Early mobilizing and dangling of the lower leg after one-stage reconstruction of Achilles tendon and overlying tissue defect using an anterolateral thigh flap with vascularized fascia lata.

We have treated two patients who had an Achilles tendon and overlying tissue defect using an anterolateral thigh flap with fascia lata. Postoperatively, skeletal suspension of the affected leg and intra-arterial heparin infusion were performed for seven days. Six weeks postoperatively, the patients could walk again.

Introduction

The Achilles tendon is essential for walking, going up stairs, and standing on tiptoe [1]. Reconstruction of a defect of the Achilles tendon with overlying tissue is challenging. This is because the tendon should have enough strength to bear the whole body weight and should be covered with well-vascularized tissue [2-17]. Many authors have reported one-stage reconstruction of a composite defect of the Achilles tendon and soft tissue using a free flap [2-17]. Recently, early dangling of lower legs after free tissue transplantation for the reconstruction following tumor ablation has been recommended [18,19]. On the other hand, there are no guidelines or reports regarding when dangling of the affected lower leg should be allowed in cases of Achilles tendon reconstruction where the ankle joint cannot be moved immediately after surgery. We have treated two patients who had a defect of the Achilles tendon and overlying tissue using a free anterolateral thigh (ALT) flap with vascularized fascia lata (FL). Postoperatively, intra-arterial infusion of heparin and skeletal suspension of the lower leg were performed. In both of our cases, active motion of the ankle joint was possible three days after surgery. In this report, we describe the details of the operative procedure and postoperative therapy.

Operative procedure

After each patient received general anesthesia there were placed in the spine position and wide debridement of the necrotic tendon and soft tissue was performed after which the flap size was determined. Next, the flap was harvested from the side opposite to the affected side. At the proximal side, FL was rolled and fixed to the proximal stump of the Achilles tendon using 4-0 nylon (Keisei Medical Industrial, Japan). At the distal side, FL was folded and fixed to the calcaneus bone using 2.7 mm self-tapping cortex screws (DePuy Synthes Japan, Tokyo, Japan) (Figure 1). During the fixation of FL, the ankle joint was kept in 0° of dorsal flexion.

Figure 1.

Schematic representation of the fascia fixation. Fascia lata was fixed to the proximal stump of the Achilles tendon and the calcaneus bone using 4-0 surgical nylon and screws, respectively.

Flow-through anastomosis was performed between the descending branch of the lateral circumflex femoral and the posterior tibial artery using 9-0 nylon. End-to-side anastomosis was performed between the descending branch of the lateral circumflex femoral vein and the posterior tibial vein, also using 9-0 nylon. The suction drain (J-VAC 10 mm flat drain, Ethicon, Somerville, NJ) was placed through separate incision that was located 3 cm lateral from flap. The flap was sutured using 3-0 Vicryl (Ethicon), 4-0 PDS (Ethicon) and 5-0 Ethilon (Ethicon). An incision was placed at the affected side and the femoral artery was dissected. From this incision, a 28G Argyle PI catheter (Covidien, Tokyo, Japan) was inserted into the femoral artery. For seven days postoperatively, the lower leg of the affected side was suspended by inserting 2 mm Kirschner wire (Synthes) through the tibia bone (Figure 2).

Figure 2.

View of the lower extremity after surgery. Skeletal suspension was performed.

Postoperative therapy and rehabilitation

Postoperatively, we performed continuous trans-arterial infusion of heparin (Mochida Pharmaceutical, Japan) via 28G PI catheter which was inserted into the femoral artery. Until two days postoperatively, the daily dose of heparin was 8000 IU. On postoperative days 3 and 4, 4000 IU and on days 5 and 6, 2000 IU heparin was administered. The activated partial thromboplastin time (APTT) level was checked every 24 h until seven days postoperatively. Prolonged APTT was not observed during this period. Eight days postoperatively, the catheter was removed. No other anti-platelet or anti-coagulant therapy was performed.

At three days postoperatively, active dorsi-flexion was started. Dangling of the affected leg was started at one week postoperatively. On postoperative days 7 and 8, the affected leg was dangled for a duration of 30 min two times a day. On postoperative days 9 and 10, the affected leg was dangled for a duration of 60 min two times a day. On postoperative days 11 and 12, the affected leg was dangled for a duration of 90 min two times a day. From postoperative day 13, the lower leg was dangled without limitation. During rehabilitation, patients could use wheelchair or walk on crutches without weight bearing. Partial-weight bearing rehabilitation was started at four weeks after surgery, with an ankle appliance in 30° of ankle plantar flexion. At five weeks after surgery, full-weight rehabilitation was started using the ankle appliance. At six weeks postoperatively, the patients were able to walk without the ankle appliance.

