The Anterolateral Thigh Flap for Achilles Tendon Reconstruction: Functional Outcomes

Reconstruction of the extensor tendon on the dorsal pedis with a chimeric skin-aponeurosis flap from the groin region

BACKGROUND

Complex defects involving the extensor tendon on the dorsal pedis have been reconstructed using multiple procedures. Skin coverage and tendon transfers have also been performed. This study aimed to present our experience using a chimeric skin-aponeurosis flap for one-stage reconstruction of composite soft-tissue defects on the dorsal pedis.

METHODS

Between May 2017 and September 2020, 12 patients with these defects received total treatment using a chimeric groin flap. Based on the superficial circumflex iliac vessels, the skin paddle resurfaced the cutaneous defect, and the vascularised external oblique aponeurosis was rolled to form a tendon-like structure to simultaneously replace the absent segment of the extensor tendons. A suitable "Y" bifurcation was dissected to enlarge the vessel diameter. Single-stage reconstruction was performed using a set of vascular anastomoses at the recipient site.

RESULTS

Flap survival was achieved without significant complications. The hammertoe deformity was completely removed. The average dimension of the skin paddle was 8.0 × 13.0 cm (range, 6.5 × 11.0-10.0 × 14.0 cm), and the mean size of the aponeurosis was 8.0 × 4.0 cm (range, 6.0 × 3.0-10.0 × 5.0 cm). At the last follow-up visit, no morbidity was observed at the donor site. Natural shapes and walking functions were successfully achieved with a protective sensation.

CONCLUSION

The chimeric groin flap with sheets of external oblique aponeurosis is a great candidate for one-stage reconstruction of composite soft tissue loss on the dorsal pedis. This approach provides cosmetic coverage, allowing faster wound healing and reduced tendon adhesions.

Graft and Flap: Orthoplastic Approach to Achilles Tendon Secondary Rupture

SUMMARY

Achilles tendon rupture represents one of the most common tendon ruptures. Although primary repair remains the treatment of choice, surgical complications, such as secondary rupture and tendon exposure, require salvage procedures. This article aims to present the authors' orthoplastic approach for the functional reconstruction of composite secondary Achilles tendon defects. Seven patients with chronic open-wound and large Achilles tendon defects (Kuwada type IV) underwent one-stage reconstruction between October of 2018 and October of 2020. The size of the average soft-tissue defect was 126.2 cm 2 (range, 86.1 to 175.9 cm 2 ), with a tendon gap of 8.2 cm (range, 7.1 to 10.3 cm). A combined team of orthoplastic surgeons performed the reconstructive procedure, using a turndown gastrocnemius fascial flap and a fascia lata autograft for the tendon reconstruction and a free fasciocutaneous anterolateral thigh flap for soft-tissue coverage (graft and flap). Subjective evaluation and quality-of-life measures were obtained preoperatively and 12 months postoperatively using the American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey questionnaire. Mean follow-up was 18.3 months (range, 12 to 24 months). The flap survival rate was 100%. Overall range of motion of the reconstructed side was 87% of the unaffected side (54 degrees versus 62 degrees). The American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey scores of all patients improved significantly ( P < 0.005) at 12 months of follow-up. A microsurgical approach combined with orthopedic techniques can solve complex cases of Achilles tendon secondary rupture, providing a reconstructed tendon that achieves satisfactory anatomic shape and function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Retrospective Matched-Pair Analysis of Long-term Outcomes after Successful Lower Extremity Free Flap Salvage

BACKGROUND

 Pedicle occlusion with total free flap loss after microvascular lower extremity reconstruction is a considerably rare yet devastating complication. Fortunately, in the majority of cases, emergency salvage takebacks of compromised free flaps are initiated in a timely manner. In this report, we present our analysis of long-term outcomes following transient vascular compromise mitigated through successful free flap salvage in the lower extremity.

METHODS

 We performed a single-center retrospective matched-pair analysis of 46 patients with lower extremity free flap reconstructions. Cases underwent successful revisions of microvascular compromise (n = 23), whereas controls had uneventful postoperative courses (n = 23). Patient-reported outcome questionnaires and physical evaluations were used to assess general quality of life, functional outcomes, and cosmesis (Lower Extremity Functional Scale [LEFS], Lower Limb Outcomes Questionnaire [LLOQ], Short Form 36 (SF-36), Vancouver Scar Scale [VSS]). The mean follow-up time was 4.4 years.

