MULTILAYER RECONSTRUCTIONS FOR DEFECTS OVERLYING THEACHILLES TENDON WITH THE LATERAL-ARM FLAP: LONG-TERMFOLLOW-UP OF 16 CASES

JEROEN M. SMIT, M.D., PH.D., CATHARINE M. DARCY, M.B. C.H.B., F.R.C.S (PLAS), THORIR AUDOLFSSON, M.D.,

ED H.M. HARTMAN, M.D., PH.D., and RAFAEL ACOSTA, M.D., F.R.A.C.S., F.E.B.O.P.R.A.S.*

Defects of the Achilles tendon and the overlying soft tissue are challenging to reconstruct. The lateral-arm flap has our preference in thisregion as it provides thin pliable skin, in addition, the fascia and tendon can be included in the flap as well. The aim of this report is toshare the experience the authors gained with this type of reconstruction. The authors report the largest series in the published reportstoday. Patients and methods: A retrospective review was performed of all patients treated between January 2000 and January 2009 with alateral-arm flap for a soft-tissue defect overlying the Achilles tendon. Results: In the reviewed period, 16 soft-tissue defects overlying theAchilles tendon were reconstructed, with a mean follow-up of 63 months. In three cases, tendon was included into the flap and in two, asensory nerve was coapted. Fifteen cases (94%) were successful, one failed. In seven cases, a secondary procedure was necessary forthinning of the flap. Conclusion: The lateral-arm flap is a good and safe option for the reconstruction of defects overlying the Achillestendon. VVC 2012 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2012.

Defects of the Achilles tendon and the overlying soft tis-

sue might be primary or secondary to direct trauma, or

caused by severe infection after tendon repair. Recon-

struction of this site is challenging; the local infection

has to be controlled, stable multilayer coverage (skin,

subcutaneous tissue, and fascia) has to be provided and

in cases where the tendon has been severely damaged

this has to be reconstructed as well. Techniques reported

to date are axial patterned flaps for smaller defects,1,2

and local3–5 and free6–10 flaps for larger defects.

Microsurgery has increased the reconstructive sur-

geon’s options in this region, especially for large and

combined defects. No further trauma is applied close to

the defect and well vascularized soft tissue can be

transferred. Of the various free flaps available, the lat-

eral-arm flap has our preference. The flap was initially

described by Song et al.11 in 1982, followed by several

anatomic studies describing the flap’s anatomy in further

detail.12–16 The flap is versatile and has a variety of clin-

ical applications.17,18 The advantage the flap offers is

that it not only provides coverage of the defect with thin

pliable skin, but with raising the flap the fascia of the

triceps muscle can be taken as well, decreasing chances

of severe adhesions between Achilles tendon and

flap.19,20 If there is a critical defect in the Achilles ten-

don, a part of the triceps tendon can be included as

well.19,20

Over the past years, the authors have used the lateral-

arm flap for defects overlying the Achilles tendon multi-

ple times. The aim of this report is to share the experi-

ence that the authors have gained with this type of recon-

struction. The authors report the largest series in the pub-

lished reports today.

PATIENTS AND METHODS

A retrospective review was performed of all patients

treated between January 2000 and January 2009 with a

lateral-arm flap for a soft-tissue defect overlying the

Achilles tendon. The age, indication for surgery, date of

surgery, American Society of Anesthesiologists (ASA)-

classification,21 nicotine use, type of anastomosis, type of

anastomotic material used, recipient vessels, complica-

tions, surgical outcome, and need of a secondary proce-

dure of all patients were noted.

Surgical Technique and Postoperative

Management

The procedure was performed in the prone position

with the foot in neutral position under general anesthesia

and tourniquet hemostasis.

First, a debridement was performed to analyze the

extent of the defect overlying the Achilles tendon (Fig.

1). The posterior tibial artery and vein were identified

and prepared as recipient site. If indicated the sural nerve

was also prepared as recipient site.

A skin island corresponding to the soft-tissue defect

was outlined on the elbow with the distal margin always

up to 4 cm below the lateral epicondyle to obtain a very

thin and pliable skin island (Fig. 2). It was of the impor-

tance to include as much fascia as possible in the flap.

