Tensor Fasciae Latae Perforator Flap for Reconstruction of Composite Achilles Tendon Defects with Skin and Vascularized Fascia

Abstract

The surgical management of large defects of the Achilles tendon and overlying skin is very demanding and necessitates, as a rule, a free vascularized graft. The ideal characteristics of a thin layer of skin and a strong tendon component, combined with a reliable blood supply and minimal morbidity at the donor site, have only been partially met by all previous grafts used in this situation. The authors performed reconstructions in five patients with large defects of the Achilles tendon and overlying skin by using a perforator flap derived from the tensor fasciae latae flap. A vascularized skin-subcutis-fascia lata flap could be raised by dissecting out two to three perforating arteries through the tensor fasciae latae muscle to the ascending branch of the lateral circumflex femoral artery; the muscle was left in situ in the process. All the flaps took well without complications. At final examination after an average of 20 months, the reconstructed Achilles tendon showed good functional results, although there was a 50 to 70 percent reduction in power during plantar flexion when compared with the normal side. A very good aesthetic result could be obtained after a debulking operation was performed on the skin flap.

Resektion der infizierten Achillessehne

“…lateralen Oberarmlappens erreichten die Patienten in den isokinetisch-dynamometrischen Messungen der Plantarflexion einen Kraftgrad von 30-60% der Gegenseite bzw. einen Kraftverlust zwischen 40-70% [6,10,18]. Eine Rekonstruktion durch Transfer der Sehne von Flexor hallucis longus, allerdings bei infektfreien Verhältnissen und nicht vorbestehender Wundproblematik, führt zu einem Kraftverlust bei Plantarflexion zwischen 20-30% verglichen mit der gesunden Seite [22,24].…”

“…Gesunde Achillessehne (c), die sich rechts nicht darstellt (d) in den sagittalen Aufnahmen armlappen kann auch in Kombination mit freier Fascia lata als Sehnenersatz eingesetzt werden [10]. Häufig wird allerdings die Fascia lata mit einem freien fasziokutanen Lappen, entweder dem Tensor fasciae latae (TFL) oder dem anterolateralen Oberschenkellappen ("antero-lateral thigh flap", ALT), zur gleichzeitigen Rekonstruktion der Sehne und Wundverschluss kombiniert [6,11,18]. Bei zweizeitigem Vorgehen kann eine Verlänge-rung des M. gastroknemius in V-Y-Technik mit primärer Sehnennaht und zusätz-licher Durchflechtung der Sehne des Plantaris longus durchgeführt werden [15].…”

Propellar flap: safe, reliable option for coverage of exposed tendo achilles

“…Various flaps have been described including the inferiorly based pedicled flap, reverse sural flap, islanded pedicled flaps, perforator flaps, propeller flaps and free flaps. [3][4][5][6][7][8][9][10][11]22 Free flaps are suitable for more extensive trauma, major avulsions and long defects, the procedure needs advanced skills, instrumentation, equipment and prolonged operating time. For moderate sized defects and majority of cases local flaps serve the purpose.…”

“…Various flaps have been described in literature for cover over TA like distally based skin flaps, advancement flap, free tissue transfers and islanded flaps. [3][4][5][6][7][8][9][10][11] The advent of islanded propeller flaps has changed the approach to reconstruction in general. Presence of abundance of perforators in the lower third of the leg arising from the posterior tibial and peroneal vessels is well documented.…”

Absence of the Arteria Profunda Femoris

“…Also, the muscular branches of femoris in the a. prof attracts considerable attention for myocutaneus procedure in plastic surgery (Cormack & Lamberty, 1985;Deiler et al, 2000). Additionally, a. profunda femoris is the entry point of diagnostic angiographic procedure (Meschan, 1975;Baum & Pentecost, 2006).…”