J Reconstr Microsurg 2023; 39(01): 009-019
DOI: 10.1055/s-0042-1748977
Original Article

Composite Free Tissue Transfer for Reconstruction of Lower Extremity Tendon Injuries: A Systematic Review

1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
,
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
,
Jonathan Day
2   Department of Orthopaedic Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
,
Christopher E. Attinger
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
,
Kenneth L. Fan
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
,
Karen K. Evans
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
› Author Affiliations
Funding None.

Abstract

Background Tendon rupture with extensive soft tissue loss has few reconstructive options. Composite free tissue transfers including skin and tendon offer an attractive reconstructive approach. Unfortunately, most studies discussing them come from sparse case reports. We systematically assess evidence supporting composite flap use in single-stage reconstruction of lower extremity tendon and soft tissue defects.

Methods A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. OvidMEDLINEqueried for records pertaining to the study question using Medical Subject Heading (MeSH) terms such as “lower extremity,” “tendon,” and “composite flap.” No limitations were placed on the year of publication, country of origin, or study size. Study characteristics and patient demographics were collected. Primary outcomes included:(1) defect location, composite flap characteristics;(2) return to ambulation;(3) joint range of motion;(4) patient satisfaction, and (5) complications.

Results In total, 29 articles examining 173 patients with lower extremity tendon defects and soft tissue loss were identified. Average age was 44.3 years (SD 17.5); most patients were male (n = 110, 66.3%). Achilles defect was mostly reported (n = 151, 86.8%), followed by patellar (n = 17, 9.8%) and other tendon defects (n = 6, 3.4%). Average tendon defect size was 8.4 cm (SD 4.0), average soft tissue loss was 80.2 cm2 (SD 40.0). Most employed composite flap was anterolateral thigh and fascia lata (ALT + FL) (n = 101, 58.0%). Most patients (n = 134, 99.3%) returned to ambulation in an average 123.1 days (SD 78.3). Average reconstructive joint degree of motion was 62.1 degrees compared with normal degree of motion 62.3 degrees. Patient-reported outcomes demonstrated increased satisfaction after reconstruction.

Conclusion Composite flaps effectively reconstruct a variety of tendon and soft tissue defects; the most reported flap is ALT + FL, which provides large flap territories and rapid healing in Achilles, patellar, and other tendon defects. In this review, patients with composite flaps demonstrated return to ambulation, minimal impairment in range of motion, and notable postoperative satisfaction.



