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Achilles Tendon Reconstruction after Sural Fasciocutaneous Flap Using Achilles Tendon Allograft with Attached Calcaneal Bone Block Uel Hansen, MD 1 , Melinda Moniz, MD 1 , Joseph Zubak, MD 2 , Jacinto Zambrano, MD 3 , Russell Bear, DO 4 1 Orthopaedic Resident Physician, William Beaumont Army Medical Center, El Paso, TX 2 Orthopaedic Staff Physician, Foot and Ankle Surgery, William Beaumont Army Medical Center, El Paso, TX 3 Plastic Surgeon, William Beaumont Army Medical Center, El Paso, TX 4 Orthopedic Staff Physician, William Beaumont Army Medical Center, El Paso, TX article info Level of Clinical Evidence: 4 Keywords: calcaneus gastrocnemius heel soleus surgery wound coverage abstract Addressing segmental loss of the Achilles tendon with overlying soft tissue loss is a serious challenge. We present a case of Achilles tendon reconstruction in a patient who had significant soft tissue loss as well as segmental loss of the tendon involving the calcaneal insertion. The staged reconstruction was undertaken with a combination of a sural fasciocutaneous flap and an Achilles tendon allograft with an attached calcaneal bone block. Ó 2010 by the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved. Combined segmental loss of the Achilles tendon with associated loss of adequate soft tissue coverage can occur as a result of trauma (1, 2), infection after a primary surgical repair of an Achilles tendon rupture (3), or as a result of local tumor resection (4, 5). To restore ankle plantarflexion, both deficits must be addressed. The surgeon has to choose between free flaps or available local tissue, such as a rota- tional flap, to gain adequate soft tissue coverage of a tendon recon- struction, and a replacement graft, either an autograft or allograft, must be selected. Finally, the surgeon must choose between a 1-stage or 2-stage reconstruction. In this report, we present the case of a patient whose primary repair of her Achilles tendon became infected and resulted in significant soft tissue loss, as well as segmental loss of the Achilles tendon involving the calcaneal inser- tion. A sural fasciocutaneous flap was undertaken to establish soft tissue coverage, combined with a staged Achilles tendon recon- struction with an Achilles tendon allograft with an attached calcaneal bone block. Case Report A 34-year-old female active-duty nurse, with a 2-year history of left Achilles tendinosis, was treated with casting, a controlled-ankle- motion boot, and a local steroid injection at an outside facility. After that treatment, she was asymptomatic for 4 months until her Achilles tendon ruptured as she stepped off a bus. She underwent a primary Achilles tendon repair that was complicated by recurrent wound dehiscence and soft tissue infection. Wound management involved significant debridement of the skin, subcutaneous tissue, including Fig. 1. Preoperative clinical photograph showing concavity of healed soft tissue proximal to the calcaneal tuberosity. Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Uel Hansen, MD, 6730 Bridge Way, Columbus, GA 31904. E-mail address: [email protected] (U. Hansen). Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org 1067-2516/$ – see front matter Ó 2010 by the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved. doi:10.1053/j.jfas.2009.08.006 The Journal of Foot & Ankle Surgery 49 (2010) 86.e5–86.e10

Achilles Tendon Reconstruction after Sural Fasciocutaneous Flap Using Achilles Tendon Allograft with Attached Calcaneal Bone Block

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Page 1: Achilles Tendon Reconstruction after Sural Fasciocutaneous Flap Using Achilles Tendon Allograft with Attached Calcaneal Bone Block

lable at ScienceDirect

The Journal of Foot & Ankle Surgery 49 (2010) 86.e5–86.e10

Contents lists avai

The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

Achilles Tendon Reconstruction after Sural Fasciocutaneous Flap Using AchillesTendon Allograft with Attached Calcaneal Bone Block

Uel Hansen, MD 1, Melinda Moniz, MD 1, Joseph Zubak, MD 2, Jacinto Zambrano, MD 3, Russell Bear, DO 4

