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Introduction

The combined loss of the Achilles tendon and overlyingsoft tissue represents a reconstructive challenge.1-5 On the onehand, cutaneous defects on the distal third of the leg requiresome of the most complex procedures in plastic surgery, suchas microsurgical techniques, which are required in many cases.On the other hand, the damaged Achilles tendon reconstructionis a procedure of great importance because of its functional im-

plications. The surgical challenge is even greater when Achillestendon and overlying soft tissue defects coexist.2,5 Optimal re-construction of the Achilles tendon should ensure not only sta-ble cover able to resist friction while walking, but also adequateankle contour to allow for the use of normal footwear, as wellas the appropriate strength, durability and tension to achieveactive plantar flexion.1-3

The purpose of this paper is to present a case report of func-tional reconstruction of a segmentary defect of the Achilles ten-

FUNCTIONAL RECONSTRUCTION OF ACUTELY BURNTACHILLES TENDON WITH COMPOSITE ANTEROLATERALTHIGH FLAP WITH FASCIA LATA: A CASE REPORTRECONSTRUCTION FONCTIONNELLE D’UNE BRÛLURE DU TENDOND’ACHILLE DANS LA PHASE AIGUE PAR UN LAMBEAU COMPOSITE ANTEROLATÉRAL DE CUISSE AVEC FASCIA LATA : À PROPOS D’UNE OBSERVATION

Andreu-Sola V.,* Aguilera-Sáez J., Rivas-Nicolls D., Bosacoma Roura P., Barret J.P.Department of Plastic, Reconstructive and Burns Surgery, Hospital Vall d’Hebron, Barcelona, Spain

SUMMARY. Soft tissue defects in the postero-inferior aspect of the leg are still challenging, especially when they affect the Achillestendon due to its important functional involvement in the normal movement of the ankle. Dorsiflexion and flexion may be affected if properreconstruction is not achieved, thus limiting daily activities such as walking, climbing stairs or running. Several techniques, including localor regional flaps, combinations of tendon substitutes with free muscular or fasciocutaneous flaps, and free composite flaps with tendonhave been described for the reconstruction of complex defects caused by burn sequelae, tumors, trauma, chronic ulcers, etc. The gold stan-dard treatment for moderate to large defects is the anterolateral thigh (ALT) flap with vascularized fascia lata. The ALT flap is reliable be-cause of a long vascular pedicle and a large donor area. Moreover, the fascia lata mimics the Achilles tendon perfectly when rolled onitself. The aim of this article is to present the application of this technique for the first time in a case of an acute burn. The timing of re-construction with free flaps is critical in acute burns. In our case, it was performed on the 24th day post-burn and no microsurgical compli-cations appeared. More than six months after surgery, the patient showed a normal gait, was able to lift his own weight against gravity andno complications were detected in the donor area.

Keywords: Achilles tendon, anterolateral thigh flap, fascia lata, acute burn

RÉSUMÉ. Les pertes de substance des parties molles de la région postéro inférieure de jambe constituent un problème majeur, surtoutquand elles intéressent le tendon d’Achille, à cause de son importante implication dans les mouvements normaux de la cheville. La dorsi-flexion et la flexion peuvent être affectées si une réparation correcte n’est pas réalisée, car elle limite les activités journalières telles quela marche, la montée d’escaliers, ou la course. Plusieurs techniques incluant les lambeaux locaux et régionaux, l’association de substitutstendineux avec des lambeaux libres musculaires ou fascio cutanés, et les lambeaux libres composites avec tendon ont été décrits pour lareconstruction des pertes de substances complexes en rapport avec séquelles de brûlures, tumeurs, traumatismes, ulcères chroniques etc.Le traitement de référence pour des pertes de substances modérées ou importantes est constitué par le lambeau antero latéral de cuisseavec fascia lata vascularisé. Ce lambeau est sûr, du fait du long pédicule vasculaire et de l’importance de la surface de la zone donneuse.Cependant, le fascia lata imite parfaitement le tendon d’Achille, que s’il est roulé sur lui-même. Le but de cet article est de présenter uneapplication de cette technique pour la première fois dans un cas de brûlures en urgence. Le moment de la reconstruction par lambeauxlibres est discuté dans les brûlures. Dans notre observation, il a été réalisé au cours du 24 e jour après la brûlure et sans complicationsmicro chirurgicales. Plus de six mois après la chirurgie, le patient affiche une démarche normale, il est capable de se lever tout seul et au-cune complication n’est apparue au niveau de la zone donneuse.

