Reconstruction of skin and tendon defects from wound complications after achilles tendon rupture

Reconstruction of Skin and TendonDefects from Wound ComplicationsAfter Achilles Tendon Rupture

Yal~in Adernoqlu, MD,1 Fuat Ozerkan, MD,2 Sait Ada, MD,1 Arslan Bora, MD,3lbrahimKaplan, MD, 1 Murat Kayalar, MD,2 and Firdevs Kul, MS4

Four patients who developed combined tendon and overlying skin defects following operative repair ofruptured Achilles tendon were presented. Three patients had an infected wound. The average intervalfrom the first operation for repairing the ruptured Achilles tendon and the reconstructive procedure was46.2 days (range, 5-65 days). All patients were treated with a one-stage operation including radicaldebridement, reconstruction of the Achilles tendon defects using vascularized or nonvascularized tendongrafts, transfer of peroneus brevis for augmentation, and skin coverage with a free flap. The patientsrecovered uneventfully. The average follow-up period was 39.2 months (range, 18- 79 months). In allpatients, an evaluation of the clinical outcome, the performance of the calf muscles using a computerizeddynamometer, and structural changes of the reconstructed Achilles tendon using magnetic resonance(MR) imaging were made. The clinical outcome was excellent in three patients and good in one. Inisokinetic testing (Cybex-Norm), strength was found to be normal in one patient and abnormal in threepatients. MR images revealed an intratendinous area of homogenous and normal intensity signal, and asignificant increase in thickness and width in all levels of the reconstructed Achilles tendon. The authorsconclude that it is possible to obtain satisfactory function in patients with complex wounds in the regionofthe Achilles tendon. (The Journal of Foot & Ankle Surgery 40(3):158-165,2001)

Key words: Achilles tendon rupture, microvascular reconstruction

Many excellent reviews have documented the considerable experience of the evolving management of theruptured Achilles tendon. Although high satisfaction rateshave been reported concerning open operative repair ofthe Achilles tendon ruptures, the main disadvantage isa postsurgical complication rate ranging from 3% to17% (1-5). Skin and tendon necrosis associated withwound infection in the Achilles tendon region may becatastrophic, and poses one of the greatest challenges tothe foot and ankle surgeon.

Prevention of infection, reconstruction of the skin andtendon defects, and restoration of the function must allbe accomplished in order to consider the result a success.

From Hand Microsurgery and Orthopaedics Traumotology Hospital,Izmir, Turkey. Address correspondence to: Yalcin Ademoglu, M.D.,Hand Microsurgery and Orthopaedics Traumatology Hospital, 1418Sokak, No: 14, 35230, Kahramanlar-IzmirrrURKEY; e-mail: [email protected].

,Assistant Professor, Orthopedic Surgeon, and Hand Surgeon.20rthopedic Surgeon and Hand Surgeon.3Professor, Orthopedic Surgeon, and Hand Surgeon."Physical Therapist.Received for publication January 10, 2000; accepted in revised form

for publication December II, 2000.The Journal of Foot & Ankle Surgery 1067-2516/01/4003-0158$4.00/0Copyright © 2001 by the American College of Foot and Ankle Surgeons

158 THE JOURNAL OF FOOT & ANKLE SURGERY

Reconstructive procedures including turned-over fascioaponeurotic flaps (6), pedicled local flaps (7), and variousfree flaps (8-15) with nonvascularized and vascularizedfascial or tendon grafts have been proposed as potential treatment options. The long-term functional resultsfollowing free transfers of compound tissues to theAchilles tendon region have been reported, but these seriesare heterogenous; they consist of cases who have incomplete and complete ruptures. They also do not includerecovery of strength and a discussion of the morphologicchanges of the reconstructed tendon as part of their objective evaluation (6- 15).

The purpose of this retrospective study was to presentour experience and functional results in four patientswho had reconstruction of combined defect of overlyingskin and Achilles tendon. Furthermore, the calf musclesperformance using computerized dynamometer and structural changes of the reconstructed Achilles tendon usingmagnetic resonance (MR) imaging were examined in thesepatients.