Publication History

Received: 20 August 2021

Accepted: 30 January 2022

Article published online:
23 June 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Stavenuiter XJR, Lubberts B, Prince III RM, Johnson AH, DiGiovanni CW, Guss D. Postoperative complications following repair of acute Achilles tendon rupture. Foot Ankle Int 2019; 40 (06) 679-686
  • 2 Willits K, Amendola A, Bryant D. et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 2010; 92 (17) 2767-2775
  • 3 Keating JF, Will EM. Operative versus non-operative treatment of acute rupture of tendon ofAchilles: a prospective randomised evaluation of functional outcome. J Bone Joint Surg Br 2011; 93 (08) 1071-1078
  • 4 Ando J, Sakuraba M, Sugawara A. et al. Free flap reconstruction of Achilles tendon and overlying skin defect using ALT and TFL fabricated chimeric flap. Case Reports Plast Surg Hand Surg 2019; 6 (01) 82-85
  • 5 Duhamel P, Mathieu L, Brachet M, Compere S, Rigal S, Bey E. Reconstruction of the Achilles tendon with a composite anterolateral thigh free flap with vascularized fascia lata: a case report. J Bone Joint Surg Am 2010; 92 (15) 2598-2603
  • 6 Lee YK, Lee M. Treatment of infected Achilles tendinitis and overlying soft tissue defect using an anterolateral thigh free flap in an elderly patient: a case report. Medicine (Baltimore) 2018; 97 (35) e11995
  • 7 Lykoudis EG, Dalianoudis I, Seretis K, Lykoudis GE, Lykissas MG. Single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata: a case report. Microsurgery 2018; 38 (03) 318-323
  • 8 Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of Achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region. PlastReconstr Surg 1988; 81 (04) 579-589
  • 9 DeFazio MV, Han KD, Iorio ML. et al. Combined free tissue transfer for the management of composite Achilles defects: functional outcomes and patient satisfaction following thigh-based vascularized reconstruction with a neotendon construct. J ReconstrMicrosurg 2014; 30 (06) 431-440
  • 10 Bekeny JC, Zolper EG, Fan KL, Evans KK. Composite cutaneous anterolateral thigh flap with rolled fascia lata for tibialis anterior tendon reconstruction. PlastReconstr Surg Glob Open 2020; 8 (07) e2959
  • 11 DeFazio MV, Han KD, Evans KK. Functional reconstruction of a combined tendocutaneous defect of the Achilles using a segmental rectus femoris myofascial construct: a viable alternative. Arch Plast Surg 2014; 41 (03) 285-289
  • 12 Kim KG, Tirrell AR, Dekker PK. et al. The need to improve patient-centered outcome reporting following lower extremity flap reconstruction: a systematic review and meta-analysis. J ReconstrMicrosurg 2021; 37 (09) 764-773
  • 13 Ehrl D, Heidekrueger P, Schmitt A. et al. The anterolateral thigh flap for Achilles tendon reconstruction: Functional outcomes. Plastic and reconstructive surgery (1963). 2019; 143 (06) 1772-1783
  • 14 Soons J, Rakhorst HA, Ruettermann M, Luijsterburg AJM, Bos PK, Zöphel OT. Reconstruction of defects involving the Achilles tendon and local soft tissues: a quick solution for a lingering problem. Bone Joint J 2015; 97-B (02) 215-220
  • 15 Lucattelli E, Delcroix L, Baldrighi C, Tanini S, Innocenti M. Quadriceps tendon reconstruction using a fascia lata included in a reverse-flow anterolateral thigh flap. Microsurgery 2019; 39 (07) 642-646
  • 16 di Summa PG, Sapino G, Cherubino M. et al. Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: long term recovery and functional outcomes. Microsurgery 2019; 39 (05) 405-415
  • 17 Isenberg JS, Fusi S. Immediate tendon Achilles reconstruction with composite palmaris longus grafts. Ann Plast Surg 1995; 34 (02) 209-211
  • 18 Kim C, Tark M, Choi C, Kang S, Kim Y. A single-stage reconstruction of a complex Achilles wound with modified free composite lateral arm flap. J ReconstrMicrosurg 2008; 24 (02) 127-130
  • 19 Smit JM, Darcy CM, Audolfsson T, Hartman EHM, Acosta R. Multilayer reconstructions for defects overlying the Achilles tendon with the lateral-arm flap: long-term follow-up of 16 cases. Microsurgery 2012; 32 (06) 438-444
