Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

518. Soft Tissue Expansion in Revision/Complex Achilles Tendon Reconstruction

Jorge I. Acevedo

SURGICAL MANAGEMENT

images Indications include neglected ruptures requiring secondary repair or revision surgery.

images Soft tissue expansion over the Achilles tendon and subsequent repair of the tendon are performed as a staged, two-part procedure about 3 to 4 weeks apart.

images This can be particularly effective when performing augmented procedures that increase the girth at the distal tendon or when the local skin is contracted.

Preoperative Planning

images MRI studies are reviewed to determine the ideal placement of the expander and to plan second-stage repair.

images The patient is instructed on the rationale for the staged procedure and the importance of weekly follow-up visits between each stage.

Positioning

images The prone position allows the best access when approaching the Achilles tendon.

images A well-padded pillow is placed underneath the knees and anterior tibia–ankle.

images This allows for free plantarflexion and dorsiflexion of the ankle.

Approach

images The preferred approach is a posteromedial incision adjacent to the Achilles tendon. This allows the surgeon to avoid injury to the short saphenous vein and sural nerve.

images Simple extension of the incision is performed for the secondstage definitive repair.

images The posteromedial incision may be extended into a lazy-S, L shape, or a direct medial approach.

TECHNIQUES

IMPLANTATION OF EXPANDER

images  The initial stage of treatment involves subcutaneous placement of a 70-mL, rectangular soft tissue expander (McGhan, Santa Barbara, CA) between the Achilles tendon and the skin (TECH FIG 1).

images  After sterile preparation, make a longitudinal incision along the medial aspect of the ankle, adjacent to the course of the Achilles tendon.

images  Perform superficial subcutaneous elevation until a pocket about 6 × 4 cm is created.

images  Insert a McGhan tissue expander into this cavity and place the injection catheter away from the implant.

images  Subcuticular closure is followed by reapproximation of the skin.

images  10 mL of normal saline is initially injected into the implant via the injection port.

images  The patient is seen 1 week postoperatively for further inflation of the implant.

images  Ten mL of normal saline is added to the expander weekly.

images

TECH FIG 1  McGhan 70-mL soft tissue expander.

REMOVAL OF EXPANDER AND TENDON REPAIR

images  The expander is removed 3 to 4 weeks postoperatively (TECH FIG 2). At that time, removal of the tissue expander and Achilles repair are performed.

images  The previously created incision is accessed and extended as necessary. The expansion balloon is then easily removed from its subcutaneous pocket.

images  Surgical repair of the injured tendon is carried out in the surgeon’s preferred fashion.

images

TECH FIG 2  Inflated soft tissue expander in place subcutaneously.

images  Careful repair of the paratenon overlying the Achilles tendon is essential at this stage to re-establish the fragile blood supply to this area.

images Upon completion of the repair, subcutaneous closure is achieved and reapproximation of the wound is then afforded by the lack of tension at the expanded skin margins (TECH FIG 3).

images

TECH FIG 3  Tension-free skin closure after Achilles tendon repair.

images

POSTOPERATIVE CARE

images After the initial stage of insertion, the patient is followed weekly for subsequent expander inflation. The inflation rate is 10 mL per week for 3 to 4 weeks.

images After expander removal and second-stage reconstruction the operative limb is placed into a short-leg splint in 10 to 15 degrees of plantarflexion.

images Non–weight-bearing with immobilization in a short-leg cast is maintained for 3 weeks. Range-of-motion exercises are initiated at 3 to 4 weeks postoperatively. Finally, weight bearing is allowed at 6 weeks after surgical repair (FIG 1).

OUTCOMES

images This technique has been used successfully in our practice with no complications related directly to soft tissue expansion.

images

FIG 1  Outcome 8 weeks after second-stage surgery.

COMPLICATIONS

images Infection

images Seroma

images Sural nerve injury

images Fibrotic reaction

REFERENCES

1.     Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon. J Bone Joint Surg Am 1975;57:253–255.

2.     Acevedo JI, Weber KS, Eidelman DI. Avoiding wound complications after neglected Achilles tendon repair: tissue expansion technique. Foot Ankle Int 2007;28:393–395.

3.     Ademoglu Y, Ozerkan F, Ada S, et al. Reconstruction of skin and tendon defects from wound complications after Achilles tendon rupture. J Foot Ankle Surg 2001;40:158–165.

4.     Dalton G, Wapner K, Hecht P. Complications of Achilles and posterior tibial tendon surgeries. Clin Orthop Relat Res 2001;391: 133–139.

5.     Kumta SM, Maffulli N. Local flap coverage for soft tissue defects following open repair of Achilles tendon rupture. Acta Orthop Belg 2003;69:59–66.

6.     Leppilahti J, Kaarela O, Teerikangas H, et al. Free tissue coverage of wound complications following Achilles tendon rupture surgery. Clin Orthop Relat Res 1996;328:171–176.

7.     Ozaki J, Fujiki J, Sugimoto K, et al. Reconstruction of neglected Achilles tendon rupture with Marlex mesh. Clin Orthop Relat Res 1989;238:204–208.

8.     Paavola M, Orava S, Leppilahti J, et al. Chronic Achilles tendon overuse injury: complications after surgical treatment. Am J Sports Med 2000;28:77–82.

9.     Parker R, Repinecz M. Neglected rupture of the Achilles tendon: treatment by modified Strayer gastrocnemius recession. J Am Podiatry Assoc 1979;69:548–555.



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