Open Achilles tendon defects: reconstructive surgeries and long term follow-up

Abstract

Objective To explore the reconstructive surgeries for open Achilles tendon defects and their long term outcomes. Methods A retrospective review was performed on 31 patients with open Achilles tendon defects treated at our center. There were 19 males and 12 females with an average age of 23.1 years (range, 4-55 years). There were 7 cases on left side and 24 on right. The injury causes included spoke injuries (18 cases), crash injuries (6 cases), machine injuries (6 cases), and cut injuries (1 case). The defect lengths of the Achilles tendons in the study ranged from 1 to 11cm and the soft tissue defects ranged from 3 cm×3 cm to 12 cm×10 cm. There were 10 cases with calcaneus fractures. Surgeries for Achilles tendon defects included sliding the Achilles tendon stump down with the sliding gastrocnemius musculocutaneous flap (15 cases), suture at the plantar flexion (10 cases), tendon flap turndown (1 case), hamstring tendon autograft (1 case), fascia lata muscle reconstruction (1 case) and tendon allograft (3 cases). Free flaps (7 cases) and non-free flaps (24 cases) were used for the coverage of concomitant skin defects. The calcaneus fractures were fixed with screws (6 cases) or K-wires (4 cases). The treatment protocols were based on the defect length of the Achilles tendon. Results The follow up period was 1-6 years (average, 1.8 years). There was no total flap failure or tendon re-rupture, while 7 cases who had partial flap loss 2-4 days after the surgeries. In the latest follow-up, all the cases had regained full walking abilities: 19 cases (61.3%, 19/31) even had regained the heel raising by the reconstructed foot while 12 cases (38.7%) cannot. Compared with the contralateral side, 31 cases' (100.0%) reconstructed ankles had the maximum plantar flexion, while 21 cases (67.7%) had the maximum dorsal extention. Ten cases (32.2%) lost their maximum dorsal extension ranging from 5° to 25°. Conclusion There are many reconstructive surgeries available for open Achilles tendon defects, however, the optimal choice should be based on the defect length of the Achilles tendon: those within 4 cm could be reconstructed with tendon reattachment and local flaps; those between 4 cm and 11 cm could be best treated with sliding gastrocnemius flap; and those over 11 cm should be reconstructed with free anterolateral thigh perforator flap with tendon autograft. The long term follow-up showed the strength and elasticity of the reconstructive Achilles tendon was satisfactory. Key words: Achilles tendon; Wounds and injuries; Surgical flaps