Achilles Tendon Rupture, Wound, and Microvascular Tendon Reconstruction

Picture #1: Achilles Tendon Infection & Wound, 1 month after Rupture and Repair
Picture #2: Gracillis Muscle Free Flap as Vascularized Musculotendinous Reconstruction of Achilles Tendon Loss after Infection
Picture #3: Full Range of Motion of Ankle with Functional and Intact Achilles Tendon
Picture #4: Full Range of Motion of Ankle with Functional and Intact Achilles Tendon

The Achilles tendon is the largest tendon in the human body and a critical component in the function of the ankle joint to allow "push off" movement in walking and running. It is commonly ruptured during sports activities that require treatment by the orthopedic surgeon to repair the tendon. Usually the patient goes on to do well from this.

In some rare circumstances, the repaired tendon can become infected which can threaten the viability of the tendon. By the time we see the patient, the wound is quite large and severely infected. The patient is concerned about playing sports again.

Depending on the severity of the infection, multiple options are available to save this situation. Most importantly the wound needs to be explored and cleaned. Afterward the anatomy of the wound is further delineated. If the tendon loss is small, the wound up may be closed with local tissues and future tendon graft. If the tendon loss is moderate to large, a more complex reconstruction can be performed with both tendon and skin. This usually requires microsurgical expertise where tissue is transplanted to reconstruct the lost tissue.

We have used both the Gracillis muscle+tendon and the ALT (Antero Lateral Thigh)  flap to reconstruct this complex defect with a high degree of success using microsurgical techniques.   This requires an orthopedic and plastic surgery approach to combine their expertise to maximize functional recovery of the leg. Patients with Achilles' tendon ruptures are usually young and healthy men. Everything should be done, and all the options discussed to bring the injured leg back to as near normal function as possible.

Cutting Edge Treatment for Varicose Veins & Spider Veins

Painful, swollen legs with bulging "varicose" veins can be treated by several methods. In the past, vein ligation and vein stripping have been the standard. However, Vein Ligation has a high recurrence rate and Vein Stripping is an extremely painful procedure, often requiring an inpatient hospital stay, bed confinement for days, and long recovery.

Varicose veins can cause a variety of symptoms: Leg swelling, aching and pain, tiredness, skin changes, and even skin ulceration (venous stasis ulcers). These issues can lead to severe problems in the quality of life and activities of daily living, and in worst cases, severe infections which may threaten the viability or function of the leg.

Nonsurgical, EndoVenous Laser Treatment (EVLT) of Symptomatic Varicose Veins has become the treatment of choice with high success rates (> 95%), can be performed as an in-office procedure under local anesthesia, and patients walk out of the office immediately afterward. It is an extremely gratifying procedure.

As a Plastic Surgeon with expertise in Microvascular Surgery, Dr. Lee offers the highest level of technical precision to this safe, effective, treatment of Varicose Veins. Most often, these treatments are covered by Insurance.

www.sfveinlaser.com

What is an ALT flap?

The ALT flap is a very common, workhorse, flap used for various soft tissue reconstructionl. ALT stands for AnteroLateral Thigh flap. It is a skin flap that is harvested from the lateral thigh with the main blood vessels coming from the Deep Femoral Artery with a branch called the Lateral Circumflex Vessels.

Treatment of Chronic Wounds & Wound Care

There are many thousands of patients in the community with chronic wounds. The definition of a chronic wound is one that has not healed by six weeks time. As most of us know, wounds of all types eventually do close within a span of six weeks. This can range from small cuts and abrasions to larger open wounds of the legs or the abdomen from trauma or surgery. There are many patients in the community who have been undergoing local wound care for many months to years with minimal to no results. These wounds can degenerate into deeper infection such as osteomyelitis-- deep bone infection, and future loss of the limb.

Local wound care is very important to healing a wound. There have been many technological advances in newer dressings that have made wound care safer and more effective for the patient and health care provider. When a wound and has stopped healing in the six-week timespan, it is important to stop and reassess the wound. More than likely there are other causative factors that are preventing the wound from healing. This is when it is time to seek consultation from wound care experts.

As reconstructive plastic surgeons, we are the premier wound care experts. We have the ability to not only asses the wound, but have every option available to us to treat the wound. We are surgeons who deal with three dimensional anatomy. What this means is that we can assess the wound from a top-down and bottom-up approach that accounts for every part of the wound anatomy. Not all health professionals in wound care can have this approach as they cannot take the patient to the operating room to fully explore the wound and it cleanse the wound via débridement. The the ability to explore and debride a wound is the most critical factor in healing a chronic wound.