Materials and Methods

Between 1993 and 1998, four patients who developedcombined skin and tendon defects following operative

TABLE1 Clinical data on four patients undergoing reconstruction

Case Age & Occupation Injury Interval from Infection Defect after Debridement Grafts for Tendon Repair

Sex Mechan ism Repair to Tendon Skin Vase. Nonvasc. Free FlapReconstr. (em) (em)

(days)

241M Football Sports 65 S. aureus 6 9 x 4.5 BR PL RadialPlayer forearm

2 301M Surgeon Sports 60 S. aureus 9 10 x 5 Plantaris Lateral armfascia lata

3 47/M Tailor Sports 55 S. aureus 5 9 x5 Triceps FCR, PL Lateral arm

4aponeurosis

39/F Housewife Motorcycle 5 None 8 10 x 5 FCR, PL Lateral armchain

BR, Brachioradialis; FCR, flexor carpi radialis; PL, palma ris longus ; Vase., vasculari zed; Nonvasc., nonvascularized .

repair of a ruptured Achill es tendon were treated in IzrnirHand and Microsurgery Hospital. Three of them werereferred to us after the first operation because of woundcomplications.

There was one female and three males, ranging in agefrom 24 to 47 years (average, 35 year s). The preinjuryemployment status and the mechanism of the injury of thepatients are shown in Table I. The average delay betweenthe rupture and the primary operation was 2.3 days (range,1-4 days). The method of tendon repair at the first operation was primary tenorrhaphy. In one patient (case I) , themethod of tendon repair was reinforcement with proximally attached gastrocnemius aponeurosis flap. In twopatients, a longer strip of tendon attached proximal to therupture was turned distally and used like a suture materialto bring the torn ends together (cases 2 and 3). Additionally, two of these patients had undergone unsuccessfulreconstructive attempts with a rotational flap because ofskin breakdown after the initial repair procedure (cases Iand 2). The other patient (case 4) sustained an open injuryinvolving disruption of the Achilles tendon and skin froma motorc ycle accident. This was treated in our hospital byinit ial debridement and leaving the wound open.

The average interval from the first operative procedureand microvascular flap transfers for the reconstructionwas 46.2 days (range, 5-65 days). Three patients had anecrotic wound that included the region of repaired tendonand clinica l evidence of an active infec tion. Cultu redirected intravenous antibiotics were begun preoperativelyand continued postoperat ively for 3 weeks. The othe rpatient who had no infection was given I g of cephtriaxone intra venously for prophylaxis.

All patients were treated with a one-stage operationaccording to the following protocol:

I. Radical debridment, including excision of all necroticand infected tissues (Fig. IB )

2. Recon struction of the defects of the Achilles tendon(Fig. IC)

3. Transfer of the peroneus brevis tendon for augmentation, as described by Turco and Spinella (16)

4. Skin coverage with free flaps (Fig. ID)

Achilles tendon defects were reconstructed using vascularized tendon grafts (brachioradialis and lateral one-thirdof triceps aponeurosis) in two patients, and nonvascular ized tendon (flexor carpi radialis and palmari s longus) andfascia lata grafts in the remaining patients. The grafts werepassed through the proximal and distal Achilles tendonstumps and then secured with interrupted sutures. Thecoverage of the skin defects was performed using lateralarm flaps in three patient s and a radial forearm flap in onepatient. All flaps were harvested associated with a largerfascial portion than the skin component. These fascialportions were used to construct a vascularized sheath thatwas placed circumferentially around the tendon repair sitefor separation from the peritendinous tissues.

Postoperatively, the extremity was immobilized witha long leg splint. The patients were discharged 7-I0days after the operation. After wound healing, a longleg cast was applied with the knee flexed 45" and theankle fixed in 30° of equinus. After 4-6 weeks, a shortleg cast with the ankle in neutral position was appliedfor 4 weeks. After this period, the cast was discontinuedand the patients were allowed partial weightbearing, anda rehabilitation program was begun. Activiti es of dailyliving were initiated after 4 months, and sports activitieswere allowed after 6 months.

