Achilles Tendon Region Defects: Delayed Composite Anterolateral Thigh Flap With Stripping of Fascia Lata: A Case Series

The Achilles tendon and calcaneal region are essential for normal ankle function, such as dorsiflexion and plantar flexion. An injury to this anatomic area can significantly impair walking, standing for long periods, and running. The incidence of acute Achilles tendon ruptures is increasing, and open surgical repair is the gold standard of treatment.¹ However, even after successful primary surgical repair, complications such as wound dehiscence, infection, and tendon exposure make reconstructive procedures challenging.^2–4 The most common complications after primary tendon repair are wound dehiscence, infection, and tendon rerupture.^5,6 Traditional treatments of these complications may include surgical debridement, vacuum-assisted closure, and subsequent skin grafts; however, this could lead to insufficient and unreliable long-lasting reconstruction.

The principles of proper composite reconstruction of this region include stable coverage and a proper tendon sheet that allows gliding and resistance to shearing forces. The ultimate goals remain the re-creation of the ankle shape for regular footwear and the restoration of dynamic movements of the ankle joint.^2,7,8 Multiple-stage procedures with or without tendon grafts have been recommended in some case series.^9–11 Nonetheless, these solutions are time-consuming and costly compared with 1-stage reconstructions.^12,13 Other authors describe the composite anterolateral thigh flap (ALT) with a strip of fascia lata as an alternative for 3-dimensional reconstruction of the Achilles tendon and the overlying soft tissue.¹⁴ In this procedure, the fascia lata is vascularized by the prefascial and subfascial vascular plexi. In addition, when it is rolled and folded across the tendon gap, the fascia lata can mimic the Achilles tendon function¹⁴ and has low donor site morbidity compared with the composite forearm free flap with flexor radialis tendon.¹⁵

Evaluating functional outcome is paramount following reconstruction of strategic body areas. The literature proposes different methods including the kinetic dynamometer^8–11 and single evaluation scales (eg, Victorian Institute of Sports Assessment-Achilles tendon [VISA-A-G], German version,¹⁶ Achilles tendon total rupture scores [ATRS],¹⁷ and the American Orthopedic Foot and Ankle Society [AOFAS] Ankle-Hindfoot Scale scores^18,19).

Self-administered outcome questionnaires focus on the psychophysical condition of patients and can be classified as generic health (eg, the 36-Item Short-Form Survey [SF-36]²⁰), disease-specific, and region-specific outcome measures. Using 2 types of questionnaires provides the examiner with more information.²¹ Various evaluation tests have been developed to assess outcomes after foot and ankle surgical procedures. The AOFAS¹⁸ measure contains objective and subjective parameters and is used most often.^22,23 The SF-36 and AOFAS scales have been successfully used together to evaluate the percutaneous reconstruction of the Achilles tendon,²¹ which can correlate in terms of symptoms and disability with the cases presented in the current study. The authors could not find previous works that compared the AOFAS and the SF-36²⁰ scales in the evaluation of microsurgical reconstructions of the Achilles tendon region. 

The goal of the present study was to evaluate the functional and physical functioning scores of 15 patients who underwent microsurgical reconstruction of the yarrow region, using a combination of objective, subjective, and semi-subjective measurements. Moreover, the authors wanted to explore the use of different, easy-to-use tests to evaluate these patients in the follow-up period without any expensive tools such as a baropodometric platform.

Between 2007 and 2018, 15 patients experienced complications after open repair of the Achilles tendon and underwent microsurgical reconstruction at the Clinic of Plastic Surgery, Padua University Hospital, Padua, Italy. During follow-up visits, the authors measured the sliding condition of the Achilles tendon by measuring the maximal range of motion (MROM) of the ankle, which is the angle between the floor and the fifth metatarsal during active dorsiflexion and plantarflexion. MROM was measured with a manual goniometer, and the maximum degree angle for both plantarflexion and dorsiflexion were recorded. Any complications following the microsurgical reconstruction were also recorded. Free flap necrosis was classified as complete when the necrosis was ≥ 60%; when necrosis was < 60%, it was considered to be partial.   