The flap was based on the deep brachial artery. The ar-

Department of Plastic and Reconstructive Surgery, Uppsala University Hos-pital, Uppsala, Sweden

*Correspondence to: Rafael Acosta, Plastic Surgeon, Geelong Hospital,Suite 3, Level 6, 80 Myers Street, Geelong, VIC 3220, Australia.E-mail: rafin57@gmail.com

Received 27 June 2011; Revision accepted 21 January 2012; Accepted 26January 2012

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.21972

VVC 2012 Wiley Periodicals, Inc.

tery was usually 1.5–2.0 mm in diameter and the com-

mitante vein was about 2.5 mm in diameter. The pedicle

could be made up to 8 cm long. If there was a need for

tendon insertion into the calcaneus, a part of the olecra-

non with triceps tendon was included in the flap. Har-

vest of the triceps tendon had to be restricted to one-

third so as not to reduce elbow extension. A branch of

the posterior cutaneous nerve of the arm could be

included in the larger flaps and dissected back to the ra-

dial nerve. In the smaller flaps, the nerve could most of

the times not be found. After harvesting of the flap, the

donor site was closed directly.

The tendon was sutured or reconstructed depending

on the amount of damage, the tendon was put under a

slight tension while reconstructing it. The flap was placed

into the defect. The tendon was then enwrapped with the

fascia of the lateral-arm flap to provide vascularized

gliding tissue around the tendon and to fill dead space

(Fig. 3). The very thin and mobile fascia produces a glid-

ing layer that allows skin and subcutaneous tissue to slide

over the tendon graft. Venous (end-to-end) and arterial

(end-to-side) microanastomoses were performed prefera-

bly but were depending on the diameter of donor and re-

cipient vessels as well. Finally, if the nerve could be

included, neurorrhaphy connected the branch of the poste-

rior cutaneous nerve to the tibial or sural nerve. In the

smaller flaps, where a nerve could not be found,

the authors relied on the surrounding tissue to provide

the flap with a protective sensation.

Initially, flaps were monitored using conventional

monitoring methods like handheld Doppler, color, and

capillary refill. Since 2006, the Cook-Swartz implantable

Doppler system was used. The Doppler probe was kept

Figure 1. The extend of damage to the Achilles tendon and its

overlying tissue could be properly analyzed after the debridement.

[Color figure can be viewed in the online issue, which is available

at wileyonlinelibrary.com.]

Figure 2. Preoperative flap design. The dotted line represent the

amount of fascia that was included, inside the dotted line the skin

pedicle was marked. The other lines represent anatomical mark-

ings. [Color figure can be viewed in the online issue, which is avail-

able at wileyonlinelibrary.com.]

2 Smit et al.

Microsurgery DOI 10.1002/micr

in place for 10–14 days. This was usually also the time

needed for patients to be ready for discharge. Patients

were on bed rest for 5 days. From day 5–7, patients were

allowed to get into a wheelchair but had to keep the

operated leg elevated. On day 7, patients could begin to

walk with crutches, while bandages were wrapped around

the flap to stimulate the venous return. If the tendon was

repaired, then the leg was nonweight bearing for 6

weeks.

RESULTS

In the reviewed period, 16 soft-tissue defects overly-

ing the Achilles tendon were reconstructed with a lateral-

arm flap. The mean follow-up was 5 years and 4 months

(range 21–115 months)

The underlying condition leading to the soft-tissue

defects were Achilles tendon rupture and repair in 10,

calcaneal fracture and tendon repair in three, and Achilles

tendonitis, diabetic wound and melanoma excision all

once. In 13 cases, the flaps were used for soft tissue cov-

erage alone; in three cases, the tendon was also recon-

structed. The mean age of the patients was 47 (range 26–

67 years). Most patients had an ASA classification of ei-

ther I or II, two patients had a classification of III. Ten

patients were smokers during the time of admission.