1 Orthopaedic Resident Physician, William Beaumont Army Medical Center, El Paso, TX2 Orthopaedic Staff Physician, Foot and Ankle Surgery, William Beaumont Army Medical Center, El Paso, TX3 Plastic Surgeon, William Beaumont Army Medical Center, El Paso, TX4 Orthopedic Staff Physician, William Beaumont Army Medical Center, El Paso, TX

a r t i c l e i n f o

Level of Clinical Evidence: 4Keywords:calcaneusgastrocnemius

heelsoleussurgerywound coverage

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Uel Hansen, MD, 6730E-mail address: [email protected] (U. Hanse

1067-2516/$ – see front matter � 2010 by the Ameridoi:10.1053/j.jfas.2009.08.006

a b s t r a c t

Addressing segmental loss of the Achilles tendon with overlying soft tissue loss is a serious challenge. Wepresent a case of Achilles tendon reconstruction in a patient who had significant soft tissue loss as well assegmental loss of the tendon involving the calcaneal insertion. The staged reconstruction was undertaken witha combination of a sural fasciocutaneous flap and an Achilles tendon allograft with an attached calcaneal boneblock.

� 2010 by the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Fig. 1. Preoperative clinical photograph showing concavity of healed soft tissue proximalto the calcaneal tuberosity.

Combined segmental loss of the Achilles tendon with associatedloss of adequate soft tissue coverage can occur as a result of trauma(1, 2), infection after a primary surgical repair of an Achilles tendonrupture (3), or as a result of local tumor resection (4, 5). To restoreankle plantarflexion, both deficits must be addressed. The surgeon hasto choose between free flaps or available local tissue, such as a rota-tional flap, to gain adequate soft tissue coverage of a tendon recon-struction, and a replacement graft, either an autograft or allograft,must be selected. Finally, the surgeon must choose between a 1-stageor 2-stage reconstruction. In this report, we present the case ofa patient whose primary repair of her Achilles tendon becameinfected and resulted in significant soft tissue loss, as well assegmental loss of the Achilles tendon involving the calcaneal inser-tion. A sural fasciocutaneous flap was undertaken to establish softtissue coverage, combined with a staged Achilles tendon recon-struction with an Achilles tendon allograft with an attached calcanealbone block.

Case Report

A 34-year-old female active-duty nurse, with a 2-year history ofleft Achilles tendinosis, was treated with casting, a controlled-ankle-motion boot, and a local steroid injection at an outside facility. After

Bridge Way, Columbus, GA 31904.n).

can College of Foot and Ankle Surgeo

that treatment, she was asymptomatic for 4 months until her Achillestendon ruptured as she stepped off a bus. She underwent a primaryAchilles tendon repair that was complicated by recurrent wounddehiscence and soft tissue infection. Wound management involvedsignificant debridement of the skin, subcutaneous tissue, including

ns. Published by Elsevier Inc. All rights reserved.

Page 2: Achilles Tendon Reconstruction after Sural Fasciocutaneous Flap Using Achilles Tendon Allograft with Attached Calcaneal Bone Block

Fig. 2. Intraoperative photographs of the distally based sural artery rotational fas-ciocutaneous flap for soft tissue coverage of the staged Achilles tendon reconstruction. (A)Outlining the flap. (B) Flap mobilized and rotated distally. (C) The flap sutured into place.

Fig. 3. Clinical photograph at the time of the staged Achilles tendon reconstruction (48days after placement of flap) showing the sural artery rotational fasciocutaneous flaphealed into place with minimal necrosis.

U. Hansen et al. / The Journal of Foot & Ankle Surgery 49 (2010) 86.e5–86.e10 86.e6

necrotic Achilles tendon and, in particular, the distal portion of thetendon near its calcaneal insertion. Five and a half months after herinitial primary repair, she was referred to our service.

At the time of presentation to our service, she was unable toplantarflex against gravity, and she required the use of a cane forambulation. The wound was well healed, but there was substantialconcavity of the soft tissues proximal to the calcaneal tuberosity. Itwas clinically obvious that a significant amount of skin had been lostand the remaining skin had been brought together under tension forwound closure. It was, in essence, clinically apparent that there wasinadequate local skin to cover a tendon reconstruction (Figure 1).

