A new incision for surgery on tendo Achillis using a distally-based fasciocutaneous flap

Abstract

he consequences of breakdown of the wound after surgery to tendo Achillis are considerable. Complex surgery is often required to reconstruct the tendon and to provide soft-tissue cover. We describe a new incision which approaches the tendon by using a distally-based fasciocutaneous flap. This reduces the risk of breakdown of the wound since it avoids making an incision directly over the tendon, provides good exposure, and maintains the vascularity of the skin overlying the tendon. The current, preferred surgical approach to tendo Achillis is a longitudinal incision, either on its medial or lateral side. 1,2 There is, however, a risk of breakdown of the wound because of poor vascularity of the skin in this region. As it heals the tendon lies directly beneath the incision. The potential complication is skin loss with exposure and necrosis of the tendon. We describe an approach to tendo Achillis which uses the principle of a distally-based fasciocutaneous flap in order to avoid making an incision too close to the tendon. Patients and MethodsOperative technique. A distally-based fasciocutaneous flap is raised with the vertical limbs just posterior to each malleolus. The transverse limb is made above the tendinous portion of gastrocnemius (Fig. 1). Since this is a randompattern fasciocutaneous flap, the ratio of the length to width is kept to a maximum of 3:1.3 The flap is raised in the subfascial plane in order to achieve exposure of the tendon (Fig. 2). On the lateral side, care must be taken to ensure T that the sural nerve is not damaged. Closure of the skin is achieved using 4-0 vicryl subcuticular dermal sutures with the knots buried and 4-0 nylon for the skin. In tendonlengthening procedures with a chronic plantar flexion deformity, deficiency of skin may require either a full-thickness graft from the groin, or a split-thickness graft from the thigh (Fig. 3). Illustrative case reportsCase 1. A 51-year-old man presented with a rupture of the right tendo Achillis sustained while playing basketball one week earlier. He underwent surgery using a distally-based fasciocutaneous flap and the tendon was repaired with 2/0 prolene. He had an uneventful postoperative recovery. At the follow-up at six months he was fully mobile, although he had a slightly hypertrophic scar at the medial malleolus. Case 2. A 45-year-old man presented with a rupture of his left tendo Achillis which he had sustained one month earlier.He underwent surgery using a distally-based fasciocutaneous flap and the tendon was repaired with 2/0 prolene. His postoperative recovery was uneventful. Seven months after surgery the scar had healed and he was walking normally. Case 3. A 25-year-old man had suffered a crush injury to his right foot and ankle ten years earlier which had remained untreated. He presented with a plantar flexion deformity of his right foot and was only able to walk on tiptoe. Examination revealed a shortened and contracted tendo Achillis. Radiographs revealed no bony abnormality. He underwent surgery to lengthen the tendon. An inci...