From January to March 2019, the authors checked the patients’ charts, retrospectively analyzed the aforementioned data, and recalled all patients to administer the AOFAS ad SF-36 questionnaires. The following inclusion criteria were set to avoid possible confounding factors: age > 18 and <  75 years, absence of other unrelated walking impairments, and no major vascular diseases. All 15 patients who underwent microsurgical reconstruction of the yarrow region met these criteria. Patients were further divided into 2 groups based on the type of microsurgical reconstruction. The first group included patients who underwent soft tissue reconstruction with an ALT flap and rolled-up fascia lata to reconstruct the Achilles tendon. The second group included patients who underwent only soft tissue reconstruction with a fasciocutaneous ALT flap and fascia lata used to cover the native Achilles tendon.  

Patients were asked about persistent symptoms as well as subjective and functional satisfaction using the AOFAS. The accredited AOFAS score results were divided into “excellent” (90–100), “good” (80–89), “fair” (60–79), and “poor” (< 60).²¹ The SF-36 (a generic health status measure used for a variety of medical conditions¹⁹) was used to assess quality of life, correlating specific aspects of the disease with overall physical functioning. 

The SF-36 is made up of 8 scored subscales. Each is directly transformed into a value that ranges from 0 to 100; 0 indicates the highest disability, and 100 is equivalent to no disability. The 8 subscales are vitality, physical functioning, bodily pain, general health perceptions, emotional role functioning, physical role functioning, social role functioning, and mental health. In the present study, the physical functioning subscale was chosen as an outcome to compare the SF-36 and AOFAS results. 

Two (2) independent researchers administered the questionnaires, collected the results on a paper sheet, and later transferred them to an Excel file. Microsoft Excel spreadsheets were used for statistical analysis. Descriptive statistics, mean values, and standard deviations were collected. A t-test was used for mean comparison, and 0.05 was considered for statistical significance. 

The study was conducted under the principles of the Declaration of Helsinki, and a written informed consent was obtained from all participants. The institution does not require ethical approval for retrospective analyses.

From 2007 to 2018, 15 patients underwent complex reconstruction with an ALT free flap and met the inclusion criteria; in 4 patients the calcaneal region was also involved. A total of 15 patients were evaluated during a mean follow-up time of 23 months (SD = 7.12) (Table 1). Eleven (11) patients were male and 4 were female, with a mean age of 39.86 years (SD = 12.44; range, 24–66 years). Trauma was the most common cause of defects at the Achilles tendon region (10 patients). All patients underwent several surgeries before final reconstruction; the most common previous procedures included surgical debridement, split-thickness skin grafts, and local flaps. Before microsurgery, primary repair of the Achilles’ tendon with the Ma-Griffith modified technique was performed in 68% of cases, Vulpius’ lengthening of the gastrocnemius in 20%, and Lindholm’s technique in 12%. 

Regarding microsurgical reconstruction, flap dimensions ranged from 6 to 10 cm and from 10 to 18 cm. The length of the strip of vascularized fascia lata ranged from 6 to 16 cm, and the width from 6 to 10 cm. All patients were treated with a 1-stage surgery including radical debridement (Figure 1A–C) followed by soft tissue reconstruction using either a fasciocutaneous ALT flap in 8 cases (Figure 2A) or composite ALT with fascia lata in 7 cases (Figure 2B and Figure 2C). When radical tendon debridement was necessary, a rolled-up strip of fascia lata was used. In cases of tendon exposure, necrosis of < 50% of the tendon, or suspected infection, the fascia lata was wrapped around the tendon to allow functional gliding. The mean follow-up time after the final reconstruction was 23.2 months (SD = 7.12; range, 12–32 months) (Table 1).