After appropriate discussion and preparation, soft tissue coveragewas restored with a distally based sural artery rotational fasciocuta-neous flap, performed by a reconstructive surgeon on our plastic

surgery service (Figure 2). This was the first operation in a stagedreconstruction that would eventually entail repair of the Achillestendon after the flap had healed enough that it could be raised andthen reapplied. At the time of the second stage of the reconstruction,which took place 48 days after the first stage, the flap had healed tothe point where it was well vascularized and displayed only marginalnecrosis (Figure 3). The flap was raised along its medial margin and,after debulking and debriding, an Achilles tendon allograft with anattached calcaneal bone block was used to reconstruct the tendon.The reconstruction was further augmented with a flexor hallucislongus tendon transfer (Figure 4), in an effort to bring additionalvascular supply to the area containing the allograft tendon. Twocancellous screws were used to secure the distal bone block ina trough made in the calcaneal tuberosity (Figure 5), and the allografttendon was sutured into the proximal stump of the native tendonunder appropriate tension (following the technique described byMyerson [6]).

Postoperatively, the patient went through a conservative rehabil-itation program and was allowed to start partial weight bearing 8weeks after the second surgery. She progressed to full weight bearingby 12 weeks after the second operation, and by 6 months after thesurgery, the patient could ambulate without an assistive device. Shewas capable of 40� of active plantarflexion and 10� of active dorsi-flexion. At that time, moreover, she could perform a bilateral toestance (Figure 6). At 15 months after the final operation, the patientcould tolerate unlimited bicycling and swimming and could exerciseup to 30 minutes on an elliptical training machine. She had been ableto continue her active-duty military service and completed an alter-native physical fitness test that entailed biking instead of running.

Discussion

The goals of this reconstruction were to restore soft tissue coverageover a functional, reconstructed Achilles tendon. Use of the Achillestendon allograft with the attached calcaneal bone block and the suralartery fasciocutaneous flap successfully addressed this patient’stendon and soft tissue morbidities. We are aware of only one previ-ously published case that involved soft tissue coverage over a recon-struction using an Achilles tendon allograft with an attached calcaneal

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Fig. 4. Operative photographs at the time of the staged Achilles tendon reconstruction.The flap has been debrided and elevated at the medial margin. (A) After scar tissue wasdebrided and the calcaneal bone prepared for allograft, the flexor hallucis longus wastransferred to provide more vascular tissue near the reconstruction. (B) Incorporation ofthe bony allograft in the calcaneus. (C) Allograft tensioned and sutured into the remainingstump of native Achilles tendon.

Fig. 5. Postoperative radiograph showing fixation of the allograft bone block into thecalcaneus.

Fig. 6. Clinical photograph at 6 months postoperative, showing the patient activelyraising both heels.

U. Hansen et al. / The Journal of Foot & Ankle Surgery 49 (2010) 86.e5–86.e1086.e7

Page 4: Achilles Tendon Reconstruction after Sural Fasciocutaneous Flap Using Achilles Tendon Allograft with Attached Calcaneal Bone Block

Table 1Previously reported Achilles tendon allografts and soft tissue coverage techniques

Type of Achilles allograft Soft tissue coverage Comments Reference

Achilles tendon allograft withcalcaneal bone block

d For chronic Achilles tendinosis Myerson (6)

Achilles tendon allograft withcalcaneal bone block

Rectus muscle free flap After resecting all soft tissue andthe entire Achilles tendon for clearcell sarcoma of the Achilles tendon

Yuen and Nicholas (7)

Achilles tendon allograft withcalcaneal bone block

d For chronic Achilles tendinosis or chronicAchilles ruptures

Haraguchi and Bluman (8)

Achilles tendon allograft Cross-leg sural artery flap Soft tissue defect and segmental Achilles lossafter trauma in a pediatric patient

Arslan et al (33)

Freeze-dried Achilles tendonallograft

d For neglected Achilles tendon rupture Lepow and Green (34)

2 strips of freeze-dried Achillestendon allograft

d Pulmonary embolism in postoperative period Nellas et al (35)

Dash indicates not described or applicable.

