Composite Free Tissue Transfer for Reconstruction of Lower Extremity Tendon Injuries: A Systematic Review

Abstract

Background Tendon rupture with extensive soft tissue loss has few reconstructive options. Composite free tissue transfers including skin and tendon offer an attractive reconstructive approach. Unfortunately, most studies discussing them come from sparse case reports. We systematically assess evidence supporting composite flap use in single-stage reconstruction of lower extremity tendon and soft tissue defects. Methods A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. OvidMEDLINEqueried for records pertaining to the study question using Medical Subject Heading (MeSH) terms such as “lower extremity,” “tendon,” and “composite flap.” No limitations were placed on the year of publication, country of origin, or study size. Study characteristics and patient demographics were collected. Primary outcomes included:(1) defect location, composite flap characteristics;(2) return to ambulation;(3) joint range of motion;(4) patient satisfaction, and (5) complications. Results In total, 29 articles examining 173 patients with lower extremity tendon defects and soft tissue loss were identified. Average age was 44.3 years (SD 17.5); most patients were male (n = 110, 66.3%). Achilles defect was mostly reported (n = 151, 86.8%), followed by patellar (n = 17, 9.8%) and other tendon defects (n = 6, 3.4%). Average tendon defect size was 8.4 cm (SD 4.0), average soft tissue loss was 80.2 cm2 (SD 40.0). Most employed composite flap was anterolateral thigh and fascia lata (ALT + FL) (n = 101, 58.0%). Most patients (n = 134, 99.3%) returned to ambulation in an average 123.1 days (SD 78.3). Average reconstructive joint degree of motion was 62.1 degrees compared with normal degree of motion 62.3 degrees. Patient-reported outcomes demonstrated increased satisfaction after reconstruction. Conclusion Composite flaps effectively reconstruct a variety of tendon and soft tissue defects; the most reported flap is ALT + FL, which provides large flap territories and rapid healing in Achilles, patellar, and other tendon defects. In this review, patients with composite flaps demonstrated return to ambulation, minimal impairment in range of motion, and notable postoperative satisfaction.

ALT in combination with triple-rolled TFL for reconstruction of a complex tendoachilles defect: technical details and rehabilitation regime

“…The most significant success of this reconstruction was the patient’s swift functional restoration. Ambulation time was 1.5 months, compared with 2 months in Son et al ’s five-patient case series and Sayyed et al ’s4 systematic review finding of 123.1-day average time to ambulation for all types of Achilles tendon reconstruction. In the same time frame, the patient in our case had resumed indoor cycling, a remarkably faster recovery than average.…”

“…To determine the best treatment for patients in lower limb reconstruction, reconstructive ladders and algorithms are often used in decision-making by plastic surgeons, alongside patient factor consideration and multidisciplinary team input 3. While less complex Achilles tendon injuries can be managed conservatively or with procedures such as primary repair, traumatic Achilles tendon ruptures with segmental soft tissue defects require careful reconstructive planning and often require the use of chimeric microvascular free flaps 4. Chimeric microvascular free flaps are a subtype of compound flap comprising different flaps arranged in specific configurations or formations 5–8.…”

Evaluation of the ankle function after Achilles tendon resection: a retrospective clinical study

“…Free flaps play a key role in ATR. Out of the fasciocutaneous flaps, the lateral arm flap, harvested with a strip of triceps tendon [ 23 ], the radial forearm flap with flexor carpi radialis tendon [ 24 ], the infragluteal flap[ 25 ], the tensor fascia lata flap [ 26 ] and ALT flap [ 27 , 28 ], both harvested with a vascularized strip of fascia lata offer healthy well-vascularized soft tissue and tendon which can improve the healing of a chronically infected, poorly vascularized wound. In a systematic review, Iorio et al report on 44 ATR with free composite grafts from 15 studies, out of which 30 vascularized tendon reconstructions and 7 avascular reconstructions.…”

Interdisziplinäre Plastische und Rekonstruktive Chirurgie von Plattenepithelkarzinomen des Kopf-Hals-Bereichs

“…Die Erstbeschreibung dieses Lappens erfolgte im Jahr 1984 durch Song und Kollegen [60]. Mittlerweile existieren zahlreiche anatomische Studien [61,62] und umschriebene Operationsvarianten [63,64] des ALT, so dass die Operationsmethode bestens etabliert ist.…”

“…The initial description of this flap was made in 1984 by Song and colleagues [60]. In the meantime, numerous anatomical studies [61,62] and circumscribed surgical variants [63,64] of the ALT exist, so that the surgical method is well established.…”