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

Abstract

The reconstruction of the posterior heel including a wide defect of the Achilles tendon is difficult as a result of complicated infection, deficient soft tissue for coverage, and functional aspects and defects of the tendon itself. As a single-stage procedure, various methods of tendon transfer and tendon graft have been reported along with details of local flaps or island flaps for coverage. With advances in microsurgical techniques and subsequent refinements, several free composite flaps, including tendon, fascia, or nerve, have been used to reconstruct large defects in this area without further damaging the traumatized leg. The authors report such a single-stage reconstruction of a composite Achilles tendon defect using the extensor digitorum longus tendon of the second to fourth toe in combination with a dorsalis pedis flap innervated by the superficial peroneal nerve. The follow-up of this case has proved a satisfactory outcome to date.

The composite anterolateral thigh flap for achilles tendon and soft tissue defect reconstruction with tendon repair by fascia with double or triple folding technique

“…Various types of free flaps have been proposed, including the muscle flap, musculocutaneous flap, fasciocutaneous flap, and perforator flap. Among these, free flaps from the upper limb, such as radial forearm flaps with the palmaris longus tendon, brachioradialis flaps with the flexor carpi radialis tendon, and lateral arm flaps with the triceps tendon, as well as some flaps from the lower limb, such as the dorsalis pedis flap with the extensor digitorum longus tendon, and the groin flap including the vascularized external oblique aponeurosis, have been used for small‐sized defects. However, these flaps lack sufficient dimension for large defects, and harvesting of the normal functioning tendon for the reconstruction increases donor site morbidity.…”

The past, present and future in scaffold-based tendon treatments

“…The use of autografts in clinical setting has been strongly supported by superior functional results [288,289]. Nonetheless, availability issues and the unavoidable site morbidity that will only partially improve the properties of the originally injured tendon tissue [290][291][292][293] pushed the field towards allogeneic [294][295][296][297][298] alternatives. Clinical data indicated no functional difference between autograft and allograft intervention in ACL repair [299][300][301]; however MRI analysis favoured the autograft, as allograft intervention brought about a less mature neotissue [302].…”

Treatment of Catastrophic Infection After Surgery for Insertional Achilles Enthesopathy

“…5,8,11 While there are no reports in the literature describing the treatment of deep Achilles tendon infection after operative treatment of insertional Achilles enthesopathy, numerous case reports exist describing treatment of deep infection after operative treatment of Achilles tendon ruptures. [3][4][5][6][7][8][9][10][11][12][13][14][15] In addition, a case report in the trauma literature describes combined allograft/ autograft treatment for extensive soft tissue loss including the Achilles tendon following a crush injury to the lower extremity. 16 Fourniols et al 4 described a technique in which postoperative Achilles tendon necrosis after operative treatment of ruptures, tendinopathy, tendon transfer, or Achilles tendon lengthening were managed with an initial radical debridement followed by serial debridement and eventual healing of the soft tissue defect by secondary intention with scar tissue creating a neotendon.…”

“…Numerous case reports describe treatment algorithms addressing the skin and tendon defects by using scar tissue, an flexor hallucis longus (FHL) transfer or free muscle flaps. [3][4][5][6][7][8][9][10][11][12][13][14][15] All the studies describing these procedures pertain to the treatment of infection after operative repair of Achilles tendon ruptures. Additionally, to our knowledge, Achilles allograft implantation for the treatment of deep infection and Achilles tendon necrosis for operative treatment of insertional Achilles enthesopathy has not previously been reported.…”