  • 20 Youn SK, Kim SW, Kim YH, Hwang KT. The composite anterolateral thigh flap for Achilles tendon and soft tissue defect reconstruction with tendon repair by fascia with double or triple folding technique. Microsurgery 2015; 35 (08) 615-621
  • 21 Jandali Z, Lam MC, Merwart B. et al. Predictors of clinical outcome after reconstruction of complex soft tissue defects involving the Achilles tendon with the composite anterolateral thigh flap with vascularized fascia lata. J ReconstrMicrosurg 2018; 34 (08) 632-641
  • 22 Lee J, Yu J, Shieh S, Liu C, Pai J. Reconstruction of the Achilles tendon and overlying soft tissue using antero-lateral thigh free flap. Br JPlastic Surg 2000; 53 (07) 574-577
  • 23 Sapino G, Zaugg P, Cherix S. et al. ALT flap with vascularized fascia lata for one-stage functional patellar tendon reconstruction. J Plastic, ReconstrAesthetic Surg 2019; 72 (03) 467-476
  • 24 Haas F, Seibert FJ, Koch H. et al. Reconstruction of combined defects of the Achilles tendon and the overlying soft tissue with a fascia lata graft and a free fasciocutaneous lateral arm flap. Ann Plast Surg 2003; 51 (04) 376-382
  • 25 Houtmeyers P, Opsomer D, Van Landuyt K, Monstrey S. Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata. Journal of reconstructive microsurgery. 2012; 28 (03) 205-210
  • 26 Kuo YR, Kuo MH, Chou WC, Liu YT, Lutz BS, Jeng SF. One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: clinical experience and functional assessment. Ann Plast Surg 2003; 50 (02) 149-155
  • 27 Kelahmetoglu O, Gules ME, Elmadag NM, Guneren E, Sonmez Ergun S. Double-layer reconstruction of the Achilles' tendon using a modified Lindholm's technique and vascularized fascia lata. J Hand Microsurg 2018; 10 (01) 49
  • 28 Dabernig J, Shilov B, Schumacher O, Lenz C, Dabernig W, Schaff J. Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap. J Plastic, Reconstr Aesth Surg 2006; 59 (02) 142-147
  • 29 Azoury SC, Stranix JT, Kovach SJ, Levin LS. Principles of orthoplastic surgery for lower extremity reconstruction: why is this important?. J ReconstrMicrosurg 2021; 37 (01) 42-50
  • 30 Song Y, Chen G, Song Y. The free thigh flap: A new free flap concept based on the septocutaneous artery. Br J Plastic Surg 1984; 37 (02) 149-159
  • 31 Inoue T, Tanaka I, Imal K, Hatoko M. Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap. Br JPlastic Surg 1990; 43 (06) 728-731
  • 32 Song SH, Choi S, Kim YM, Lee SR, Choi YW, Oh SH. The composite anterolateral thigh flap for knee extensor and skin reconstruction. Arch Orthop Trauma Surg 2013; 133 (11) 1517-1520
  • 33 Mundy LR, Klassen A, Sergesketter AR. et al. Content validity of the LIMB-Q: a patient-reported outcome instrument for lower extremity trauma patients. J ReconstrMicrosurg 2020; 36 (09) 625-633
  • 34 Kuo Y, An P, Kuo M, Kueh N, Yao S, Jeng S. Reconstruction of knee joint soft tissue and patellar tendon defects using a composite anterolateral thigh flap with vascularized fascia lata. J Plastic, ReconstrAesth Surg 2006; 61 (02) 195-199
  • 35 Acar MA, Güleç A, Aydin BK, Erkoçak ÖF, Yilmaz G, Şenaran H. Reconstruction of foot and ankle defects with a free anterolateral thigh flap in pediatric patients. J ReconstrMicrosurg 2015; 31 (03) 225-232
  • 36 Andreu-Sola V, Aguilera-Sáez J, Rivas-Nicolls D, BosacomaRoura P, Barret JP. Functional reconstruction of acutely burnt Achilles tendon with composite anterolateral thigh flap with fascia lata: a case report. Ann Burns Fire Disasters 2017; 30 (04) 309-312
  • 37 Haddad JL, Chavez-Abraham V, Carrera JG, Vilchis JL, Sastre NO. Microsurgical reconstruction of the Achilles tendon with a fascia lata flap. Journal of reconstructive microsurgery. 1997; 13 (05) 309-312
  • 38 Hu R, Ren YJ, Yan L. et al. A free anterolateral thigh flap and iliotibial band for reconstruction of soft tissue defects at children's feet and ankles. Injury 2015; 46 (10) 2019-2023
  • 39 Tiengo C, Sonda R, Monticelli A. et al. Achilles tendon region defects: delayed composite anterolateral thigh flap with stripping of fascia lata: a case series. Wound ManagPrev 2020; 66 (12) 13-22