SLR - April 2010 - Ryan T Scott
Reference:
Jepegnanam JS et al. (2009). Reconstruction of open contaminated Achilles tendon injuries with soft tissue loss. The Journal of Trauma, 66(3),774-779.
Scientific Literature Reviews
Reviewed by: Ryan T Scott, DPM
Residency Program: Detroit Medical Center
Podiatric Relevance:
Reconstruction of open Achilles tendon injuries in tramautic injuries can be very complicated. This article discusses the use of sural artery, nerve, and vein rotational grafts for coverage of degloved injuries.
Methods:
8 patients were identified in this study having traumatic degloving injuries to the posterior aspect of the leg with Achilles tendon pathology. This group involved both acute versus chronic open Achilles tendon injuries with and without contamination. Debridement of the injured Achilles tendon was performed with augmentation or a primary repair. Augmentation included a medial raphe turn down augmentation with attachment to the calcaneus via a drill hole sutured back on itself. A rotational flap was then raised from the posterior leg including the superficial sural artery, nerve, and vein. This was a full thickness graft that was rotated about a central axis 180 degrees and sutured into place. The distal pedicle of the flap was kept to a maximum of 3 to 4 cm to preserve the neurovascular bundle. The donor site was then covered with a split thickness skin graft from the posterior thigh. Post-operatively the leg was immobilized in a short leg cast with plantarflexion of 30 degrees. Patients were in a plaster cast for a total of 8 weeks with a general decrease in plantar flexion to neutral. All patients were then placed in a one inch heel lift on the affected side.
Results:
All the flaps survivied with only one which had minimal necrosis at the distal tip. All eight patients were able to return to active function of the Achilles tendon to pre-injury levels at roughly 4 months. All eight patients healed the soft tissue void created by the initial traumatic event. There were some biomechanical limiting factors due to reconstruction of the Achilles tendon secondary to large focal defecits. However, all eight were able to stand on their tip toes. Radiograph exam was alos performed to ensure restoration of Kager's Triangle to ensure no further rupture status post. None of the patients complained of parasthesias over the lateral border of the foot.
Conclusions:
The use of the sural artery, nerve, vein rotational flap provided an appropriate solution for open Achilles tendon injury with soft tissue loss. However, this procedure should be reserved for patients with significant soft tissue deficit. The parameters in this paper included deficits greater than 6 x 5 cm with a limit of 15 x 10 cm. This is a procedure that can be performed in individuals with other comorbidities without exacerbation of their other medical conditions. This rotational graft also reduces the risk of infection in the case of STSG from donor sites and the use of biological designed materials.