Graft and Flap: Orthoplastic Approach to Achilles Tendon Secondary Rupture.

SUMMARY: Achilles tendon rupture represents one of the most common tendon ruptures. Although primary repair remains the treatment of choice, surgical complications, such as secondary rupture and tendon exposure, require salvage procedures. This article aims to present the authors' orthoplastic approach for the functional reconstruction of composite secondary Achilles tendon defects. Seven patients with chronic open-wound and large Achilles tendon defects (Kuwada type IV) underwent one-stage reconstruction between October of 2018 and October of 2020. The size of the average soft-tissue defect was 126.2 cm 2 (range, 86.1 to 175.9 cm 2 ), with a tendon gap of 8.2 cm (range, 7.1 to 10.3 cm). A combined team of orthoplastic surgeons performed the reconstructive procedure, using a turndown gastrocnemius fascial flap and a fascia lata autograft for the tendon reconstruction and a free fasciocutaneous anterolateral thigh flap for soft-tissue coverage (graft and flap). Subjective evaluation and quality-of-life measures were obtained preoperatively and 12 months postoperatively using the American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey questionnaire. Mean follow-up was 18.3 months (range, 12 to 24 months). The flap survival rate was 100%. Overall range of motion of the reconstructed side was 87% of the unaffected side (54 degrees versus 62 degrees). The American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey scores of all patients improved significantly ( P < 0.005) at 12 months of follow-up. A microsurgical approach combined with orthopedic techniques can solve complex cases of Achilles tendon secondary rupture, providing a reconstructed tendon that achieves satisfactory anatomic shape and function. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Post-traumatic instability of the first metatarsophalangeal joint: a novel surgical technique of capsular reconstruction in a young kickboxer.

Aim To report a novel surgical technique of capsular reconstruction of post-traumatic instability of the first metatarsophalangeal joint (MTPJ). Methods The clinical case is related to a 24-year-old male athlete whose clinical symptoms began with pain and spontaneous dislocation of the left first MTPJ during a kickboxing fight. He received conservative treatment (cryotherapy and rest) at first. Afterwards, he referred persistent hallux instability associated with moderate pain, despite normal anatomic alignment with no evidence of first ray deformity. Plain traditional x-rays of the left foot, magnetic resonance imaging (MRI), static and dynamic ultrasonography (US) and clinical tests were performed in order to diagnose capsular ligamentous structure lesions. Results The plain x-rays showed hallux abductus angle of 3°. The MRI and US demonstrated a rupture of the lateral capsular ligamentous structures and detachment of the abductor tendon. The pull out medium-lateral of the capsule with the abductor suture was performed as a treatment for dynamic hallux varus deformity. At six-month follow up, the patient walked without lameness with complete active and passive range of motion and with a stable first MTPJ. Conclusion The patient presented with the post traumatic instability of the first metatarsophalangeal joint treated with a novel surgical technique of capsular reconstruction. The patient returned to the full weight-bearing in only 2 months of rehab. To the best of our knowledge, the surgical correction proposed has not been previously described.