The options available to plastic surgeons include local wound care, negative-pressure (VAC, EZCare Negative Pressure, etc), to high-tech dressings such as Actcoat, Apligraf, Dermagraft, Integra, etc. After this we have the ability to place skin grafts that are split-thickness or full-thickness. We also have the ability to perform a local flaps which allow us to move tissue into the local area to close the wound. Finally, a plastic surgeon has the ultimate tool in reconstructive surgery--Microsurgery. We are able to transplant live tissue from another part of the body to the wound that requires this new tissue. We are able to reconnect the blood vessels to the transplanted tissues to close wounds that were never thought possible. Specifically, wounds that have been radiated or are chronically infected for many years have very few options for treatment. With microsurgical free tissue transfer, we have all of the options available in the reconstructive ladder to heal any wound, of any type, and size.

I encourage those who have been living with difficult wounds in their life to seek consultation with us to see if there are better options than the status quo of a nonhealing chronic wound.

Treatment of Osteomyelitis in the Extremity

Osteomyelitis is a severe and devastating bone infection. This can occur from simple wounds (venous stasis ulcers) to severe trauma of the extremity from open fractures.

In our practice, we find that many patients have not been adequately treated for osteomyelitis. In our view, osteomyelitis is a surgical disease. This means that IV antibiotics and other lesser therapies (such as hyperbaric oxygen) have only a minor role in the true treatment of this disease. The only sure way to eradicate osteomyelitis is to debride all necrotic and infected tissue, including the bone. The reason why this is not always done is because of the concern for removing bone , and soft tissue, which is not always replaceable.

At the PROS Center, we worked hand in hand with our orthopedic colleagues to have an OrthoPlastic approach to osteomyelitis. This means that we have our orthopedic surgeons, as the bone specialists, to remove all of infected bone. As plastic surgeons, we then have the expertise to provide all of the options for stable soft tissue coverage. Once the soft tissue envelope is stabilized, the orthopedic surgeons may return to perform other ancillary procedures to replace or stabilize the bone.

There are a few centers in the country, where there can be one-stop shopping to treat these extremely complex disorders such as osteomyelitis.

Face Transplantation

My friends and colleagues, Drs. Risal Djohan and Robert Lohman, were lead surgeons who helped perform this monumental operation today at the Cleveland Clinic. They are to be congratulated for putting together a great team of surgeons and taking this huge step in "Composite Tissue Allotransplantation." How is this different from "solid organ" transplantation? Not very different at all.

Most people do not know the history of Transplantation and that Plastic Surgeons have been at the forefront of this area since the beginning. These concepts have grown from skin grafts, to organs, and now to "composite tissue"--face, hands, limbs, etc. This is the new era of reconstructive plastic surgery: with Microsurgery--reconnecting small blood vessels and nerves--all of this is possible.

The question for a long time has been "Can we peform a facial or hand transplantation?" The answer for the past 20 years has been, "yes." We can and have been able to technically "replant" an amputed hand and facial part, the question now has become, "Should we do this?" The simple answer of course is "yes." There are many patients who would benefit from these types of procedures. However, the issues with long-term immunosuppression that can potentially cause many disease processes is still the critical issue in performing these kinds of operations. The holy Grail is still at large. When the immunosuppression issue falls to the background, this is when composite tissue allotransplantation will no longer make headlines, but become a routine surgery, just as plastic surgeons performing reconstructive microsurgery to reconstruct limbs and cancer defects, is done on a daily basis.

Reconstructive Surgery Team

Members of our Team in Reconstructive Plastic Surgery

We offer over 20years of combined experience in Microsurgical Free Tissue Transfer, Complex Wound and Extremity Reconstruction, Breast Reconstruction, Head & Neck Reconstruction, and Limb Salvage:

The Team approach offers patients the highest standard of care for patient safety, high success, shortened operating times, and superb results.


Dr. David Chang
http://plastic.surgery.ucsf.edu/faculty/david-chang-md.aspx

Dr. Scott L. Hansen
http://plastic.surgery.ucsf.edu/faculty/scott-hansen-md.aspx

Dr. Charles K. Lee
http://www.lplasticsurgery.com/about.html

Dr. David M. Young
http://plastic.surgery.ucsf.edu/faculty/david-m-young-md.aspx