Mots-clés: tendon d’Achille, lambeau antérolatéral de cuisse, fascia lata, brûlures aigue en urgence

*Corresponding author: Victor Andreu-Sola, Department of Plastic, Reconstructive and Burns Surgery, Resident, Hospital Vall d’Hebron, Passeig de la Vall d’Hebron,119-129, 08035 Barcelona, Spain. E-mail: vandreusola@gmail.comManuscript: submitted 17/10/2017, accepted 28/11/2017.

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don and the overlying skin produced by acute thermal burns usinga free composite anterolateral thigh (ALT) flap with fascia lata.

Case report

In February 2017, a 24-year-old male with no medical his-tory was admitted to our hospital with deep second and third

degree burns in the postero-lateral aspect of the distal third ofhis right leg, caused by a domestic accident with the flamesfrom a fireplace two weeks before (Fig. 1).

Debridement of the burns was performed in a first surgicalattempt 20 days after the accident. Achilles tendon exposure,a devitalized appearance and purulent exudates were observed.For this reason, definitive cover and reconstruction of the de-fect was rejected in favour of a temporary cover made withpartial thickness skin grafts obtained from the right thigh.Wound cultures were obtained in which a Cloxacillin sensibleStaphylococcus aureus was grown, whereby antibiotic treat-ment with Cloxacillin was initiated for 7 days. The resultingdefect was approximately 15x5 cm and it showed 5 cm of di-rect exposure of the Achilles tendon in the lower half (Fig. 2).

In a second attempt, 24 days after the burn and having op-timized the wound with antibiotic therapy, definitive coveragewas performed with a free fasciocutaneous anterolateral leftthigh (ALT) flap, measuring 17x7.5 cm (Fig. 3), anastomosedend-to-side to the posterior tibial artery and end-to-end to thetwo posterior tibial veins (Fig. 4). All recipient vessels wereidentified and dissected within the tissues proximal to the upperedge of the wound, at an approximate distance of 3 cm. The flapincluded a lateral extension to incorporate 8 cm of the left thighfascia lata, which was rolled and sutured on itself and, after flaptransposition, it was anchored with anchors to the calcaneus boneon the one side and to the healthy proximal remnant of Achillestendon with a non-absorbable suture on the other (Fig. 5).

Fig. 1 - Second and third degree burns of the posterior aspect of the distalthird of the right leg of a 24 year-old-man, produced by a flare.

Fig. 2 - Burn appearance after the first debridement. Exposure of theAchilles tendon can be seen in the center of the defect.

Fig. 3 - Anterolateral thigh (ALT) flap with a strip of fascia lata. Note thelong vascular pedicle, about 10 cm.

Fig. 4 - ALT flap anastomosed 3 cm proximal to the wound, end-to-sideto the posterior tibial artery and end-to-end to the two posterior tibialveins. The fascia lata has been rolled on itself.

Fig. 5 - Intraoperative final result of the functional reconstruction of theAchilles tendon.

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The postoperative course was uneventful. Two weeks aftersurgery, the patient progressively restarted his workload. Sixmonths after surgery and after a process of motor rehabilitation,the patient presented a normal gait and he was able to lift hisown weight against gravity (Fig. 6). No complications hadbeen reported in the donor area: the knee extension was com-plete, the gait was normal and the patient had not reported anyhypoesthesias in the thigh. The aesthetic result of both thedonor and recipient areas was optimal and he was not expectedto require secondary procedures.