Case reports

Case 1

A 64-year-old woman had an Achilles tendon rupture while climbing a mountain and was admitted to a local hospital. Repair of the Achilles tendon was performed three times. However, her Achilles tendon ruptured the fourth time with skin necrosis was after which she was referred to our hospital (Figure 3(a)). Preoperatively, her ankle was fixed in 20° plantar flexion. The blood flow of posterior tibial artery was confirmed using CT angiography. Wide debridement results showed that she had a 3 × 8 cm soft tissue defect and a 6 cm Achilles tendon defect (Figure 3(b)). A 15 × 8 cm ALT flap with 18 × 10 cm FL was then harvested (Figure 3(c)). End-to-side anastomosis was performed between the descending branch of the lateral circumflex femoral vein and the posterior tibial vein. The diameter of the posterior tibial vein was 1.5 mm and the diameter of lateral circumflex femoral vein was 2 mm. The FL was folded and fixed to the calcaneus bone and a skin paddle of the ALT flap was fixed to the soft tissue defect (Figure 3(d)). During fascia fixation, the ankle joint was kept in 0° of dorsal flexion. The donor site of the ALT flap was closed directly. The activated partial thromboplastin time (APTT) level was checked every 24 h until seven days postoperatively. Prolonged APTT was not seen. The postoperative course was uneventful. Seven months postoperatively, scar revision and defatting of the skin paddle were performed. Twelve months postoperatively, the active range of motion of the ankle joint was 55° (10° dorsiflexion, 45° plantar flexion) (Figure 3(e)) and she had no disability in her daily life.

Figure 3.

(a) A 64-year-old woman had a chronic ulcer and necrosis of the Achilles tendon. (b) After debridement of soft tissue and the Achilles tendon. (c) Harvesting an anterolateral thigh flap with fascia. A 15×8cm skin paddle with 18×10cm fascia lata was harvested from the non-affected side. (d) The vascularized fascia was folded and fixed to the calcaneus bone and the skin paddle of the anterolateral thigh flap was then fixed to the soft tissue defect. (e) One-year postoperative view. The patient could stand on tip toe without help.

Case 2

A 60-year-old man was admitted to a local hospital with an Achilles tendon rupture that had occurred while playing table tennis. Repair of the Achilles tendon was performed twice. However, his Achilles tendon ruptured the third time with skin necrosis, and then was referred to our hospital (Figure 4(a)). Preoperatively, his ankle was fixed in 5° plantar flexion. The blood flow of posterior tibial artery was confirmed using CT angiography. Wide debridement results showed that he had a 10 × 8 cm soft tissue defect and a 10 cm Achilles tendon defect (Figure 4(b)). A 15 × 10 cm ALT flap with 20 × 12 cm FL was harvested (Figure 4(c)). End-to-side anastomosis was performed between the descending branch of the lateral circumflex femoral and the posterior tibial vein. The diameter of posterior tibial vein was 1.5 and the diameter of lateral circumflex femoral vein was 2.5 mm, respectively. The FL was folded and fixed to the calcaneus bone and then a skin paddle of the ALT flap was fixed to the soft tissue defect (Figure 4(d)). During FL fixation, the ankle joint was kept in 0° of dorsal flexion. The donor site of the ALT flap was closed directly. The postoperative course was uneventful. Twelve months postoperatively, scar revision and defatting of the skin paddle were performed. The active range of motion of the ankle joint was 70° (15° dorsiflexion, 55° plantar flexion) (Figure 4(e)). He then was able to play table tennis again.

Figure 4.

(a) A 60-year-old man had a chronic ulcer and necrosis of the Achilles tendon. (b) After debridement of soft tissue and the Achilles tendon. (c) The anterolateral thigh flap with fascia lata was harvested. A 15×10cm skin paddle with 20×12cm fascia lata was harvested from the non-affected side. (d) The vascularized fascia was folded and fixed to the calcaneus bone and the skin paddle of the anterolateral thigh flap was then fixed to the soft tissue defect. (e) One-year postoperative view. The patient could stand on tip toe without help.

