British Journalof Plasric Surgery (1990), 43,72X-731 0 1990 The Trustees of British Association of Plastic Surgeons
Case Report Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap T. INOUE, I. TANAKA,
K. IMAI and M. HATOKO
Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, Ka wagoe, Japan
Summary-A case of Achilles tendon reconstruction lateral thigh flap is reported. This is a simple one-stage can be obtained. Laceration of the Achilles tendon is very common in trauma around the ankle and the majority of such cases heal with suturing alone. Unfortunately, some injuries lead to such severe tendon loss that direct repair is impossible. Reconstruction by reflection of a fascia-aponeurotic flap from the gastrocnemius muscle (Fumarola, 1985) or with artificial substances such as Marlex mesh (Ozaki et al., 1989) has been performed in these cases, but in most traumatic cases there is also skin loss and the problem then is to replace both tendon and skin simultaneously. We have recently used a strip of vascularised fascia lata attached to a lateral thigh flap for microvascular repair of an Achilles tendon rupture with skin loss, and obtained a very satisfactory result.
Case report An l&year-old woman suffered an open fracture of the left ankle joint, laceration of the Achilles tendon and an abraded wound of a wide area of the posterior surface of the distal leg in a traffic accident. Immediately after the accident the fracture was treated by reduction and fixation together with repair of the Achilles tendon and the skin, by orthopaedic surgeons. About 1 week later most of the skin and the Achilles tendon were necrotic (Fig. 1) and the patient was referred to our department for reconstruction. This was performed with the patient prone, under general anaesthesia. After debridement there was a skin defect of about 10 x 15 cm with an Achilles tendon defect of 6 cm in length and about three-quarters of its width (Fig. 2). Simultaneous reconstruction of the Achilles tendon and skin was performed with a composite flap in which a fascia lata strip was joined to a lateral thigh flap. The
using free vascularised fascia lata joined to a reconstruction and a sufficiently strong tendon
lateral thigh flap, 10 x 20 cm in size, was designed on the right thigh (Fig. 3) and raised. After confirmation of the third and fourth perforators of the profunda femoris artery, a 4 x 8 cm section of fascia lata was raised, still attached to the branches from these perforators, and the composite lateral thigh flap was then elevated (Fig. 4). Both the fascia lata and the skin of the lateral thigh flap were shown to be adequately perfused by the third and fourth perforators. The vascular pedicles were separated down to the profunda femoris artery and vein and, following division, were anastomosed to the posterior tibia1 artery and veins. After revascularisation and bleeding from the fascia lata were confirmed, one-half of the distal fascia lata was separated from the lateral thigh flap and folded in two for reconstruction of the Achilles tendon defect. When reconstruction of the Achilles tendon was completed (Fig. 5), the skin defect was repaired with the cutaneous part of the lateral thigh flap. One month after the operation the patient was permitted to walk and by 2 months could walk normally. Ankle joint movements were approximately the same as the opposite side 6 months after surgery, at which time a defatting procedure was carried out because of the bulky skin flap. Further thinning was done 1 year after the initial surgery. At the defatting operations the wellreconstructed Achilles tendon was observed (Fig. 6). Eighteen months after reconstruction the patient’s ankle has normal function (Fig. 7).
