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J Reconstr Microsurg 2014; 30(08): 569-580
DOI: 10.1055/s-0033-1358787
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Open Achilles Tendon Defects: A 12-year Study on the Injury Mechanisms, Reconstructions, and Late Complications

Yue-Liang Zhu
1   Department of Orthopaedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, Yunnan Province, China
,
Yong-Qing Xu
1   Department of Orthopaedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, Yunnan Province, China
,
Liang-Bin Mei
1   Department of Orthopaedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, Yunnan Province, China
,
Yi Wang
1   Department of Orthopaedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, Yunnan Province, China
,
Fu-Bing Li
1   Department of Orthopaedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, Yunnan Province, China
,
Lin-Hui Sun
1   Department of Orthopaedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, Yunnan Province, China
› Author Affiliations
Further Information

Publication History

24 June 2013

07 September 2013

Publication Date:
15 July 2014 (online)

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Abstract

Background Open injuries of the Achilles tendon, which can be complicated by skin and bone injuries, continue to be a great challenge for surgeons. This study aims to report our experience with treatment of open Achilles tendon defects, focusing on the injury mechanisms, soft tissue coverage and late complications.

Methods A retrospective review was performed on 31 patients with open Achilles tendon defects between 1999 and 2011. The analyzed factors were injury mechanisms, surgeries, and long follow-up complications. The defect lengths of the Achilles tendons in the study ranged from 1 to 11 cm and the soft tissue defects ranged from 3 × 3 to 12 × 10 cm. Nine types of flaps were used for the coverage of concomitant skin defects.

Results Motorcycle spoke injuries were the most common cause of injury. There was no complete flap loss or rerupture of the reconstructed Achilles tendon. At the latest follow-up, all limbs were preserved and all the patients had regained full walking abilities. The algorithm of one-stage reconstruction was established, according to the defect length of the Achilles tendon and the defect size of skin. Late complications included maximum dorsiflexion loss and failure of heel raising ability on the single reconstructed foot.

Conclusion Open Achilles tendon defects are characteristic of concurrent skin and bone injuries and the reconstruction protocols of the different tissues should not be separated.

