AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

Achilles Tendon Reconstruction with the Gracilis Musculotendinous Free Tissue Transfer: A Single-Institution
Experience
Institution where the work was prepared: The Buncke Clinic, San Francisco, CA, USA
Bauback Safa, MD1; Charles K. Lee2; Gil S. Kryger, MD1; Gregory M. Buncke3; (1)Stanford University, (2)The Buncke Clinic, (3)California Pacific Medical Center
Background:
The surgical management of Achilles tendon defects represents a significant reconstructive challenge. Various techniques have been described including local
flap coverage as well as microvascular free tissue transfer for single-stage reconstruction of the Achilles tendon. Each technique has its limitations; however,
the functional and anatomical requirements of Achilles tendon reconstruction with both soft tissue and tendon constraints point to an ideal flap option—the
gracilis musculotendinous unit. We report our single-institution experience with the gracilis free tissue transfer for Achilles tendon reconstruction.
Methods:
A retrospective chart review was performed for 14 patients who underwent Achilles tendon reconstruction with a gracilis free tissue transfer. The gracilis tendon
was used to bridge the Achilles tendon defect with intratendinous weaving and the muscular portion was folded over to cover the tendon repair with a
split thickness skin graft. Microvascular anastomosis was performed to the posterior tibial artery and vein. Parameters measured were age, sex, comorbidities,
wound type, length of open wound, size of wound (soft tissue and Achilles defect), complications, and follow-up time. Patients were evaluated for range of
motion, ambulation, heel height in the tiptoe position, climbing stairs, and donor site morbidity.
Results:
All 14 gracilis flaps were successful with no flap loss. The mean patient age was 47. The average wound size was 13 cm2 with an average Achilles tendon
defect of 3.4cm. One patient had partial skin graft loss which healed with local wound care. One patient developed a donor site seroma which required surgical
drainage. There was one case of intraoperative venous thrombosis requiring a vein graft. There were no cases of early or late tendon ruptures or further
infection. Patients had an average plantar flexion of 100 degrees and reported no difficulty with ambulation. All reconstructed Achilles tendons showed good
functional and aesthetic results. All patients returned to their previous level of activity and could stand on tiptoes on the affected foot.
Conclusion:
The gracilis musculotendinous free tissue transfer represents an ideal reconstructive modality for a single-stage, vascularized reconstruction of the Achilles tendon
and soft tissue. It is ideal for moderate to large defects with a high success rate and longevity with minimal donor site morbidity. Patients who have undergone
this procedure demonstrate excellent functional and aesthetic outcomes and have been able to return to their previous level of activity.
Fibula Free Flap Reconstruction of the Ilium in Children after Resection of the Hemipelvis
Institution where the work was prepared: Children's Hospital of Philadelphia & University of Pennsylvania, Philadelphia, PA, USA
Darrin M. Hubert, MD1; John P. Dormans, MD2; David W. Low, MD1; Benjamin Chang, MD2; (1)University of Pennsylvania, (2)The Children's Hospital of Philadelphia
Introduction:
Neoadjuvant chemotherapy for Ewing's sarcoma has made wide resection with limb salvage frequently possible. However, resection of iliac tumors causes proximal
pelvic migration and significant leg length discrepancy. Free vascularized bone autografts represent the optimal method for iliac reconstruction because
they heal faster and hypertrophy sooner than nonvascularized bone grafts. Furthermore, they may be more durable in the setting of neoadjuvant chemotherapy
or radiation therapy.
Purpose:
The purpose of this study is to characterize the successful reconstruction of the ilium in children using the fibula free flap following resection of the hemipelvis.
Methods: Four patients were identified who underwent fibula free flap reconstruction of the pelvis after resection of the ilium, with preservation of the hip
joint. All had Ewing's sarcoma of the iliac wing without evidence of metastasis (stage IIB) and had pre-operative chemotherapy. Review of their operative records
and clinic charts was performed.
Results:
Mean age was 13.4 years (range 10-14). Mean follow-up was 4.0 years (1.5-5.3). Mean time to union of the fibular struts was 6.8 months (6-9.5). All patients
began toe-touch weight-bearing ambulation with crutches following removal of their trunk spica casts at 8-12 weeks. Lengths of the fibula free flaps were
20, 25, 18, and 17 cm. Mean leg length discrepancy was 2.3 cm (1.0-3.5 cm). No flap loss or post-operative infection occurred. All patients remained without
metastasis or local recurrence. Trendelenberg gait was noted in three patients due to loss of lower extremity abduction following iliac resection. One patient
underwent subsequent contralateral lower extremity epiphysiodesis to correct leg length discrepancy.
Conclusion:
Successful reconstruction of the pelvic ring utilizing a triangular double-barreled fibula free flap in four children is described along with functional outcomes.
Early union followed by early weight-bearing may be critical to minimize the leg length discrepancy in the immature skeleton of the pediatric population.
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