Discussion The Achilles tendon is essential for normal ankle joint movement but it is unexpectedly difficult to reconstruct a defect of the tendon. There have been various reports of reconstruction, for example by replacement with a free fascial graft covered with a fascia-aponeurotic flap from the gastrocnemius 728
729
RECONSTRUCTION OF ACHILLES TENDON
Achilles
Fig. 1
tendon
Fig. 2
l&year-old girl sustained a laceration of the Achilles tendon and compound fracture of the lower tibia. Onle a.fter emergency surgery the repaired tendon and soft tissue were necrotic. Figure 2-Skin and tendon defect. I Ggure l-An
muscle (Fumarola, 1985) and artificial substances (Ozaki er al., 1989), but such reconstruction is easily complicated by infection, leading to prolonged healing, and does not result in the attainment of sufficient strength. Reconstruction of the Achilles tendon with vascularised fascia has become possible owing to the development of microsurgery. Wei er al. (1988) reported reconstruction of the Achilles tendon by attaching a segment of the abdominal external oblique muscle fascia to a groin flap and rolling up the fascial strip. Lidman et al. (1987) reconstructed the Achilles tendon using a free tensor fasciae latae flap as a neurovascular flap. This also resulted in a strong tendon with sensitive skin. According to their reports, reconstruction of the Achilles tendon with the vascularised fascia induced early healing and displayed a high resistance to infection. We obtained similar results with our method. Achilles tendon defects associated with skin loss are best reconstructed using a technique which
week
allows simultaneous transfer of the fascia and skin. In this regard, Wei’s, Lidman’s and the present method are superior to other conventional methods. In the lateral thigh flap, which is one of the two new cutaneous flaps on the thigh reported by Baek in 1983, the third perforator is used. Similar flaps, including the lateral thigh fasciocutaneous Aap reported by Maruyama et al. in 1984, in which the first perforator is used, have been used in various reconstructions and these excellent gaps have many advantages including easy elevation and safe vascularisation (Inoue et al., 1985). The method of reconstructing the Achilles tendon by attaching fascia lata to the lateral thigh flap is technically very simple and can produce sufficiently strong tendon. We consider it is superior to Wei’s method for cases without bone defects, and superior to Lidman’s if the gastrocnemius muscle is intact. However, the ankle region is normally quite thin and all these flaps are too bulky, requiring defatting after reconstruction.
730
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 3
Fig. 5
Fig. 4
Fig. 6
Figure S-The lateral thigh flap marked on the right thigh with the patient prone. It is 10 x 20 cm in size with a 4 x 8 cm section of fascia lata. The lines at the upper right comer of the photograph mark the lower border of the gluteus maximus muscle. Figure 4Both the lateral thigh flap and the fascia lata were fed by the third and fourth perforators. Figure S-The folded fascia lata sutured to the residual Achilles tendon. Figure &The well-reconstructed Achilles tendon was observed during the defatting procedure, 6 months after operation.
731
RECONSTRUCTION OF ACHILLES TENDON
of the tendo Achilles and the overlying skin. Brjtish Journal oj Plastic Surgery, 38,403.
Inoue, T., Harashina, T. and Fujino, T. (1985). Our clinical experiences with the lateral thigh flap. Japanese Journal of Plastic and Reconstructive Surgery, 28, 561.
Lidman, D., Nettelblad, H., Berggren, A. and R&n, S. (1987). Reconstruction of soft tissue defects including the Achilles tendon with the free neurovascular tensor fascia lata flap and fascia lata. Scandinavian Journal qf Plastic and Reconstructitle Surgery, 21,213.
Maruyama, Y., Ohnlahl, K. and Takeuchi, S. (1984). The lateral thigh fasciocutaneous flap in the repair of ischial and trochanteric defects. British JoumalqfPlastic Surgery, 37. 103. Ozaki, J., Fqjikl, J., Sugimoto, K., Tamai, S. and Masuhara, K. (1989). Reconstruction of neglected Achilles tendon rupture with Mariex mesh. Clinical Orthopuedicsand Refated Research, 238,204.
Wei, F. C., Chen, H. C., Chuang, C. C. and Noordhoff, M. S. (1988). Reconstruction of Achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region. Plastic and Reconstructroe Surgery, 81, 579.
The Authors
Fig. 7 Figure ‘I-Final result 18 months after reconstruction, showing good plantar gexion.
References Baek, S. (1983). Two new cutaneous free flaps: the medial and lateral thigh flaps. Plastic and Reconstructive Surgery, 71,354. Fumarola, A. (1985). A one-stage reconstruction of a large defect
Takeo Iooue, MD, Assistant Professor. IchIro Tanaka, MD, Instructor Keisuke Imai, MD, Resident. Mitsuo Hatoko, MD, Resident Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, 1981 Tsujido, Kamoda, Kawagoe, 350 Japan. Requests for reprints to Dr Inoue at the above address. Paper received 15 December 1989. Accepted 17 April 1990.