The flap survival rate was 93.3%. Necrosis of the superior margin was reported in 1 case. One (1) patient had superficial popliteal vein thrombosis, which was treated with antithrombotic therapy and hyperbaric oxygen therapy. Vein thrombosis and hematoma near the microsurgical anastomosis was reported in 1 case the day after surgery, but the ALT flap survived after surgical revision. Without further debulking procedures, all patients could wear shoes. Walk-training was started 2 weeks postoperatively. All patients were able to stand, walk, stand tiptoe, and climb stairs without any further support (Figure 3A and Figure 3B). However, 9 patients reported mild difficulties when running. 

The mean overall MROM plantar flexion was 42.86 degrees (SD ± 11.48) and dorsiflexion was 26.2 degrees (SD ± 7.53) using the Kapandji scale. The mean MROM was 42.71 degrees (SD ±2.9; median = 42) of plantar flexion and 24.85 degrees (SD ± 4.29; median = 26) of dorsiflexion in patients who received a composite ALT flap with a strip of triple-folded, rolled-up fascia lata (Figure 4A–D; Table 2). In patients whose fascia lata was used to wrap the tendon or to cover it (Figure 5A), mean MROM was 43 degrees (SD ± 5.37; median = 44) of plantar flexion and 27.37 degrees (SD ± 3.2; median = 28.5) of dorsiflexion (Table 3). Unlike patients in the first group (n = 7), patients in the second group (n = 8) had a relevant residual portion of their native Achilles tendon and were still able to perform many daily activities, such as standing for a long time, standing tiptoe, and climbing stairs (Figure 5B).  The AOFAS was 82 (SD ± 7.81; median = 83) and the SF-36 physical functioning score was 82.57 (SD ± 6.82; median = 84) among those with a tendon reconstruction (n = 7). The AOFAS was 86.87 (SD ± 9.96; median = 91) and the SF-36 physical functioning score was 81.5 (SD ± 22.9; median = 82.5) for those who had undergone only tendon coverage (n = 8). 

The mean values for MROM during plantarflexion and dorsiflexion were compared between the 2 groups and showed no statistical significance, with P values of 0.89 and 0.22, respectively. Results of the AOFAS and SF-36 were also compared and showed no statistical significance between the 2 groups, with P values of 0.30 and 0.84, respectively.

The results of this case series suggest that the single-stage composite reconstruction with a fasciocutaneous flap with or without a strip of fascia lata is a safe and reliable strategy for composite reconstruction of the Achilles tendon region. No statistical difference was found between the 2 groups, suggesting that even in case of complete reconstruction of the Achilles tendon, a patient can achieve results comparable to those without a complete lesion. 

In the current study, the mean total MROM of the ankle was 69.06 degrees in people without functional limitations. This value is close to the mean value of 71.6 degrees (the mean value of MROM of males and females in a 20- to 44-year-old population sample reported by Soucie et al²⁴). The patients in the current study reported a more reduced MROM in plantarflexion compared with general population and also better dorsiflexion compared with people who did not have limitations.²⁴

Scores between 90 and 100 on the AOFAS are classified as “excellent.” Patients, after composite ALT flap with a rolled-up fascia lata, had mean values of 82 (SD ± 7.81) and  the second group had an outcome of 86.87 (SD ± 9.96). These scores are considered to be “good” results as reported by Ceccarelli et al.²¹ However, somewhat lower values on the SF-36 were reported (in the physical functioning subcategory, 82.57 in patients whose fascia lata was used to wrap the tendon or to cover it, and  81.5 in those who had a relevant residual portion of their native Achilles tendon) compared with the general population, which has a mean value of 84.46 as reported by Apolone et al.²⁵ It is interesting although not statistically different (P = .84) that people with a preoperative complete rupture and complete loss of function of the Achilles tendon scored a slightly higher SF-36 score than did those who had some residual preoperative function of the tendon.