The size of the flap used varied from 3 cm 3 3 cm

to 15 cm 3 6 cm. In all cases, the posterior tibial vessels

were used as recipient vessels. In four cases, a second ve-

nous anastomosis was performed. The arterial anastomo-

sis was made in an end-to-side fashion in 10 cases, the

remaining six cases were performed in an end-to-end

fashion. In all cases, sutures were used for the arterial

anastomoses. A nerve neurorrhaphy was performed

in two cases. Both patients had return of protective

sensation.

Two patients had to return to the theater for revision

of the anastomosis, both times for a venous thrombosis.

In one of these cases, the revision was unsuccessful.

Apart from this case, no further failures occurred, neither

partial nor complete. In this case, a vacuum assisted clo-

sure system was used to close the defect. After the

wound was health, the patient was given an orthopedic

device to provide sufficient plantar flexion of foot. In two

cases, an infection occurred which was treated conserva-

tively with antibiotics. In one of these cases, a partial

wound dehiscence occurred due to the infection. There

were two patients with an hematoma, one on the day of

surgery and the other six days after surgery.

The long-term results of the reconstruction were

good. All patients were able to mobilize without limita-

tions. Patients were able to perform activities such as

jumping, pivoting, and running. In seven cases, thinning

of the flap by liposuction was performed between 6 and

34 months, with a mean time of 17 months after the ini-

tial reconstruction. Two of these patients underwent a

partial skin excision (Table 1).

CASE REPORTS

Case 1

This 30-year-old male had a spontaneous rupture of

his Achilles tendon, which was surgically repaired. Post-

operatively, the wound became infected causing dehis-

cence of the tendon and necrosis of the overlying tissue.

After the infection was treated with systemic antibiotics,

surgical debridement was performed (Fig. 4a). The ten-

don was reconstructed using the modified Lindholm tech-

nique and covered by a lateral-arm flap (Fig. 4b). During

the 7 years of follow-up, the patient had a full return of

function of his Achilles tendon and was able to return

playing soccer. After 1 year, he had protective sensation

in the flap.

Figure 3. A picture taken directly postoperative, showing the skin

flap where once was the soft-tissue defect. [Color figure can be

viewed in the online issue, which is available at wileyonlinelibrary.

com.]