The subjective evalu ation consisted of assessment ofcomplaints during daily and sporting activities, problemswith conventional shoe wear, and cosmesis. Objectiveassessment included measurements of range of motion ofthe ankle joint, ankle and calf circumferences, the abilityto stand and to walk on tiptoes, the stability and sensation(with Semmes-Weinstein monofilaments) of the flaps, andthe presence of adhesions. Clinic al results were evaluatedby the method of Percy and Conochi e (17). Criteria forexcellent results were full return to level of preinju ry

VOLUME 40, NUMBER 3, MAY/JUNE 2001 159

FIGURE 1 A 30-year-old surgeon (case 2) who sustained a complete rupture of the Achilles tendon during a sporting activity . Skin sloughand deep infection had developed following primary tenorrhaphy and Bosworth procedure. Forty days postoperative, the unhealed woundhad been debrided to control infection. A, He was referred to us 55 days after the first operation . B, A 9-cm tendon defect occurred afterdebridement of necrotic and infected tissues. C, The tendon reconstruction was performed with a nonvascularized fascia lata and plantaristendon grafts, and the peroneus brevis was transferred to the distal stump of the Achilles tendon. D, Skin coverage was provided by a lateralarm flap, and fascial portion of the flap was wrapped circumferentially around the reconstructed tendon region. E-G, 30 months later, hehas a fully functional ankle.


TABLE 2 Results of clinical evaluation

Case Follow-up(months)

1 792 303 304 18

Return to Flap Diameter Walk on Ankle Range of MotionPreinjury Sensation Difference (em) tip-toe (Affected/Unaffected)

Activity Stab ility (SW) Cosmesis Calf Ankle Plantar- Dorsi- Clinical(months) flexion flexion Outcome

12 Good 3.84 Accept. - 1.5 3 Yes 47"/500 12°/14 ° Excellent6 Good 4.17 Accept. - 1 4 Yes 45°/48 0 12°/13° Excellent6 Good 4.31 Accept. - 2 3.5 Yes 42 0 /46 0 10°/12 ° Excellent

10 Good 4.08 Unaccept. - 1.5 5 Yes 40°/48° 10°/13 ° Good

SW, Semmes-Weinstein.

acti vity, no residual symptoms, and stable free flap. Theresult was characterized as good when the patient hadslight stiffness and an adherent scar but experi enced afull return to the preinjury activity level. A fair result wasassigned if there was definite weakne ss, moderate pain,or some decrease in level of activity. A poor result wasassigned when there was severe weakness, marked limp.an unstable microvascular graft, and no return to level ofactivity before the injury ( 17).

The Cybex-Norm dynamomete r' was used to measurethe muscular performance. Isokinetic strength testing ofthe calf muscles was performed bilaterally using standardized protocol. The knee was maint ained in appro ximately10° of fl exion, with the patients in supine position. Twosubmaximal and one maximal trials were done befo re eachtest session. A 30-second rest period was set between eachtest. Testing was performed with three maximal dorsiflexion and plantarftexion cycles for 30° per second and1200 per second. Maximal torque values of the plantarmuscles were recorded , and calcul ated as a percentageof those of the unaffected side. These values were interpreted according to the guidelines of Sapega (18): in bilateral comparison, imbalances of strength less than 10%were considered normal , differences of 10%-20% werepossibl y abnormal, and those greater than 20% were probably abnormal.

Multiplanar imaging of the reconstructed Achill es tendon and the surrounding tissues was performed on a 1.5-Tsuperco nductive MR unit (Philips NT). TSE (Turbo spinecho) proton density-weighted and T2-weighted imagesin the axial and sagittal planes were obtained with thepatient in supine position with the knee in full extensionand the ankle in neutral position. The signal intensitychanges of the recon structed Achilles tendon and theappearance of the surrounding peri tendinous tissues wereevaluated. The width and the thickness of the Achille stendon were measured on both planes, 5 cm above thecalcaneal insertion of the tendon. All measurements werecompared with those of the unaffected side.