RESULTS

 The health-related quality of life assessed by the SF-36 did not differ significantly between both groups in any of the subscales (p ≥ 0.15 for all subscales). Functional outcomes did not show significant differences between both groups according to the LEFS (p = 0.78) and LLOQ (p = 0.45). The overall scar appearance assessed by the VSS showed significantly poorer cosmesis in the re-exploration group (p = 0.014).

CONCLUSION

 Salvage of compromised free flaps in the lower extremity yields similar long-term outcomes compared to noncompromised free flaps with regard to function and quality of life. However, free flap revisions may lead to impaired scar formation. This study provides further evidence that the opportunity for urgent re-exploration is indispensable.

Reconstruction of the severe Achilles tendon and soft-tissue loss with the bi-pedicled conjoined flap and vascularized fasciae latae: A consecutive case series of 15 patients

BACKGROUND

Historically, the segmental loss of the Achilles tendon with overlying soft-tissue defects had been frequently reconstructed with the composite anterolateral thigh (ALTP) flap, including the iliotibial tract or fasciae latae. This study aimed to present our modified combination using the bi-pedicled conjoined flap with vascularized fasciae latae, for the approximately total reconstruction of the Achilles tendon and extensive soft tissue.

METHODS

From May 2015 to March 2018, 15 patients (9 male and 6 female) with a mean age of 36 years (ranged, 18-52 years) underwent microvascular Achilles tendon reconstruction. Harvested on the abdomen and groin, the conjoined flap was chimeric with the vascularized fasciae latae. Primary donor-site closure was accomplished in all patients. A standard assessment of the functional and esthetical outcomes was completed.

RESULTS

Mean follow-up time was 42 months (ranged, 32-48 months). The average dimension of the conjoined flap was 25 × 14 cm (ranged, 18 × 10-35 × 18 cm), and the average size of the folded fasciae latae was 15 × 6 cm (ranged, 12 × 5-25 × 8 cm). At the last follow-up, the Thompson test was negative in all patients. The mean American Orthopedic Foot and Ankle Society (AOFAS) score was 91.0. The mean Achilles tendon total rupture score (ATRS) was 18.5. The mean Vancouver Scar Scale (VSS) score was 3.0.

CONCLUSIONS

The composite bi-pedicled flap including vascularized fasciae latae provides an alternative approach with great functional and esthetic outcomes, in selected patients who suffered severe Achilles tendon and skin defects. The one-stage procedure facilitates better rehabilitation postoperatively.

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

[Reconstruction of Soft Tissue Defects of the Achilles Tendon Region: a Literature Review]

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.

One-stage reconstruction of the complex defects of the Achilles tendon and the adjoining calcaneus using the chimeric superolateral thigh flap: A case report

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.

Long Term Follow-up of Composite Flaps for Single-stage Reconstruction of Concomitant Tendon and Soft Tissue Defects

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.

[Application of free anterolateral thigh flap with fascia lata for diabetic foot ulcers with bone exposure]

OBJECTIVE

To investigate the effectiveness of free anterolateral thigh flap (ALTF) with fascia lata in repairing diabetic foot ulcers (DFUs) with bone exposure.

METHODS

Between January 2019 and January 2021, 20 patients with DFUs with bone exposure were admitted. There were 17 males and 3 females with a median age of 57.5 years (range, 48-76 years). There were 10 cases of Wagner grade 3 and 10 cases of grade 4. The DFUs formed 1 to 14 months, with a median time of 3 months. The patients underwent CT angiography, which showed extensive atherosclerosis in both lower limbs; 6 of them were severely narrowed or occluded and underwent percutaneous transluminal angioplasty. The size of wound ranged from 7 cm×6 cm to 27 cm×10 cm after applied first-stage debridement combined with vacuum sealing drainage treatment. In the second-stage, free ALTF with fascia lata was used to repair wounds and partial defects of tendons. The size of flap ranged from 8 cm×5 cm to 28 cm×11 cm. The wound of the donor site was sutured directly. The survival of the flap, the healing time of the wound, and the complications were recorded. The laser speckle blood flow imaging system was used to detect the blood perfusion of the flap and the skin around the flap at 2 weeks and 6 months after operation. The foot function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score at 6 months after operation.