Articles have recently been published about the reliability and validity of different region-specific outcomes tools.^21,26,27 Specifically, Ceccarelli et al²¹ investigated the correlation between the AOFAS Ankle-Hindfoot Score and the SF-36. They showed a moderate correlation between 2 different domains—bodily pain and physical functioning—of the SF-36 and the AOFAS in patients who underwent percutaneous repair of the Achilles tendons. The present report reinforces the idea of using the AOFAS and the physical functioning SF-36 together when evaluating a reconstructed Achilles tendon.

The Achilles tendon and ankle regions represent a challenge for reconstructive surgeons because of their anatomy and unique functional demands. The Achilles tendon is the strongest tendon in the human body. It withstands up to 12.5 times the bodyweight of force, and its loss strongly compromises daily activities, affecting the flex extension of the ankle joint.²⁸ Because of the paucity of local soft tissue, traumatic defects or chronic wounds often require free tissue transfer to restore the integrity of this anatomic region and weight-bearing function. Many options have been proposed in the literature such as local, propeller, and free flaps²⁹; however, some of these techniques may require multiple surgical stages. Moreover, because the local vascular damage may be larger than it seems, some authors believe that a free flap from the contralateral limb may preserve the injured limb from further insults.²⁹ The perfusion of propeller and perforator flaps from the peroneal artery or the posterior tibial artery of an injured leg could be unreliable, and a suitable perforator could be difficult to find. Above all, the use of traditional regional flaps, such as a sural fasciocutaneous flap or gastrocnemius musculocutaneous flap, is debated because of their rotational arc and donor site morbidity. In the authors’ experience, the composite-free ALT flap with a strip of fascia lata represents a good solution for the reconstruction of posterior heel composite defects. The strip of fascia lata is usually harvested more laterally during the flap dissection compared with ordinary composite ALT flaps, providing good soft tissue coverage with no tension. Achieving good gliding performances is fundamental to allow the maximal range of movement of the foot. 

To the authors’ knowledge, the scientific literature lacks an objective functional method for evaluating microsurgical Achilles tendon region reconstruction during follow-up and without the use of expensive tools. A functional outcome measurement is crucial to compare different techniques. The current results support the idea that a triple layer of vascularized fascia lata may mimic the tensile strength of the Achilles tendon, providing an adequate gliding effect and similar functional results to patients whose tendon was mostly intact before the final reconstruction.  

The most important limitation of this study was the small number of patients. In addition, the authors did not consider the time between the initial injury and final reconstruction. Most cases were late interventions after several other procedures had been performed. 

More studies are needed to compare the different reconstructive techniques of the Achilles tendon region. The current proposed evaluation method could provide researchers with an objective and reliable tool to compare different techniques and find the most valuable one. 

The current case series shows that reconstructive surgeons can use different techniques in the Achilles tendon region. In particular, there was no statistical difference between soft tissue and tendon reconstruction with a triple-layer of vascularized fascia lata and soft tissue reconstruction with only tendon coverage. Both techniques provided good functional outcomes in terms of range of motion, physical function, and patient satisfaction. Objective, subjective, and semi-subjective evaluation methods were used together to evaluate the reconstructions. These tools are exceedingly easy and affordable to use and provide a complete picture of the functional outcome after complex reconstruction of the ankle. Therefore, the authors suggest the introduction of the MROM, AOFAS scores, and SF-36 scores for use in clinical practice or future research.

Dr. Tiengo is a professor in plastic surgery, Dr. Sonda is a resident in plastic surgery,  Dr. Monticelli is a plastic surgeon,  Dr. Messana is a resident in plastic surgery, Dr. Crema is a resident in plastic surgery, Dr. Toninello is a resident in plastic surgery, and Dr. Bassetto is a professor in plastic surgery, Plastic and Reconstructive Surgery Department, Padua University Hospital, Padua, Italy. Address all correspondence to Regina Sonda, MD, Plastic and Reconstructive Surgery Department, Padua University Hospital, Padua, Italy; email: sondaregina89@gmail.com.