Case Report Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap T. INOUE, I. TANAKA,
K. IMAI and M. HATOKO
Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, Ka wagoe, Japan
Summary-A case of Achilles tendon reconstruction lateral thigh flap is reported. This is a simple one-stage can be obtained. Laceration of the Achilles tendon is very common in trauma around the ankle and the majority of such cases heal with suturing alone. Unfortunately, some injuries lead to such severe tendon loss that direct repair is impossible. Reconstruction by reflection of a fascia-aponeurotic flap from the gastrocnemius muscle (Fumarola, 1985) or with artificial substances such as Marlex mesh (Ozaki et al., 1989) has been performed in these cases, but in most traumatic cases there is also skin loss and the problem then is to replace both tendon and skin simultaneously. We have recently used a strip of vascularised fascia lata attached to a lateral thigh flap for microvascular repair of an Achilles tendon rupture with skin loss, and obtained a very satisfactory result.
Case report An l&year-old woman suffered an open fracture of the left ankle joint, laceration of the Achilles tendon and an abraded wound of a wide area of the posterior surface of the distal leg in a traffic accident. Immediately after the accident the fracture was treated by reduction and fixation together with repair of the Achilles tendon and the skin, by orthopaedic surgeons. About 1 week later most of the skin and the Achilles tendon were necrotic (Fig. 1) and the patient was referred to our department for reconstruction. This was performed with the patient prone, under general anaesthesia. After debridement there was a skin defect of about 10 x 15 cm with an Achilles tendon defect of 6 cm in length and about three-quarters of its width (Fig. 2). Simultaneous reconstruction of the Achilles tendon and skin was performed with a composite flap in which a fascia lata strip was joined to a lateral thigh flap. The
using free vascularised fascia lata joined to a reconstruction and a sufficiently strong tendon
lateral thigh flap, 10 x 20 cm in size, was designed on the right thigh (Fig. 3) and raised. After confirmation of the third and fourth perforators of the profunda femoris artery, a 4 x 8 cm section of fascia lata was raised, still attached to the branches from these perforators, and the composite lateral thigh flap was then elevated (Fig. 4). Both the fascia lata and the skin of the lateral thigh flap were shown to be adequately perfused by the third and fourth perforators. The vascular pedicles were separated down to the profunda femoris artery and vein and, following division, were anastomosed to the posterior tibia1 artery and veins. After revascularisation and bleeding from the fascia lata were confirmed, one-half of the distal fascia lata was separated from the lateral thigh flap and folded in two for reconstruction of the Achilles tendon defect. When reconstruction of the Achilles tendon was completed (Fig. 5), the skin defect was repaired with the cutaneous part of the lateral thigh flap. One month after the operation the patient was permitted to walk and by 2 months could walk normally. Ankle joint movements were approximately the same as the opposite side 6 months after surgery, at which time a defatting procedure was carried out because of the bulky skin flap. Further thinning was done 1 year after the initial surgery. At the defatting operations the wellreconstructed Achilles tendon was observed (Fig. 6). Eighteen months after reconstruction the patient’s ankle has normal function (Fig. 7).