5 Henley Healtbcare, New York.

162 THE JOURNAL OF FOOT & ANK LE SURGERY

Results

The average defect of the Achille s tendon after debridement was 7.5 em (range, 5-9 ern). The cutaneous portionof the flaps measured an average of 9.5 by 5 em (range,9 x 4.5 em to 10 x 5 ern). All of the flaps survived . Onlyone patient had a reoperation within 12 hours after theprocedure for a postoperati ve arterial thrombosis.

The patients were followed for an average of 39.2months (range, 18-79 months) after the recon structiveprocedure. The results of the clinic al evaluation are shownin Table 2. All of the patients returned to their formeroccupations within I year of reconstruction. One patient(case I), a profe ssional football player, was able to joinhis team 1 year after recons truction and continued playingfootball for 4 years. Three patients noted occasional andmild pain during extreme activities. All of the flaps hadgood stability and protecti ve sensibility. Three patientshad an acceptable appearance of the affected ankle andwere able to wear conventional shoes. One patient (case4) had an unsati sfactory appearance of the ankle, andrequired specially fitted shoes to accommodate the contourof his leg. The patients had an average reduct ion of1.5 em (range, 1-2 ern) in calf circumference. The anklecircumference was on average 3.8 em (range, 3-5 cm)greater than that of the unaffected side. All the patientswere able to stand and walk on their tiptoes. The anklejoint arc of acti ve motion as compared to that of theunaffected side in all patients was nearly normal, withdorsiflexion averaging 110 and plantarflex ion averaging43S (Table 2). According to the criteria of Percy andConochie (17), the clinical results were excellent in threepatients and good in one.

The peak torque values as a percentage of the unaffected side are listed in Table 3. The results of isokineti cmuscle strength in our series , at 300 per second. wasnormal in one patient , probabl y abnormal in three patients,and. at 120 0 per second, was possibly abnorm al in twopatients, and probabl y abnormal in two patients.

TSE proton density-weighted and T2-wei ghted MRimages showed homogenous and normal intensity signal atall levels of the reconstructed tendon in three patients. Inone patient (case 3), on sagittal and axial T2- weighted

TABLE 3 Results of isokinetic testing of calf muscles and MR imaging of the Achilles tendon

Case Isokinetic Peak Torque8

300/s 1200/s

Magnetic Resonance Imaging

Width (mm) Thickness (mm)Affected Unaffected Affected Unaffected

Side Side Side Side

Peritendinous Fibrosis

in MRI

1 94 86 18.2 13.7 12.6 4.6 Less2 78 82 17.4 12.7 12.4 5.3 None3 75 72 14.1 13.6 9.5 6.9 None4 70 74 16.7 14.9 13.6 5.4 None

8Thevalues are given as a percentage of unaffected side.

FIGURE 2 MR images of case 2, 30 months after reconstruction. A, Sagittal TSE T2-weighted image. The substance of the Achillestendon has a normal intensity signal and a smooth contour. B, Axial view shows a marked thickening of healed tendon and an absence ofperitendinous fibrosis.

TSE images, vertically oriented intermediate intensitysignal stripes were observed within the tendon. Diffusetendon thickening with well-defined margins along theentire length of the reconstructed tendon site was observedin all images of the axial and sagittal planes (Fig. 2).The measurements of the thickness and the width of theAchilles tendon are listed in Table 3. When the ratios ofthese measurements were calculated at the same level, thereconstructed tendons were 2.7, 2.3, 1.3, and 2.5 timesthicker, and 1.3, lA, 1.0, and 1.1 times wider than theunaffected side, respectively. None of the MR images

in three patients revealed the findings of the surroundingperitendinous fibrosis. In one patient (case 1), axial planeimages showed a low intensity signal between the reconstructed Achilles tendon and anterior soft tissues.

Discussion

Wound complications following Achilles tendon surgery may significantly diminish the capacity to preservefunction of the muscle tendon unit. This catastrophicsituation is complicated not only by the presence of an


open defect with a poorly vascularized and contaminatedsoft-tissue cover, but also by an exposed and necrotictendon segment. In the present study, we report thefunctional results of microvascular reconstruction in fourpatients with a defect involving the skin and the Achillestendon following the repair of a ruptured Achilles tendon.