Keywords

Achilles tendon - defect - flap
 

  • References

  • 1 Maffulli N, Ajis A. Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am 2008; 90 (6) 1348-1360
    CrossrefPubMedGoogle Scholar
  • 2 Mudgal CS, Martin TL, Wilson MG. Reconstruction of Achilles tendon defect with a free quadriceps bone-tendon graft without anastamosis. Foot Ankle Int 2000; 21 (1) 10-13
    PubMedGoogle Scholar
  • 3 Fumarola A. A one-stage reconstruction of a large defect of the tendo Achilles and the overlying skin. Br J Plast Surg 1985; 38 (3) 403-406
    CrossrefPubMedGoogle Scholar
  • 4 Linton PC. The combined medial and lateral gastrocnemius musculocutaneous V-Y island advancement flap. Plast Reconstr Surg 1982; 70 (4) 490-493
    CrossrefPubMedGoogle Scholar
  • 5 Lidman D, Nettelblad H, Berggren A, Rajan S. 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 (2) 213-218
    CrossrefPubMedGoogle Scholar
  • 6 Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of Achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region. Plast Reconstr Surg 1988; 81 (4) 579-589
    CrossrefPubMedGoogle Scholar
  • 7 Inoue T, Tanaka I, Imai K, Hatoko M. Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap. Br J Plast Surg 1990; 43 (6) 728-731
    CrossrefPubMedGoogle Scholar
  • 8 Feibel RJ, Jackson RL, Lineaweaver WC, Buncke HJ. Management of chronic achilles tendon infection with musculotendinous gracilis interposition free-flap coverage. J Reconstr Microsurg 1993; 9 (5) 321-325
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Hou SM, Liu TK. Vascularized tendon graft using lateral arm flap. 5 microsurgery cases. Acta Orthop Scand 1993; 64 (3) 373-376
    CrossrefPubMedGoogle Scholar
  • 10 Babu V, Chittaranjan S, Abraham G, Korula RJ. 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 (5) 1090-1094
    CrossrefPubMedGoogle Scholar
  • 11 Isenberg JS, Fusi S. Immediate tendon Achilles reconstruction with composite palmaris longus grafts. Ann Plast Surg 1995; 34 (2) 209-211
    CrossrefPubMedGoogle Scholar
  • 12 Sylaidis P, Fatah MF. A composite lateral arm flap for the secondary repair of a multiply ruptured Achilles tendon. Plast Reconstr Surg 1995; 96 (7) 1719-1723
    CrossrefPubMedGoogle Scholar
  • 13 Leppilahti J, Kaarela O, Teerikangas H, Raatikainen T, Orava S, Waris T. Free tissue coverage of wound complications following Achilles tendon rupture surgery. Clin Orthop Relat Res 1996; (328) 171-176
    PubMedGoogle Scholar
  • 14 Haddad JL, Chavez-Abraham V, Carrera J, Vilchis J, Sastre N. Microsurgical reconstruction of the Achilles tendon with a fascia lata flap. J Reconstr Microsurg 1997; 13 (5) 309-312
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 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 (5) 1618-1622
    CrossrefPubMedGoogle Scholar
  • 16 Gao JM, Xu DC, Wu SP , et al. Transplantation of the vascularized adductor magnus tendon for the repair of Achilles tendon defect. Chin J Orthop 1999; 19: 3
    PubMedGoogle Scholar
  • 17 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 (1) 111-119
    CrossrefPubMedGoogle Scholar
  • 18 Stanec S, Stanec Z, Delimar D, Martinac P. A composite forearm free flap for the secondary repair of the ruptured Achilles tendon. Plast Reconstr Surg 1999; 104 (5) 1409-1412
    CrossrefPubMedGoogle Scholar
  • 19 Deiler S, Pfadenhauer A, Widmann J, Stützle H, Kanz KG, Stock W. Tensor fasciae latae perforator flap for reconstruction of composite Achilles tendon defects with skin and vascularized fascia. Plast Reconstr Surg 2000; 106 (2) 342-349
    CrossrefPubMedGoogle Scholar
  • 20 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 (7) 574-577
    CrossrefPubMedGoogle Scholar
  • 21 Ademoğlu Y, Ozerkan F, Ada S , et al. Reconstruction of skin and tendon defects from wound complications after Achilles tendon rupture. J Foot Ankle Surg 2001; 40 (3) 158-165
    CrossrefPubMedGoogle Scholar
  • 22 Dumont CE, Kessler J. A composite medial plantar flap for the repair of an achilles' tendon defect: a case report. Ann Plast Surg 2001; 47 (6) 666-668
    CrossrefPubMedGoogle Scholar
  • 23 Möller M, Karlsson J, Lind K, Mark H, Fogdestam I. Tissue expansion for repair of severely complicated Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2001; 9 (4) 228-232
    CrossrefPubMedGoogle Scholar
  • 24 Yajima H, Kobata Y, Yamauchi T, Tamai S. Reconstruction of achilles tendon and skin defects using peroneal cutaneotendinous flaps. Plast Reconstr Surg 2001; 107 (6) 1500-1503
