One-staged Microsurgical Reconstruction Of Defects Of The Achilles Tendon And The Overlying Soft Tissue

Objective: To summarize the curative effects and experience of five one-staged microsurgery methods to reconstruct the combined loss of Achilles tendon and the overlying skin,and compare respective advantage, disadvantage, indication.Method: From April 2001 to April 2007, we used five one-staged microsurgery options to reconstruct the combined loss of Achilles tendon and the overlying skin in 21 cases. The age of the patients ranged from 5 to 56 years. There were many causes which contribute to the combined defects, ten cases were caused by motorcycle wheel spoke, other traffic accidents in 4 cases, concis in 3 cases, crush in 3 cases, and athletics injury in 1 cases. We used the combined medial and lateral gastrocnemius musculocutaneous advancement flap in 1 patient,the free anterolateral thigh flap with iliotibial tract in 1 patient, the free paraumbilic flap with anterior sheath of rectus abdominis in 1 patient, the distally based sural neurovascular fasciocutaneous compound flap with aponeurosis of gastrocnemious muscle in 4 patients, the peroneus brevis tendon transfer and the distally based sural neurovascular fasciocutaneous flap in 12 patients, the peroneus brevis tendon transfer and the distally based sural neurovascular fasciocutaneous compound flap with aponeurosis of gastrocnemious muscle in 2 patients. The Achilles tendon defects ranged from 2.5cm to 8.0cm. The dimension of the flap varied from 6×5 cm to 32×11 cm.Result: All the distally based sural neurovascular fasciocutaneous flaps survived uneventfully, the survival rate of the distally based sural neurovascular fasciocutaneous flaps in our group was 100%;the free paraumbilic flap used in 1 patient survived completely; the free anterolateral thigh flap used in another patient underwent marginal necrosis,and the wound disappeared through secondary suture; the combined medial and lateral gastrocnemius musculocutaneous advancement flap in 1 patient underwent diatally superficial necrosis,and healed after given change dress; the Arner-Lindholm evaluation standard was taken to evaluate curative effect. Evaluation of the 3 patients given the combined medial and lateral gastrocnemius musculocutaneous advancement flap , the free anterolateral thigh flap,or the free paraumbilic flap was not done for short follow-up time or losing follow up.The other 18 patients underwent 3—26 months follow up(mean 15.4 months), no Achilles tendon reruptures had been observed to date, the results were excellent in 13 patients, good in 4 patients,but not satisfactory in 1 patients, 94.4% patients got ideal results.Conclusion: Using the peroneus brevis tendon transfer and the distally based sural neurovascular fasciocutaneous flap to reconstruct combined loss of the Achilles tendon and the overlying skin has the following merits :the curative effects are reliable,the operation is easy, the reconstructions are single-staged procedures, the identify of proximal end of the tendon of the peroneus brevis and the design of flap are in the same part ,the function recovers well, it is an ideal option to reconstruct combined loss of the distal two thirds Achilles tendon and the overlying skin; the distally based sural neurovascular fasciocutaneous compound flap with aponeurosis of gastrocnemious muscle has good blood supply, anti-infection ability, thus has little postoperative adhesions, and the single-staged operation is finished in the same cut, this method especially suitable to reinforce the Achilles tendon reconstructed and repair partial Achilles tendon defects in coronal plane with overlying skin loss; the distally based sural neurovascular fasciocutaneous flap has the following distinct advantagesis: simplicity, high success rates, no damage to major vessels, suitable thickness,and large survival dimension,the flap offers an ideal option to resurface the skin and soft tissue defects in hindfoot; the free anterolateral thigh flap with iliotibial tract and the free paraumbilic flap with anterior sheath of rectus abdominis are ideal to reconstruct Achilles tendon defects larger than 6cm accompanied with larger area skin loss.