Discussion

The Achilles tendon is essential for walking, going up stairs and standing on tiptoe [20]. The rate of Achilles tendon rupture differs depending on country or race [21,22] and 12–22 patients in 100,000 have Achilles tendon ruptures every year in European countries [21], while there is no report on such rate in Japan. Excellent results of non-operative reconstruction treatment after Achilles tendon rupture have been reported [20]. However, reconstruction of a defect of the Achilles tendon with overlying tissue is still challenging [2-17]. This is because the reconstructed tendon should have enough strength to bear the whole body weight and should be covered with well-vascularized tissue. One-stage reconstruction of a composite defect of the Achilles tendon and soft tissue using a free flap with vascularized FL transfer was introduced by Wei et al. [3]. They harvested a free groin flap with abdominal external oblique muscle fascia. Inoue et al. reported of the reconstruction of the Achilles tendon using a lateral thigh flap with FL [4]. In 1993, Hou et al. reported a lateral upper arm flap with triceps tendon transfer [5] and Stanec et al. reported a forearm flap with brachioradialis tendon transfer in 1999 [6]. We used a free ALT flap with vascularized FL in the one-stage reconstruction, a commonly performed and reported procedure [15,16]. The advantage of this procedure is that a large and well-vascularized fascia can be harvested with a large skin paddle. However, no guidelines exist regarding postoperative therapy and rehabilitation. Until the year 2000, many authors reported that patients were not able to walk for more than three months after surgery [2-6,9]. Free tissue transfer for the lower leg has been common, however, patients were not able to walk within two months postoperatively even after 2000 [16-19]. In the present cases, active dorsiflexion was started at three days postoperatively. At one week postoperatively our patients were allowed to dangle the lower leg and were able to walk six weeks after surgery. Some authors have reported that early dangling of the lower leg after free flap transfer does not increase the risk of free flap failure. In 2013, Jokuszies et al. recommended their lower-leg dangling protocol. In their report, they started dangling of the lower leg at three days postoperatively [18]. In addition, Miyamoto et al. reported that even starting mobilization at one day postoperatively did not cause flap failure and necrosis of skin grafting [19]. In their report, there was no differences in a survival rate between flap types. However, their cases did not include the cases who received tendon reconstruction using free flap transfer [18,19]. Early dangling of the lower leg is difficult after reconstruction of the tendon as in our cases. We worried that venous congestion might cause insufficient adhesion between the FL and the Achilles tendon because Miyamoto et al. reported that in eight of the 11 cases they had to place the suction drain at the recipient site for up to seven days postoperatively.

Early mobilization of the ankle joint is required to prevent adhesion of the Achilles tendon to the FL. Even in a recent studies authors fixed the ankle joint for more than two weeks postoperatively [16,17]. In our cases, we did not put the patient's leg on a pillow because the reconstructed Achilles tendon and overlying tissue were located at the posterior aspect of the leg. To avoid suppressing deformity due to self-weight of lower leg, skeletal suspension was useful. We believe that the skeletal suspension made it possible to start the dorsal flexion of the ankle joint earlier than other reports.

In 2007, Xipoleas et al. conducted a survey on the postoperative anticoagulant therapy. According to their survey, 11.2% of American Society of Plastic Surgeons members used heparin for postoperative anticoagulation therapy. Among them, 63.6% administered 10,000 or 15,000 U/day of heparin [23]. On the other hand, in our cases, the maximal dose of heparin was 8000 U/day and this dose was decreased every two days because intra-arterial infusion can administer the heparin selectively to flap compare to intravenous infusion or subcutaneous injection. Many authors have reported the reconstruction of Achilles tendon and overlying tissue defect using a free flap [2-17]. However,only few authors mentioned the details of postoperative anticoagulant therapy. Further study is needed in order to determine the effectiveness of postoperative anticoagulant therapy.

Recently, heparin-induced thrombocytopenia (HIT) has become widely known. With the exception of patients who do not have previous heparin exposure within 100 days, HIT usually occurs between 5–10 days following heparin initiation [24]. We performed intra-arterial heparin infusion until seven days postoperatively in the present cases and believe that the risk of HIT was low.

In this study, we were limited by the small number of cases. We believe further study is needed in order to determine the effectiveness of early mobilization of affected leg combined with continuous heparin infusion and skeletal suspension.

One-stage reconstruction of the Achilles tendon and overlying tissue using an ALT flap with FL is a reliable option. To achieve good result, postoperative rehabilitation should be started as early as possible.