    CrossrefPubMedGoogle Scholar
  • 25 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 (7) 1807-1811
    CrossrefPubMedGoogle Scholar
  • 26 Coskunfirat OK, Sheu TJ, Jeng SF, Wei FC. 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 (1) 215-219
    CrossrefPubMedGoogle Scholar
  • 27 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 (4) 376-382
    CrossrefPubMedGoogle Scholar
  • 28 Kim SW, Hong JP, Lee WJ, Chung YK, Tark KC. 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 (6) 653-657
    CrossrefPubMedGoogle Scholar
  • 29 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 (2) 149-155
    CrossrefPubMedGoogle Scholar
  • 30 Papp C, Todoroff BP, Windhofer C, Gruber S. Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap. Plast Reconstr Surg 2003; 112 (3) 777-783
    CrossrefPubMedGoogle Scholar
  • 31 Koshima I, Ozaki T, Gonda K, Okazaki M, Asato H. Posterior tibial adiposal flap for repair of wide, full-thickness defect of the Achilles tendon. J Reconstr Microsurg 2005; 21 (8) 551-554
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Arslan E, Milcan A, Aksoy A, Unal S, Demirkan F. Use of distally based cross-leg sural artery flap and cadaveric Achilles tendon graft in the reconstruction of a combined defect of the Achilles tendon and overlying soft tissue. Plast Reconstr Surg 2006; 117 (4) 1365-1367
    CrossrefPubMedGoogle Scholar
  • 33 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 (1) 266-271
    CrossrefPubMedGoogle Scholar
  • 34 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 (2) 142-147
    CrossrefPubMedGoogle Scholar
  • 35 Boopalan PR, Jepegnanam TS, Titus VT, Prasad SY, Chittaranjan SB. 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 (2) 96-99
    CrossrefPubMedGoogle Scholar
  • 36 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 (4) e406-e410
    CrossrefPubMedGoogle Scholar
  • 37 Baden JM, Warr RP, Khan U. Immediate free tissue transfer for coverage of Achilles tendon injury or reconstruction. Foot Ankle Surg 2010; 16 (4) 164-169
    CrossrefPubMedGoogle Scholar
  • 38 Chalmers R, Tare M, Niranjan N. Vascularised Achilles tendon graft reconstruction—by the tendon for the tendon. J Plast Reconstr Aesthet Surg 2010; 63 (3) e273-e276
    CrossrefPubMedGoogle Scholar
  • 39 Hansen U, Moniz M, Zubak J, Zambrano J, Bear R. Achilles tendon reconstruction after sural fasciocutaneous flap using Achilles tendon allograft with attached calcaneal bone block. J Foot Ankle Surg 2010; 49 (1) e5-e10
    CrossrefPubMedGoogle Scholar
  • 40 Lykoudis EG, Contodimos GV, Ristanis S, Georgoulis AD, Lazarou SA. One-stage complex Achilles tendon defect reconstruction with an Achilles tendon allograft and a gracilis free flap. Foot Ankle Int 2010; 31 (7) 634-638
    CrossrefPubMedGoogle Scholar
  • 41 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 (3) 205-209
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Nellas ZJ, Loder BG, Wertheimer SJ. Reconstruction of an Achilles tendon defect utilizing an Achilles tendon allograft. J Foot Ankle Surg 1996; 35 (2) 144-148 , discussion 190
    CrossrefPubMedGoogle Scholar
  • 43 Hallock GG. A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps. J Reconstr Microsurg 2013; 29 (4) 233-240
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Aldridge III JM, Easley M, Nunley JA. Open calcaneal fractures: results of operative treatment. J Orthop Trauma 2004; 18 (1) 7-11
    CrossrefPubMedGoogle Scholar
  • 45 Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004; 18 (1) 1-6
    CrossrefPubMedGoogle Scholar
  • 46 Berry GK, Stevens DG, Kreder HJ, McKee M, Schemitsch E, Stephen DJ. Open fractures of the calcaneus: a review of treatment and outcome. J Orthop Trauma 2004; 18 (4) 202-206
    CrossrefPubMedGoogle Scholar
  • 47 Lawrence SJ, Grau GF. Open fractures of the calcaneus: soft-tissue injury determines outcome. J Bone Joint Surg Am 2004; 86-A (11) 2568 , author reply 2569
    PubMedGoogle Scholar
  • 48 Oztürk S, Bayram Y, Möhür H, Deveci M, Sengezer M. Evaluation of late functional results of patients treated with free muscle flaps for heel defects caused by land-mine explosions. Plast Reconstr Surg 2005; 116 (7) 1926-1936
    CrossrefPubMedGoogle Scholar
  • 49 Ulusal AE, Lin CH, Lin YT, Ulusal BG, Yazar S. The use of free flaps in the management of type IIIB open calcaneal fractures. Plast Reconstr Surg 2008; 121 (6) 2010-2019
    CrossrefPubMedGoogle Scholar