Lateral Arm Flap for Achilles Tendon Defects 3

Microsurgery DOI 10.1002/micr

Table

1.PatientCharacteristicsandDetails

oftheSurgicalProcedure

Case

Indication

Sex

Age

ASAClass

Nicotine

abuse

Other

risk

factors

Recipient

vessel

Typeof

anastomoses

Secondary

venous

anastomosis

Tendon

included

Nerve

included

Reconstructive

Outcome

Functional

Outcome

Sensory

outcome

Complication

Seco

ndary

procedure

1Calcanealfracture

andtendoninjury

Male

67

IYes

No

Tibialposterior

End-to-end

No

No

Yes

Success

Fullreturn

todaily

activities

Return

ofsensation

No

No

2Diabeticwoundon

heel

Male

57

III

Yes

Diabetes

Tibialposterior

End-to-side

No

No

No

Success

Fullreturn

todaily

activities

Noreturn

ofsensation

Venousthrombosis

thenextday

No

3Calcanealfracture

andtendoninjury

Male

44

IINo

No

Tibialposterior

End-to-side

No

No

Yes

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

No

No

4Achillestendon

rupture

andrepair

Male

30

IYes

No

Tibialposterior

End-to-side

No

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

No

No

5Achillestendon

rupture

andrepair

Female

61

IIYes

No

Tibialposterior

End-to-side

No

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

Hematomaunder

flap,eva

cuated

samedayas

initialsurgery

Liposuctionand

skin

reductio

n

ninemonths

afterinitial

surgery

6Achillestendon

rupture

andrepair

Male

50

III

Yes

No

Tibialposterior

End-to-side

Yes

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

Infectiontreated

withantib

iotics

No

7Achillestendon

rupture

andrepair

Male

45

IYes

No

Tibialposterior

End-to-side

Yes

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

Hematomanear

flap,eva

cuated

six

daysafter

initialsurgery

8Achillestendon

rupture

andrepair

Female

51

IIYes

No

Tibialposterior

End-to-side

Yes

No

No

Failure

Fullreturn

todaily

activities

Return

ofprotective

sensation

Venousthrombosis

thesame

dayasinitial

surgery

No

9Achillestendon

rupture

andrepair

Male

38

IIYes

No

Tibialposterior

End-to-end

Yes

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

Infectiontreated

withantib

iotics

Liposuction28

months

afterinitial

surgery

10

Calcaneusfracture

andtendoninjury

Female

26

IIYes

No

Tibialposterior

End-to-end

No

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

No

No

11

Achillestendon

rupture

andrepair

Male

32

IYes

No

Tibialposterior

End-to-side

No

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

No

Liposuction13

monthsafter

initialsurgery

12

Achillestendon

rupture

andrepair

Male

36

IINo

No

Tibialposterior

End-to-end

No

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

No

Liposuction34

months

afterinitial

surgery

13

Achillestendonitis

Female

59

INo

No

Tibialposterior

End-to-side

No

Yes

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

Earlywound

dehiscence

andfatnecrosis

dueto

infection

Liposuction15

months

afterinitial

surgery

followed

byskin

reduction17

monthslater

14

Achillestendon

rupture

andrepair

Male

54

IINo

No

Tibialposterior

End-to-side

No

Yes

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

No

No

15

6mm

thickmelanoma

Male

47

INo

No

Tibialposterior

End-to-end

No

No

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

No

Liposuction12

monthsafter

initialsurgery

16

Achillestendon

rupture

andrepair

Male

50

INo

No

Tibialposterior

End-to-end

No

Yes

No

Success

Fullreturn

todaily

activities

Return

ofprotective

sensation

No

Liposuctionsix

monthsafter

initialsurgery

Case 2

This case involved a 57-year-old male with a diabetic

ulcer on the medial heel. The defect was initially treated

unsuccessfully with a local flap, followed by an unsuc-

cessful treatment with a split-skin graft. The wound

became infected, which affected the Achilles tendon as

well (Fig. 5a). The infection was treated with systemic

antibiotics, followed by surgical debridement. The defect

was reconstructed with a lateral-arm flap (Fig. 5b). De-

spite the considerable size of the flap (15 cm 3 6 cm), it

was decided not to include a nerve for neurorrhaphy due

to small chance on return of protective sensibility in a

patient with diabetes. The donorsite was closed primary.

Postoperatively, the case was complicated by a venous

thrombosis, which was successfully treated by a revision

of the venous anastomosis. The patient had a full return

of function. He did not have return of sensibility. The

time of follow-up was 8 years.

DISCUSSION

Defects overlying the Achilles tendon are often the

results of postoperative infections or other wound compli-

cations after Achilles tendon repair. Achilles tendon rup-

tures are a commonly seen injury and can occur during

recreational sports that require bursts of jumping, pivot-

ing, and running. Most often these are tennis, racquetball,

basketball, and badminton. The male-to-female ratio is

nearly 20:1 and the average age of patients is 30–40

years. In up to 7% of the cases that require surgery com-

plications occur of which almost half are wound infec-

tions. Patients with known risk factors like diabetes mel-

litus, smoking, and rheumatoid arthritis necessitating cor-

ticosteroid therapy are at greater risk for these

complications.20,22

Although smaller defects overlying the Achilles ten-

don can be closed with local skin flaps, larger defects

require a local pedicled or free flap reconstruction. Local

pedicled flaps that have been reported for this use are

propeller flaps,23 the super extended abductor hallucis

Figure 4. The dehiscent tendon with the overlying defect after de-

bridement (a). After reconstruction of the tendon the remaining

defect was closed with the help of a lateral-arm flap (b). [Color

figure can be viewed in the online issue, which is available at

wileyonlinelibrary.com.]

Figure 5. The defect caused by a diabetic ulcer after failure of the

local flap as well as the split skin graft (a). The defect was closed

with the help of al lateral-arm flap (b). [Color figure can be viewed

in the online issue, which is available at wileyonlinelibrary.com.]