Discussion

While the simple rupture of the Achilles tendon can bemanaged only with sutures or tendon grafts, the managementof segmental defects combined with soft tissue involvementremains a complex reconstructive challenge owing to the lackof suitable tissue on site.1 The Achilles tendon is essential fornormal ankle joint movement. For this reason, loss of its func-tion seriously affects dorsiflexion and flexion of the joint,therefore affecting daily activities such as walking, climbingstairs, standing for long periods of time or running.2,3,5,6

In the treatment of complex defects in the postero-inferioraspect of the leg, local or regional flaps can jeopardize the sur-vival of the previously injured leg. In addition, lesions thatcause the defect may also affect the vascularization of the re-gion because the zone of injury is usually larger than it appearson simple clinical examination. Given the fact that local flapsare not available to provide structures similar to a tendon, thebest solution to functional and cover problems are free flaps.5

Regarding this, it is vitally important to perform the recon-struction with a flap able to bring both the vascularized tendonand the skin coverage together.5 A vascularized tendinous sub-stitute may have the advantages of increased resistance to in-fection, faster healing, less adhesion to surrounding tissue andgreater sliding capacity.1-4 Reconstruction options that combineisolated components, such as tendon allografts, with muscular(latissimus dorsi, gracilis, tensor fasciae latae) or fasciocuta-neous free flaps (radial forearm) have become outdated.5 Oth-erwise, free flaps from the upper limb, such as radial forearmflaps with the palmaris longus tendon, brachioradialis flapswith the flexor carpi radialis tendon, and lateral arm flaps withthe triceps tendon, as well as some flaps from the lower limb,like the dorsalis pedis flap with the extensor digitorum longustendon and the groin flap including the vascularized externaloblique aponeurosis,1,3-6 have been used for small-sizeddefects.5

Given the large size of our defect (15x5 cm) and the needto perform a fully functional reconstruction, we consideredthe anterolateral thigh (ALT) flap with fascia lata to bethe best option. The free composite ALT flap provides all thecomponents needed: vascularized fascia lata for tendon re-construction and soft tissue cover. When the fascia lata stripis rolled on itself, it mimics a tendon that adequately replacesthe Achilles tendon defect. The fascia lata receives sufficientblood supply via the prefascial and subfascial vascular plexuswhen it remains attached to the ALT flap.3 Furthermore, theALT flap with vascularized fascia lata has been shown toachieve an acceptable ankle potency and an optimal range ofmotion in the composite reconstruction of the Achilles ten-don,2 thus providing all the advantages required for tendinousreconstruction of this area. Donor area morbidity, despite ob-jectively existing, is slight and does not interfere with dailyactivities.2 The ALT flap has the advantage of having a longvascular pedicle, a great donor area, the quality of durableskin, freedom in design and tissue thinness. For this reason,the ALT flap with fascia lata is considered the gold stan-dard in the functional reconstruction of Achilles tendon largedefects.1,5

The reconstruction of complex defects of the postero-in-ferior aspect of the leg with free ALT composite flap with fas-cia lata was first described by Lee and co. in 2000.3 Since then,it has been used by different groups for the treatment of defectsof multiple etiologies, including burn sequelae, tumors, traumaproduced by sport, work or traffic accidents, chronic ulcers,etc..1-6 However, this technique has not been described forthe treatment of acute burns as in our case. Kuo and co.demonstrated in their study that blood vessels 3 cm proximalto the skin defect produced by burns could be used for micro-surgical anastomosis if their walls had normal elasticity, an in-tact endothelium not separated from the media and goodarterial bleeding when sectioned.7 These 3 premises were ful-filled by the recipient vessels of our patient, so no microvas-cular complication appeared.

