Single stage reconstruction of combined skin and Achilles tendon defects with free composite perforator flaps

J.A. Jeevaratnam, N. Jacobs, R. Dunn, A. Crick

Introduction: Combined defects of the Achilles tendon and its overlying skin are uncommon but complex reconstructive problems. Delayed referral may contribute to the high incidence of wound sepsis and occult deep vein thrombosis. They most frequently develop following open repair of a closed Achilles tendon rupture. Reconstruction of these defects aims to restore continuity but also the excursion and resilience of the Achilles tendon and to resurface this with thin, pliant, durable skin.

Methods: Between 2008 and 2016, 27 consecutive patients, aged 21 to 83 years, underwent single stage reconstruction of combined skin and Achilles tendon defects with free composite perforator flaps. Vascularised deep fascia, largely separated from the skin component of the flap, which may then be thinned, was used to reconstruct partial or complete segmental defects of the Achilles tendon. A standard rehabilitation regime was used, aligned with that used for operative and non-operative management of closed Achilles tendon ruptures in our hospital. All patients have been followed for at least one year post reconstruction.

Results: Four patients required subsequent trans-tibial amputation, two for persistent neuropathic pain relating to previous tibial nerve injury, one for mechanical pain and one diabetic patient, who developed chronic calcaneal osteomyelitis in association with bone anchors used for the original tendon repair. All other patients now wear normal shoes and have returned to their pre-injury activities. Their mean Achilles Tendon Rupture Score was 8.3.

Conclusion: Use of free composite perforator flaps safely allows single stage reconstruction of combined skin and Achilles tendon defects from a single donor site, despite the presence of sepsis. This technique restores function of the Achilles tendon and therefore avoids the need to consider tendon transfer to recover strong active ankle plantar flexion.