Lateral Arm Flap for Achilles Tendon Defects 5

Microsurgery DOI 10.1002/micr

muscle flap,3 the distal soleus adiposal pull-through com-

posite flap,5 and the reverse flow sural flap.14,23 The

advantage these flaps offer is that no vascular anastomo-

sis need to be made.3 Disadvantages are that these flaps

are harvested near an infected site, and that muscle and

fascia flaps without a skin component have to be covered

with a skin graft,3,4 which is of less quality than normal

skin. Several types of free flaps are reported for covering

defects overlying the Achilles tendon, such as the antero-

lateral thigh,7,9,10 tensor fasciae latae,7 and infragluteal8

flap.

Advantages that free flaps offer are the number of do-

nor sites from which can be chosen and the fact that only

healthy tissue is transferred. Disadvantages are that they

require microsurgical expertise and often longer operative

times.24 Furthermore, not all patients are suitable candi-

dates.3

The lateral-arm flap has been described before in the

reconstruction of these defects.16,19,25,26 It has been

reported as composite flap including tendon4,24 or an

olecranon fragment with tendon as a workable anchor,20

as well as sole fasciocutaneous flap in combination with

a tendon graft.25 Apart from its versatility, another

advantage is that the cutaneous nerve of the flap can be

coapted providing protective sensation.6,25,26

Our experience is that the lateral-arm flap is a good

reconstructive option in defects overlying/including the

Achilles tendon. The authors used the posterior tibial ves-

sels as recipient vessels: these vessels are easily accessi-

ble from the defect as they are located just medially. De-

spite the fact that the vessels were close to the infected

site, they were of sufficient quality in all cases. To pre-

serve the blood flow toward the foot as much as possible,

the authors performed an end-to-side anastomosis of the

artery when possible. In six cases, this was not possible

and an end-to-end anastomosis had to be performed.

Another advantage of this recipient site is that the tibial

posterior vessels are accompanied by the tibial nerve to

which the cutaneous branch of the flap can be coapted in

an end-to-side fashion. Alternatively, the cutaneous nerve

of the flap can be coapted in an end-to-side fashion to

the sural nerve. Although, the authors only able to coapt

a branch of the posterior cutaneous nerve in two cases, it

is crucial to be aware of the importance of protective

sensibility at this site. Without this, the flap is more

prone to ulcers due to the wearing of shoes. In the flaps

with a smaller skin pedicle, it was however often not

possible to include a nerve. In these cases, the authors

relied on the surrounding tissue to provide the flap sen-

sory reinnervation. Although possible, the authors did not

include tendon into the flap in this series. In all cases, it

was possible to suture the Achilles tendon primary or

with the help of local reconstructions such as the modi-

fied Lindholm technique.

Although most authors report it as a single-stage pro-

cedure,6,19,25,26 the authors have performed a secondary

flap thinning using liposuction in seven cases. Two

patients requested a further reduction of the flap to

improve the cosmetic appearance. In general, most

patients were very much satisfied with their result.

The Cook–Swartz implantable Doppler system

enabled authors to improve their postoperative mobiliza-

tion protocol, because it offers direct information about

the flow in the vein. With the conventional monitoring

methods, strict time slots were used for mobilization as

the bandages made it impossible to visually inspect the

flap during mobilization. When the leg was dependent

with the implantable Doppler system, it was turned on to

confirm blood flow in the vein. If the signal continued

while the leg was dependent, then the mobilization could

be continued, if there was a change in signal (indicating

congestion of the flap), the leg was elevated again.

Therefore, the physiotherapy was no longer bound to

strict time limits but the duration of therapy depended on

the signal of the monitoring system, creating a more per-

sonalized mobilization protocol.

CONCLUSION

The lateral-arm flap is a good and safe option for the

reconstruction of defects overlying the Achilles tendon.

In almost half of the cases, a secondary procedure was

needed for thinning of the flap. This article reports one

of the largest series in the published reports today.

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Microsurgery DOI 10.1002/micr