RESULTS

After operation, effusion under the flap happened in 6 cases, which cured after symptomatic treatment. Flaps survived completely in 14 cases. The tissue necrosis at the edges of the flaps occurred in 3 cases and healed after dressing changes. Venous crisis of flaps occurred in 3 cases, of which 1 case was completely necrotic after exploration, and the other 2 cases were partially alive. The wounds of 3 cases were repaired with skin grafts after debridement and dressing. The flap survival rate was 95.0%, and the limb salvage rate was 100%. The wound healing time after flap transplantation was 14-30 days, with an average of 19.1 days. Two patients had recurrence of peripheral skin ulcers of the flaps within 1 month after healing, which healed after conservative dressing changes. Eighteen cases of incisions at donor site healed by first intention, 2 cases had local skin necrosis and healed by debridement and suture. All patients were followed up 6-30 months, with a median time of 11 months. The texture, appearance, and elasticity of the flaps were good. All patients could walk alone without pain. At 6 months after operation, the AOFAS score was 75.9±11.9, which was significantly different from that (44.7±18.4) before operation ( t=-7.025, P=0.000). The blood perfusion value increased from (38.1±7.8) PU at 2 weeks to (42.7±10.3) PU, and the difference was significant ( t=-4.680, P=0.001).

CONCLUSION

Free ALTF with fascia lata has a rich blood supply and a high survival rate. It can be used to repair DFUs with bone exposure. After the free skin flap healed, it can promote revascularization of the affected foot, reduce the probability of ulcer recurrence, and avoid amputation.

Composite sural neurocutaneous flap with gastrocnemius tendon for repairing defects of Achilles tendon and overlying soft tissue

PURPOSE

Defect of Achilles tendon and overlying soft tissue remains a surgical challenge due to its insufficient blood supply and high requirement of function. This study aims to report the clinical efficacy of the composite sural neurocutaneous composite flap with gastrocnemius tendon on the complicated defect of Achilles region.

METHODS

Seven cases of defects of Achilles tendon and overlying soft tissue were reconstructed by the composite sural neurocutaneous composite flaps with gastrocnemius tendons. It is important to keep the connection between gastrocnemius tendon and deep fascia of the composite flap during operation. The smallest and the largest areas of transferred skin flaps were 7.5 cm × 4.5 cm and 11 cm × 10 cm respectively. The size of gastrocnemius tendon ranged from 5 cm × 3 cm to 9 cm × 4 cm. Patients was evaluated by using the Arner-Lindholm scale at the last follow-up.

RESULTS

Six flaps survived completely with no complication. One flap developed wound dehiscence and went on to heal by daily dressing. With 12-60 months follow-up, all patients gained satisfactory appearance and function of ankle, without tendon re-rupture or recurrent infection. Based on Arner-Lindholm scale, six cases were noted to be excellent and one was good.

CONCLUSION

The composite sural neurocutaneous flap with gastrocnemius tendon is a viable and practical method to salvage Achilles tendon defect and overlying soft tissue coverage, with minimal adhesion and satisfactory function.

Anterolateral Thigh and Vascularized-tensor Fascia Lata Flaps for Long-gap Achilles Tendon Reconstruction

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.

Performing Distance Measurements in Curved Facial Regions: A Comparison between Three-Dimensional Surface Scanning and Ultrasound Imaging

Facial flap surgery depends strongly on thorough preoperative planning and precise surgical performance. To increase the dimensional accuracy of transferred facial flaps, the methods of ultrasound and three-dimensional (3D) surface scanning offer great possibilities. This study aimed to compare different methods of measuring distances in the facial region and where they can be used reliably. The study population consisted of 20 volunteers (10 males and 10 females) with a mean age of 26.7 ± 7.2 years and a mean body mass index of 22.6 ± 2.2 kg/m². Adhesives with a standardized length of 20 mm were measured in various facial regions through ultrasound and 3D surface scans, and the results were compared. Regardless of the facial region, the mean length measured through ultrasound was 18.83 mm, whereas it was 19.89 mm for 3D surface scans, with both p < 0.0001. Thus, the mean difference was 1.17 mm for ultrasound measurements and 0.11 mm for 3D surface scans. Curved facial regions show a great complexity when it comes to measuring distances due to the concavity and convexity of the face. Distance measurements through 3D surface scanning showed more accurate distances than the ultrasound measurement. Especially in "complex" facial regions (e.g., glabella region and labiomental sulcus), the 3D surface scanning showed clear advantages.

