SLR - June 2023 - Jenna Brettschneider, DPM
Title: Graft and Flap. A Novel Orthoplastic approach to Achilles Tendon Secondary RuptureReference: Maruccia M, Tedeschi P, Caizzi G, Palmiotto F, Di Summa PG, Vicenti G, Moretti B, Giudice G, Elia R. GRAFT AND FLAP. A NOVEL ORTHOPLASTIC APPROACH TO ACHILLES TENDON SECONDARY RUPTURE. Plast Reconstr Surg. 2023 Apr 25. doi: 10.1097/PRS.0000000000010566. Epub ahead of print. PMID: 37092978.
Level of Evidence: IV
Scientific Literature Review
Reviewed By: Jenna Brettschneider, DPM
Residency Program: Ascension St John, Detroit Michigan
Podiatric Relevance: As a podiatric resident we encounter numerous Achilles tendon ruptures and re-ruptures that require podiatrist to perform salvage procedures and tendon transfers. The authors were attempting to show that the functional reconstruction of composite secondary Achilles tendon defects can be achieved with a fascia lata autograft with turndown gastrocnemius fascia flap, free flap, and external fixator device.
Methods: Retrospective review and prospectively collected data was performed from October 2018 to October 2020. Inclusion criteria was 1. Chronic open Achilles tendon rupture lasting more than 6 weeks; 2. Kuwada type 4 after radial debridement; 3. Chronic damage to the overlying soft tissues. Diagnosis of chronic Achilles tendon rupture was made by clinical examination and physical tests such as the Thompson Test and the Single leg heel Raise test. Radiological evaluation and MRI were also performed for diagnosis. Surgical technique: A team of orthoplastic surgeons performed debridement of the Achilles tendon stumps and the overlying soft tissues. A turndown gastrocnemius fascial flap and a fascia lata autograft was utilized. A fasciocutaneous anterolateral thigh (ALT) free flap was harvested in all cases for soft tissue coverage. A circular external fixator was positioned in the tibial shaft and locked with the ankle joint immobilized at 90 degrees. The external fixator was removed 6 weeks post-operatively and a graded rehabilitation program was started. All patients were followed up at 1, 3, 6, 12, 18 and 24 months. The American Orthopedic Foot and Ankle Score survey and Short-Form Health Survey (SF-36) were administrated before surgery and 12 months postoperatively
Results: 7 patients with a mean age of 55.6 years were included in this study. The mean follow up was 18.2 months. All 7 patients healed well and the flap coverage was functional. There was no re-rupture of the Achilles tendon reported at the last follow up. Full weight bearing was started after 10 weeks and with ROM, the reconstructed side was on average 87% of the unaffected side. Dorsiflexory strength was not affected but plantarflexion was decreased as expected when compared to the healthy side.
Conclusions: The surgical repair did not impair functional outcomes and daily activities. This surgical technique is considered a relatively safe reconstructive option for an extensive secondary rupture of the Achilles tendon from the authors. This is a great alternative to allografting, extensor hallucis longus tendon grafting or Gracilis muscle grafting for a large Achilles tendon deficit due to a secondary rupture. More research is needed to determine if this is a better alternative then tendon grafting or augmentation. I would also like to a see a price comparison and comparison in plantarflexory strength of secondary Achilles tendon rupture repair techniques. This is a more complex technique and I could see myself working with a plastic surgeon attempting this procedure when the there is a greater than 6cm defect of the Achilles tendon.