- constr Surg 2019; 143: 1772-1783
• 58 Houtmeyers P, Opsomer D, Van Landuyt K. et al. Reconstruction of the achilles tendon and overlying soft tissue by free composite anterolate- ral thigh flap with vascularized fascia lata. J Reconstr Microsurg 2012; 28: 205-209
• 59 Inoue T, Tanaka I, Imal K. et al. Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap. Br J Plast Surg 1990; 43: 728-731
• 60 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 func- tional assessment. Ann Plast Surg 2003; 50: 149-155
• 61 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
• 62 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. Med (United States) 2018; 97: e11995
• 63 Dobke M, Suliman A, Mackert GA. et al. Single-Stage Reconstruction of Achilles Tendon and Overlying Tissue With the Extended Tempo- roparietal Fasciagaleal Flap – 23-Year Follow-Up and the Review of the Literature. Ann Plast Surg 2016; 76: 165-170
• 64 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
• 65 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 Im Internet:
• 66 Kelahmetoglu O, Gules M, Elmadag N. et al. Double-layer reconstruc- tion of the Achilles’ tendon using a modified Lindholm’s technique and vascularized fascia lata. J Hand Microsurg 2018; 10: 49-51
• 67 Chalmers R, Tare M, Niranjan N. Vascularised Achilles tendon graft re-construction – By the tendon for the tendon. J Plast Reconstr Aesthetic Surg 2010; 63: 273-276 Im Internet:
• 68 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
• 69 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 recon- struction with a neotendon construct. J Reconstr Microsurg 2014; 30: 431-440
• 70 Upton J, Baker TM, Shoen SL. et al. Fascial flap coverage of achilles tendon defects. Plast Reconstr Surg 1995; 95: 1056-1061
• 71 Brent B, Upton J, Acland RD. et al. Experience with temporoparietal fascial free flap. Plast Reconstr Surg 1985; 76: 177-188
• 72 Stamate T, Budurca A, Tamas C. et al. A free microsurgical transfer of a radial (Chinese) flap in reconstructing the lower limb. Rev Med Chir Soc Med Nat Iasi 1998; 102: 161-166
• 73 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
• 74 Papp C, Todoroff BP, Windhofer C. et al. Partial and complete re- construction of Achilles tendon defects with the fasciocutaneous infragluteal free flap. Plast Reconstr Surg 2003; 112: 777-783
• 75 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: 321-323+325
• 76 Babu V, Chittaranjan S, Abraham G. et al. Single-stage recontruction of soft-tissue defects including the achilles tendon using the dorsalis pe- dis arterialized flap along with the extensor digitorum brevis as bridge graft. Plast Reconstr Surg 1994; 93: 1090-1094
• 77 Coskunfirat OK, Sheu TJ, Jeng SF. et al. Reconstruction of Achilles ten- don and overlying skin with composite groin-fascial free flap: A case report of 14-year follow-up. Plast Reconstr Surg 2003; 112: 215-219
• 78 Iorio ML, Han KD, Evans KK. et al. Combined Achilles tendon and soft tissue defects: Functional outcomes of free tissue transfers and tendon vascularization. Ann Plast Surg 2015; 74: 121-125
• 79 Kaya M, Karahan N, Yilmaz B. tendon structure and classification. In: Tendons. Intech Open 2019; 1-9
• 80 Doral MN, Alam M, Bozkurt M. et al. Functional anatomy of the Achilles tendon. Knee Surg Sport Traumatol Arthrosc 2010; 18: 638-643
• 81 Sebastian H, Datta B, Maffulli N. et al. Mechanical properties of recon- structed Achilles tendon with transfer of peroneus brevis or flexor hallucis longus tendon. J Foot Ankle Surg 2007; 46: 424-428
• 82 Lin CZ, Xia X, Wang H. et al. Surgical reconstruction of the fascia lata and posterior tibial artery perforator flap to treat children with simultaneous injury to the Achilles tendon and heel skin. Med (United States) 2018; 97: 10-13
• 83 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
• 84 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
• 85 Berthe JV, Toussaint D, Coessens B. 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
• 86 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
• 87 Lidman D, Nettelblad H, Berggren A. et al. Reconstruction of soft tissue defects including the achilles tendon with free neurovascular tensor fascia lata flap and fascia lata: Case report. Scand J Plast Reconstr Surg Hand Surg 1987; 21: 213-218
• 88 Sylaidis P, Fatah MFT. A composite lateral arm flap for the secondary repair of a multiply ruptured achilles tendon. Plast Reconstr Surg 1995; 96: 1719-1723
• 89 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