A number of reports have described the successful use ofmicrovascular free flaps with nonvascularized and vascularized tendon or fascial grafts to manage the complexwounds of the Achilles tendon region (6-15). Most ofthese series have included little information regardingobjective quantification of the performance of the tricepssurae and structural changes of the reconstructed Achillestendon. Only the study by Leppilahti et al. (11) reported thedetailed functional results of the four patients who developed skin breakdown after Achilles tendon surgery whowere treated using free flaps. They reported good results inthree patients and an excellent result in the other one.

Although the vascularized tendon grafts have someadvantages such as rapid healing, preservation of thetendon structure, and fewer adhesions in a poorly vascularized bed, it is difficult to replace extensive defectsand still attain optimal tension of the graft. Conventionalfree tendon grafts can also achieve satisfactory results inwell-vascularized beds. We preferred to use a vascularizedtendon graft to replace small defects (less than 5 em), andnonvascularized tendon and fascia lata grafts to replacemore extensive defects. To create a well-vascularized bed,fascial portions of the free flaps that were harvested asdescribed above, were wrapped circumferentially aroundthe reconstructed tendon region. This technique, to ourknowledge, is original and offers the potential benefits ofdecreasing firm adhesions and improving tendon gliding.Accordingly, the clinical results and MR imaging findingsobtained in this study support the positive effect of thisprocedure, despite the relatively small number of cases.

For the unique zone at the posterior aspect of the ankle,pliable and thin innervated tissue is required to allow thewearing of conventional footwear. Many authors havesuggested that the lateral arm, the radial forearm, andthe dorsalis pedis innervated flaps are the best selection of appropriate coverage for this region (7-11, 13).Good alternatives for reconstruction of the defects of theAchilles tendon and overlying skin include the groin flapwith a vascularized fascio-aponeurotic segment, the tensorfascia lata flap, and a lateral thigh flap with vascularized fascia lata (12, ]4, 15). The disadvantages are thatthey are too bulky and the harvesting technique is difficult. In our series, we preferred the lateral arm flap inthree patients, and the radial forearm flap in the otherone. All flaps offered good stability and protective sensibility. Three patients had an acceptable appearance andwere able to wear normal shoes. The other one had unacceptable cosmesis and problems with conventional shoe


wear. In this patient, the wound was located just abovethe insertion of the Achilles tendon, and was rather wide.Although a debulking procedure was recommended, thepatient refused it.

Augmentation with tendon transfers to increase theoverall strength of the plantarflexion in the delayed treatment of previously ruptured Achilles tendons has beenrecommended by some authors (1, 16). We used theperoneus brevis tendon transfer for this purpose in allpatients. We have considered that tendon transfer hascontributed to the good clinical outcome of our patients.However, the results of isokinetic strength testing are notin accordance with the clinical results.

The MR images allowed quantitative assessment of thereconstructed Achilles tendon and the surrounding tissues.The consistent findings in comparison to the unaffectedside were no changes in signal intensity (minimal changesin one patient) and a marked increase in the thickening andthe width of the reconstructed Achilles tendon. The causesof these changes in tendon caliber can be explained bythe abundance of tendon grafts, the presence of peroneusbrevis tendon, and hypertrophy as a result of proliferativecollagenous ingrowth.

In summary, this report demonstrates that microvascular reconstruction may result in satisfactory functionin patients with combined defects of overlying skin andtendon following Achilles tendon surgery that are nototherwise treatable by conventional methods. Althoughthe present study consists of a small number of cases,it provides useful guidance to manage these patients.

Acknowledgments

The authors gratefully thank Prof. Berrin Durmaz, MD,from Department of Physical Therapy at the AegeanUniversity School of Medicine, for help with the isokinetic testing; and Radiologist Murat Uygur, MD, fromIZEMAR, for support in MR imaging.

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Reconstruction of skin and tendon defects from wound complications after achilles tendon rupture

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