Discussion The Achilles tendon is essential for normal ankle joint movement but it is unexpectedly difficult to reconstruct a defect of the tendon. There have been various reports of reconstruction, for example by replacement with a free fascial graft covered with a fascia-aponeurotic flap from the gastrocnemius 728
729
RECONSTRUCTION OF ACHILLES TENDON
Achilles
Fig. 1
tendon
Fig. 2
l&year-old girl sustained a laceration of the Achilles tendon and compound fracture of the lower tibia. Onle a.fter emergency surgery the repaired tendon and soft tissue were necrotic. Figure 2-Skin and tendon defect. I Ggure l-An
muscle (Fumarola, 1985) and artificial substances (Ozaki er al., 1989), but such reconstruction is easily complicated by infection, leading to prolonged healing, and does not result in the attainment of sufficient strength. Reconstruction of the Achilles tendon with vascularised fascia has become possible owing to the development of microsurgery. Wei er al. (1988) reported reconstruction of the Achilles tendon by attaching a segment of the abdominal external oblique muscle fascia to a groin flap and rolling up the fascial strip. Lidman et al. (1987) reconstructed the Achilles tendon using a free tensor fasciae latae flap as a neurovascular flap. This also resulted in a strong tendon with sensitive skin. According to their reports, reconstruction of the Achilles tendon with the vascularised fascia induced early healing and displayed a high resistance to infection. We obtained similar results with our method. Achilles tendon defects associated with skin loss are best reconstructed using a technique which
week
allows simultaneous transfer of the fascia and skin. In this regard, Wei’s, Lidman’s and the present method are superior to other conventional methods. In the lateral thigh flap, which is one of the two new cutaneous flaps on the thigh reported by Baek in 1983, the third perforator is used. Similar flaps, including the lateral thigh fasciocutaneous Aap reported by Maruyama et al. in 1984, in which the first perforator is used, have been used in various reconstructions and these excellent gaps have many advantages including easy elevation and safe vascularisation (Inoue et al., 1985). The method of reconstructing the Achilles tendon by attaching fascia lata to the lateral thigh flap is technically very simple and can produce sufficiently strong tendon. We consider it is superior to Wei’s method for cases without bone defects, and superior to Lidman’s if the gastrocnemius muscle is intact. However, the ankle region is normally quite thin and all these flaps are too bulky, requiring defatting after reconstruction.
730
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 3
Fig. 5
Fig. 4
Fig. 6
Figure S-The lateral thigh flap marked on the right thigh with the patient prone. It is 10 x 20 cm in size with a 4 x 8 cm section of fascia lata. The lines at the upper right comer of the photograph mark the lower border of the gluteus maximus muscle. Figure 4Both the lateral thigh flap and the fascia lata were fed by the third and fourth perforators. Figure S-The folded fascia lata sutured to the residual Achilles tendon. Figure &The well-reconstructed Achilles tendon was observed during the defatting procedure, 6 months after operation.
731
RECONSTRUCTION OF ACHILLES TENDON
of the tendo Achilles and the overlying skin. Brjtish Journal oj Plastic Surgery, 38,403.
Inoue, T., Harashina, T. and Fujino, T. (1985). Our clinical experiences with the lateral thigh flap. Japanese Journal of Plastic and Reconstructive Surgery, 28, 561.
Lidman, D., Nettelblad, H., Berggren, A. and R&n, S. (1987). Reconstruction of soft tissue defects including the Achilles tendon with the free neurovascular tensor fascia lata flap and fascia lata. Scandinavian Journal qf Plastic and Reconstructitle Surgery, 21,213.
Maruyama, Y., Ohnlahl, K. and Takeuchi, S. (1984). The lateral thigh fasciocutaneous flap in the repair of ischial and trochanteric defects. British JoumalqfPlastic Surgery, 37. 103. Ozaki, J., Fqjikl, J., Sugimoto, K., Tamai, S. and Masuhara, K. (1989). Reconstruction of neglected Achilles tendon rupture with Mariex mesh. Clinical Orthopuedicsand Refated Research, 238,204.
Wei, F. C., Chen, H. C., Chuang, C. C. and Noordhoff, M. S. (1988). Reconstruction of Achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region. Plastic and Reconstructroe Surgery, 81, 579.
The Authors
Fig. 7 Figure ‘I-Final result 18 months after reconstruction, showing good plantar gexion.
References Baek, S. (1983). Two new cutaneous free flaps: the medial and lateral thigh flaps. Plastic and Reconstructive Surgery, 71,354. Fumarola, A. (1985). A one-stage reconstruction of a large defect
Takeo Iooue, MD, Assistant Professor. IchIro Tanaka, MD, Instructor Keisuke Imai, MD, Resident. Mitsuo Hatoko, MD, Resident Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, 1981 Tsujido, Kamoda, Kawagoe, 350 Japan. Requests for reprints to Dr Inoue at the above address. Paper received 15 December 1989. Accepted 17 April 1990.