U. Hansen et al. / The Journal of Foot & Ankle Surgery 49 (2010) 86.e5–86.e10 86.e8

bone block (7). In that case, the soft tissue was reestablished witha rectus muscle free flap.

Myerson (6) described the use of an Achilles tendon allograft witha calcaneal bone block for the treatment of degenerative Achillestendinopathy. Although he did not address soft tissue defects over-lying the degenerative tendon, he emphasized the importance ofappropriate tensioning of the graft after fixation of the allograft boneblock to the native calcaneus. In addition to chronic Achilles tendi-nosis, Haraguchi and Bluman (8) also included chronic rupture of theAchilles tendon as an indication for use of an Achilles allograft withattached calcaneal bone block. Various forms of Achilles allograft havebeen used to reconstruct the Achilles tendon (Table 1), although notall have included an attached calcaneal bone block.

Addressing Achilles tendon segmental loss at the level of thetendon’s insertion is a particularly challenging problem. Drillinga hole in the calcaneus, passing the soft tissue autograft through thecanal, and then suturing the graft back upon itself have beendescribed (5). Anchoring of the distal portion of the reconstructedtendon by suturing it to the plantar fascia has also been described (9).Still further, various suture anchors have also been described foraddressing primary repairs or reconstructions that involve theAchilles tendon near its insertion (10).

Various tendon autografts and allografts with attached bone havebeen used to reconstruct the Achilles tendon at its calcaneal attach-ment (Table 2). The attached allograft bone is desirable because itallows for secure screw fixation of the graft distally into the calcaneus.Besse et al (11) performed reconstruction of the Achilles insertion ina small series of patients using autograft patellar tendon with

Table 2Grafts with attached bone blocks used to address loss of the Achilles tendon insertion

Achilles tendon allograft withcalcaneal bone block

Myerson (6), Yuen and Nicholas (7),Haraguchi and Bluman (8)

Brachioradialis tendon autograftwith radial bone block

Stanec et al (15)

Patellar tendon autograft withtibial tuberosity bone block

Besse et al (11)

Quadriceps tendon autograftwith patellar bone block

Besse et al (11), Mudgal et al (32)

attached bone from the tibial tuberosity. The autograft bone portion oftheir grafts was fixed into a drill hole in the posterior-superior aspectof the calcaneus with an interference screw. The patients in theirseries had intact soft tissue coverage at the time of reconstruction.Coskunfirat et al (12) addressed their case of Achilles insertionaldeficit by attaching an autograft directly to the calcaneus with screwfixation and covering the autograft with a groin free flap. Daberniget al (13, 14) described performing a horizontal osteotomy in thecalcaneus, placing tensor fascia lata autograft into the osteotomy andsecuring the tendon between the osteotomized portions of the bonewith an interfragmental compression screw. Stanec et al (15) usedbrachioradialis autograft tendon with an attached radial bone block,and the bone was inset in the calcaneus and secured with a cancellousscrew.

Many autografts have been described for Achilles reconstruction incombination with a variety of soft tissue flaps (Table 3). Free flapsfrom the upper or lower extremities, as well as local rotational flaps,have been described for coverage of soft tissue defects about the heel(16–25). The use of rotational sural fasciocutaneous flaps is wellestablished (26–31). The use of a local rotational flap has the advan-tage of an established blood supply and, as such, does not require re-anastomosis of the pedicle blood supply, as in free flaps. The suralartery flap also has a large excursion, which makes it very useful fordistal coverage of the Achilles tendon. Mudgal et al (32) used therotational sural fasciocutaneous flap in a staged reconstruction of theAchilles tendon. In the first stage, they debrided the soft tissues andnonviable Achilles tendon and covered the defect with the sural fas-ciocutaneous flap. Similar to the surgical plan of this case report, theydelayed reconstruction of the Achilles tendon until after the softtissue bed was well established. Arlsan et al (33) covered an allograftAchilles tendon reconstruction with a cross-leg sural artery flap. Inthat report, the legs of the patient were cast-immobilized for 25 daysuntil a second operation, when the flap proved to be viable enough toseparate and then reattach.