The timing of burn reconstruction with free flaps requiresimportant planning. Compared to the use of free flaps for otherindications (trauma, breast reconstruction, head and neck on-cology, etc.), flap failure rate tends to be higher in burn recon-struction, especially for surgeries carried out during the 5th-21st

day post-burn.8-10 Infection, post-surgical inflammatorychanges and vascular damage (most likely from inadequate de-bridement and wound cleaning) are etiological factors poten-tially causing the failure of microsurgical reconstruction at thisearly stage.11 In our case, microsurgery was performed on the24th day post-burn and, as already mentioned, no complicationswere detected.

Conclusion

The free ALT composite flap with vascularized fascia lataoffers a reliable option for a single stage Achilles tendon re-construction including the overlying soft tissue defects. Thepresent case demonstrates that it is also useful for the correc-tion of defects secondary to acute burns, and this was not foundin the consulted bibliography. Adequate surgical timing (avoid-ing microsurgery in the early period) and the choice of receptorvessels (at least 3 cm away from the wound) will not ensuresurgery success, but they may decrease the rate of complica-tions in burn reconstruction with free flaps.

Fig. 6 - More than 6 months after surgery, the patient is able to lift hisown weight against gravity with a good aesthetic result.

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BIBLIOGRAPHY

1. Houtmeyers P, Opsomer D, Van Landuyt K, Monstrey S: Reconstruc-tion of the Achilles tendon and overlying soft tissue by free compositeanterolateral thigh flap with vascularized fascia lata. J Reconstr Micro-surg, 28: 205-209, 2012.

2. Kuo Y-R, Kuo M-H, Chou W-C, Liu Y-T et al.: One-stage reconstruc-tion of soft tissue and Achilles’ tendon defects using a composite freeanterolateral thigh flap with vascularized fascia lata: clinical experienceand functional assessment. Ann Plast Surg, 50: 149-155, 2003.

3. Lee JW, Yu JC, Shieh SJ, Liu C et al.: Reconstruction of Achilles tendonand overlying soft tissue using antero-lateral thigh free flap. Br J PlastSurg, 53: 574-577, 2000.

4. Duhamel P, Mathieu L, Brachet M, Compere S et al.: Reconstructionof the Achilles tendon with a composite antero-lateral thigh free flapwith vascularized fascia lata: a case report. J Bone Joint Surg Am, 92:2598-2603, 2010.

5. Ki Youn S, Kim SW, Kim YH, Hwang KT et al.: The composite an-terolateral thigh flap for Achilles tendon and soft tissue defect recon-struction with tendon repair by fascia with double or triple foldingtechnique. Microsurgery, 35: 615-621, 2015.

6. Inoue T, Tanaka I, Imai K, Hatoko M: Reconstruction of Achilles ten-don using vascularized fascia lata with free lateral thigh flap. Br J PlastSurg, 43(6): 728-31, 1990.

7. Kuo ET: Experimental study of free flap transplantation after debride-ment in early stage of electric burn. Zhonghua Zheng Xing Shao ShangWai Ke Za Zhi, 6(4): 285-7, 318, 1990.

8. Ibrahim A, Skoracki R, Goverman JG, Sarhane KA et al.: Microsurgeryin the burn population - A review of the literature. Ann Burns Fire Dis-asters, 28(1): 39-45, 2015.

9. Baumeister S, Köller M, Dragu A, Germann G et al.: Principles of mi-crovascular reconstruction in burn and electrical burn injuries. Burns,31(1): 92-8, 2005.

10. Sauerbier M, Ofer N, Germann G, Baumeister S: Microvascular recon-struction in burn and electrical burn injuries of the severely traumatizedupper extremity. Plast Reconstr Surg, 119(2): 605-15, 2007.

11. Oni G, Saint-Cyr M, Mojallal A: Free tissue transfer in acute burns. JReconstr Microsurg, 28(2): 77-84, 2012.

Conflict of interest. All the authors of this paper declarethat they have no conflict of interest related to this article.