title: Combined Achilles tendon and soft tissue defects: functional outcomes of free tissue transfers and tendon vascularization.
abstract: BACKGROUND
  Rupture of the Achilles tendon can be a debilitating event, affecting ankle stability and gait efficiency. When this rupture is combined with a large soft tissue defect, reconstruction of the tendon and free tissue transfer for wound resurfacing should be considered.
  
  
  METHODS
  A systematic review of the MEDLINE and Cochrane databases from January 1950 to August 2012 was completed. Search criteria identified all reports of vascularized, autograft, and allograft Achilles tendon reconstruction in combination with free tissue transfer. Inclusion criteria included strict objective outcomes of ankle range of motion and/or dynamometer testing. Correlated outcomes for the affected and normal extremities were accomplished using a subgroup comparison for the vascularized and avascular tendon reconstruction techniques with a 2-tailed z test for independent proportions.
  
  
  RESULTS
  Fifteen retrospective studies fit the inclusion criteria, representing 44 patients at an average age of 33 years. Twenty-two (50%) patients had a localized infection before reconstruction. Average skin defect was 85.3 (74.4) cm2, and average tendon gap was 7.8 (1.7) cm. Thirty (68%) patients underwent free tissue transfer with vascularized tendon reconstruction, 7 (16%) had either nonvascularized autograft or allograft, 5 (11%) had a muscle interposition, and 2 (5%) patients had combined vascularized and nonvascularized tendon repair. Overall average total range of motion was 54.6 (11.5) degrees. Repairs with vascularized tendon had an overall range of motion 80% of the unaffected side (55.4 vs 69.4 degrees) compared to avascular tendon repairs, at an average range of motion 82% of the unaffected side (51.2 vs 62.3 degrees) (P = 0.73). Dynamometric comparison with the unaffected extremity gave an average deficit for avascular reconstructions at 21.2% and 24.8% for 30 to 60 and 120 degrees/s, respectively, compared to an average deficit of 32.3% and 31.5% in the vascularized reconstructions (P = 0.55 and P = 0.78, respectively).
  
  
  CONCLUSIONS
  For combined free tissue transfer and Achilles tendon reconstruction, there seems to be no functional superiority in ankle range of motion or strength when vascularized tendon repairs were compared to avascular autograft and allograft methods.
authors.affiliation: From the Department of Plastic Surgery, Georgetown University Hospital, Washington, DC.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Iorio
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Han
authors.forename: Karen K
authors.initials: KK
authors.lastname: Evans
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Attinger
mesh_terms: D000125:Achilles Tendon / Q000098:blood supply / Q000293:injuries* / Q000601:surgery; D016512:Ankle Injuries / Q000601:surgery*; D058752:Free Tissue Flaps / Q000637:transplantation*; D006801:Humans; D019651:Plastic Surgery Procedures / Q000379:methods*; D012421:Rupture / Q000601:surgery; D017695:Soft Tissue Injuries / Q000601:surgery; D013708:Tendon Injuries / Q000601:surgery*; D016896:Treatment Outcome