The Anterolateral Thigh Perforator Flap: Its Expanding Role in Lower Extremity Reconstruction

The anterolateral thigh (ALT) flap is a popular flap for lower extremity reconstruction despite its varied pedicle anatomy. Beyond its use for soft tissue coverage, using the chimeric flap concept, the ALT flap is useful for tendon and ligament reconstruction and the creation of a gliding surface with the fascia lata component. The vastus lateralis muscle can be included for dead-space obliteration. The main pedicle is long and is a similar size match for major artery reconstruction. If several perforators are available, a split flap could be fashioned into a multitude of shapes all arising from the same pedicle.

"Repair and Flap technique": A Retrospective Analysis of Single Stage Reconstruction Method for Treatment of Chronic Open Achilles Tendon Defect with Proximal Turndown Flap and Reverse Sural Flap

BACKGROUND

Management of complex wounds of the lower extremity with concomitant Achilles tendon injury is a challenging situation for orthopaedic surgeons and plastic surgeons. The objective of the current study was to evaluate the clinical outcome of chronic open defects of the Achilles tendon with composite tissue loss. We have performed single stage reconstruction using the central segment of the proximal part of the Achilles tendon as turn-down flap and was covered immediately with reverse sural flap.

MATERIALS AND METHODS

Between March 2017 and February 2020, five cases of chronic open composite Achilles tendon defects which were treated by a single stage reconstruction method of "Repair and Flap technique" were included in this study. The patient with the defect for more than 4 weeks duration and had substance loss of Achilles tendon together with loss of overlying skin and soft tissue was included the current study.

RESULTS

All the flaps survived and healed well, providing stable coverage of the wound. The mean operative duration, including flap elevation, definitive flap inset and donor-site coverage was 98 min (range 90-120 min). Focal areas of skin graft loss were seen in two patients which healed with conservative management. The functional results evaluation was performed with The Achilles Tendon Total Rupture Score (ATRS). The mean Achilles Tendon Total Rupture Score (ATRS) was 70 (range 65-76).

CONCLUSION

To conclude, use of proximal turned down flap and coverage with reverse sural flap can be opted as a first option for the management of chronic open wounds with composite defects of the Achilles tendon. "Repair and Flap technique" will be a useful method of reconstruction in centres with limited resources for microsurgical flap. However, a multicenter study with more number of patients are required to further analyse this method.

The vascularized fascia lata free flap: an anatomical study and clinical considerations

Purpose

Fascia lata (FL) is often used as fascial component of the anterolateral thigh (ALT) flap in head and neck reconstruction. No distinct data exist on whether the FL has its own reliable vascular supply and whether the fascia alone can be harvested as a fascia lata free flap.

Methods

We dissected 25 thighs of 15 cadavers. The lateral circumflex femoral artery (LCFA) was identified, and the size of stained fascia and skin were measured after injection of methylene blue into the descending branch (DB). Finally, topography of fascial vessels was determined.

Results

Staining of fascia and skin paddle was found in all 25 cases. Ascending skin perforators of the DB of the LCFA gave off branches for supply of the FL enabling harvest of a fascia lata free flap. Septo- or musculocutaneous perforators pierced FL and entered skin within the proximal 38.6–60% of the thigh. The mean length and width of stained FL was 15.8 ± 4.1 cm and 8.7 ± 2.0 cm, respectively, and size of stained FL ranged from 40.0 to 336.0 cm². In 20 cases (80%), skin paddles were 2.4 times larger on average compared to corresponding FL.

Conclusion

We could demonstrate that the FL receives its own vascular supply from perforators of the DB originating from the LCFA. Hence, harvest of a fascia lata free flap is possible, reliable, and the size of the fascia is suitable for reconstruction of small and large defects of the head and neck.