In conclusion, this case addresses a complicated condition whereinthe Achilles tendon ruptured and then required surgical reconstruc-tion, which resulted in a postoperative infection associated withextensive loss of the Achilles tendon insertion and overlying skin andsoft tissue. The sural fasciocutaneous flap used in this case success-fully addressed the soft tissue coverage requirements for stagedreconstruction of the tendon. The combination of this flap and anAchilles tendon allograft with an attached calcaneal bone block maybe useful in other cases involving distal loss of the Achilles tendon andits overlying soft tissue coverage.

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Table 3Various autografts used for Achilles tendon reconstruction and associated soft tissue coverage

Type of autograft Soft tissue coverage Comments Reference

Tensor fascialatae reinforced with fascio-aponeuroticgastrocnemius turn-down

Local fasciocutaneous flap After trauma, single-stagereconstruction

Fumarola (1)

Vascularized tensor fascia latae Lateral thigh flap After complicated open ankle fracture,single-stage reconstruction

Inoue et al (2)

Split peroneus longus tendon Peroneal cutaneotendinous flap After infected primary repair Yajima et al (3)Soleus fascia turn-down Posterior tibial adiposal flap After resection of recurrent

liposarcoma near Achilles tendonKoshima et al (4)

Gastrocnemius aponeurosisand tensor fascia latae

Free neurovasculartensor fascia latae flap

Delayed reconstructionafter complete Achillestendon resection for highlydifferentiated synovial cellsarcoma adherent to tendon

Lidman et al (5)

Latissimus dorsi muscle Latissimus dorsi muscle free flap 4 patients, single-stage reconstruction Lee et al (9)Patellar tendon with tibial tuberosity

bone block, quadriceps tendon withpatellar bone block

d For chronic ruptures without softtissue coverage issues

Besse et al (11)

External oblique aponeurosis Groin free flap Single-stage reconstruction Coskunfirat et al (12)Tensor fascia latae Tensor fascia latae free flap Multiple debridements followed

by single-stage reconstructionDabernig et al (14)

Brachioradialis tendonwith radial bone block

Forearm free flap Secondary reconstruction Stanec et al (15)

Quadriceps tendonwith patellar bone block

Sural fasciocutaneous flap 2-stage reconstruction, graft augmentedwith flexor hallucis longus tendontransfer

Mudgal et al (32)

Vascularized and nonvascularizedtendons from brachioradialis/flexorcarpi radialis/palmaris longus

Lateral arm free flap/radialforearm free flap

4 patients, single-stage reconstruction;all with peroneus brevis tendonaugmentation of reconstruction

Ademoglu et al (36)

Extensor digitorum brevis Dorsalis pedis arterialized flap Single-stage reconstruction Babu et al (37)Triceps tendon Distal lateral arm flap Single-stage reconstruction Berthe et al (38)Soleus tendon Posterior tibial perforator-saphenous

subcutaneous flapSingle-stage reconstruction Cavadas and Landin (39)

Tensor fascia latae Tensor fascialatae perforator flap

3 of 5 required flap debulking Deiler et al (40)

Extensor digitorum longus Sensate free flap of dorsalis pedis Single-stage reconstruction Kim et al (41)Vascularized tensor fascia latae Anterolateral thigh composite flap 4 patients, single-stage reconstruction Kuo et al (42)Gracilis tendon d Chronic Achilles ruptures in 21 patients Maffulli and Leadbetter (43)Peroneus brevis tendon d Chronic Achilles ruptures McClelland and Maffulli (44)Gastrocnemius aponeurosis Tissue expansion of local tissue 2 patients Moller et al (45)Gluteus muscle fascia Fasciocutaneous infragluteal

free flapSeries of 7 patients Papp et al (46)

Gastrocnemius fascial flap d For chronic Achilles ruptures withoutsoft tissue compromise

Takao et al (47)

Dash indicates not described or applicable.

U. Hansen et al. / The Journal of Foot & Ankle Surgery 49 (2010) 86.e5–86.e1086.e9

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