The new distal soleus adiposal pull-through composite flap for reconstruction of defects overlying the Achilles tendon: the anatomy and clinical experience.

Abstract

Defects overlying the Achilles tendon are common in patients after immobilization, particularly in those with vascular disease. Conservative wound management and local or free flaps are well-known treatments. Rapid recovery is important, especially in elderly patients; therefore, we looked for an alternative local surgical technique. We introduced for the first time the distal soleus adiposal pull-through flap for covering limited defects over the Achilles tendon. In 10 cadaveric feet, the vascular supply of the sub-Achilles adiposal tissue was studied to clarify the possible clinical utilization. We introduced this novel technique in 6 clinical cases. First, debridement was carried out and the Achilles tendon was divided in the midline. Next, the underlying soleus muscle and sub-Achilles adiposal tissue were carefully dissected. After detaching the flap distally, it was pulled through the Achilles tendon and fixed into the defect. Forty-eight hours later, the flap was covered with meshed split-thickness skin graft. Our anatomic findings showed a sufficient blood supply of the sub-Achilles adiposal tissue by perforators from the soleus muscle, even after ligation of all perforators from the posterior tibial artery and fibular artery. This novel technique allowed a successful defect reconstruction with good functional and cosmetic outcome in all our cases. Two weeks after operation, all patients were fully mobile. The distal soleus adiposal pull-through flap is a reliable flap for coverage of defects overlying the Achilles tendon, especially in patients with vascular problems and/or elderly patients. The ease of handling, short operative time, and the early mobilization are of great benefit to patients. Therefore, this novel technique should be considered for limited defect reconstructions overlying the Achilles tendon.