Injury, Int. J.

Care Injured 47S (2016) S147S153

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Soft-tissue defects of the Achilles tendon region: Management and

reconstructive ladder. Review of the literature
A. Marchesia,* , PC. Parodib , M. Brioschic , M. Ricciod , RE. Perrottae, M. Colombof ,
GM. Calorif , L. Vaientig
a
Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato, Universit degli Studi di Milano, San Donato Milanese, Via Morandi, 30 20097, Milan, Italy
b
Department of Plastic and Reconstructive Surgery, University of Udine, Udine, Italy
c
Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato. Universit degli Studi di Milano, San Donato Milanese, Milan, Italy
d
Department of Reconstructive Plastic Surgery-Hand Surgery, AOU Ospedali Riuniti, Ancona, Italy
e
Department of Medical and Surgery Specialties, Section of Plastic Surgery, University of Catania, Catania, Italy
f
Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy
g
Department of Plastic and Reconstructive Surgery. I.R.C.C.S. Policlinico San Donato, Universit degli Studi di Milano, San Donato Milanese, Milan, Italy

A R T I C L E I N F O

Keywords:
Soft-tissue
Wounds
Defects
Achilles region
Debridement
Management
Reconstructive ladder
Flaps
HBOT

A B S T R A C T

Introduction: Defects of the Achilles tendon region represent a challenge for reconstructive surgeons.
Several options are available but there is still no reconstructive ladder for this specic and tricky area. An
up-to-date reconstructive ladder according to local and general conditions is proposed based on our
multicentre experience and an extensive review of the English literature on PubMed.
Materials and methods: An extensive review of the English literature was performed on PubMed using the
following key-words: Achilles region, heel, soft-tissue reconstruction, aps, grafts and dermal
substitutes.
Results: A total of 69 complete papers were selected, covering the last thirty years literature. Although
most of the studies were based on limited case-series, local and general conditions were always reported.
A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles
region has been created based on our personal multicentre experience and the results of the literature
review.
Conclusions: The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides
decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of
the surgeon and the wishes of the patient, is the one that implies less sacrice of the donor site. Perforator
aps should be the rst-line option for small-to-moderate defects; the distally-based sural ap is the
most reported for moderate-to-large defects of the Achilles region, and free aps should be reserved
mainly for complex and wide reconstructions.
2016 Elsevier Ltd. All rights reserved.

Introduction
The Achilles tendon region is easily injured. Repair of Achilles
tendon wounds constitutes a real dilemma in reconstructive
surgery because of the function of the tendon and the paucity of
soft tissues surrounding the area, and requires a multidisciplinary
approach involving plastic and orthopaedic expertise. Soft-tissue
defects range from minimal tendon exposure to severe infected
bone exposure, in which there is likely to be simultaneous tendon

* Corresponding author.
E-mail address: ilmarchesiandrea@gmail.com (A. Marchesi).
http://dx.doi.org/10.1016/j.injury.2016.07.053
0020-1383/ 2016 Elsevier Ltd. All rights reserved.

loss that requires repair to guarantee plantar exion. Defects of the

Achilles tendon and the overlying region might be primary to
systemic illness, secondary to direct trauma, iatrogenic complications following steroid inltration or the result of surgical repair of
ruptures of the Achilles tendon. Epidemiology of soft tissue defects
shows that the male-to-female ratio is nearly 20:1 and the average
age of patients is 3040 years. Patients with risk factors like
diabetes mellitus, smoking, and rheumatoid arthritis undergoing
corticosteroid therapy are at greater risk for these complications
[1]. Furthermore, the Achilles tendon is the most frequently
damaged tendon in the lower limb and constitutes 20% of all large
tendon lesions.

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A. Marchesi et al. / Injury, Int. J. Care Injured 47S (2016) S147S153

Fig. 1. Debridement protocol.

*in case of high-energy blunt trauma, fasciotomies of the involved compartments are recommended.

The management of lower limb wounds requires a complex and

staged strategy. The rst approach is based on cultural swabs for
eventual targeted therapy, surgical debridement (this must always
be performed) and wound evaluation for reconstruction planning
(Fig. 1).
This paper has been written based on our multicentre
experience and an extensive review of the English literature on
PubMed using the following key-words: Achilles region; heel;
soft-tissue reconstruction; aps; grafts and dermal substitutes.
Materials and method
An extensive literature review was performed and 69 complete
papers were selected, covering the last thirty years literature.
Although most of the studies were based on limited case-series,
local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive
techniques for the Achilles region has been created based on
our personal multicentre experience and the results of the
literature review.
Debridement
Debridement is the key to success in the management of major
limb injuries [2]. As stated by Hallock, three words aptly
summarise what is neededdebridement, debridement, and then
more debridementuntil only viable tissues remain [3]. Indeed,
skin excision with a 23 mm margin around the contaminated and
grit-laden tissues, exploration through all layers, and excision of
damaged muscle are mandatory. Any dead and contaminated
tissue, if left, would become a medium for infection and therefore
must be removed. We never perform debridement of the skin or of
deeper tissues under tourniquet control so as to preserve only
viable tissues. The rst look should be performed within 6
12 hours of injury for the best results [4,5]. At the end of the

procedure, the wound should be washed with abundant quantities

of saline, preferably as pulsed lavage. Once a wound is clean and
there is no bleeding, soft-tissue coverage should be planned in the
form of primary closure (such as suturing, skin grafts or aps) or in
the form of secondary closure (such as vacuum-assisted closure
[VAC], dermal substitutes or advanced dressings) depending on the
intraoperative wound condition. If the wound at rst look is largely
contaminated or there are signs of infection, reconstruction must
be delayed and a second look (and further looks, if necessary) will
be needed and repeat debridement may be required every
4872 hours. In fact, infection is directly proportional to inadequacy of debridement [6]. According to Medina et al., in addition to
the soft-tissue evaluation, the vascular status of the limb needs to
be assessed early on [7]. Obvious arterial insufciency must be
rectied immediately, with urgent fasciotomies performed, if
required, to normalise compartment pressures before huge
irreversible damages occur [8].
Antibiotic therapy
Besides surgical debridement, lower limb wounds should
always be treated with the administration of intravenous antibiotics and tetanus prophylaxis. As demonstrated by Gosselin et al.
in a Cochrane review, there is a signicant reduction in wound
infections in patients who received antibiotic prophylaxis for all
types of open fractures compared with patients who received no
antibiotic prophylaxis [9]. Moreover, Patzakis and Wilkins
reviewed more than 1,000 open fractures and concluded that
the single most important factor in reducing infection rate was the
early administration of antibiotics [10]. In their study, patients who
were administered antibiotics within 3 h of trauma had an
infection rate of 4.7%, compared to 7.5% in those for whom
antibiotic treatment was administered 3 h or more after trauma.
Despite the importance of antibiotic administration in lower limb
wounds, the exact length of treatment remains controversial and
arbitrary. There are no specic guidelines regarding the type of

A. Marchesi et al. / Injury, Int. J. Care Injured 47S (2016) S147S153

perioperative antibiotic therapy that should be used. In most cases

the antibiotic therapy begins empirically with a cephalosporin and
then proceeds into targeted therapy when cultures results become
available. Yarrow et al. achieved good results in all their patients
affected by open tibial diaphyseal fractures by administering a
single dose of gentamicin 1.5 mg/kg IV in addition to co-amoxiclav
prophylaxis [11]. Moreover, in their study the standard for
denitive coverage alongside skeletal xation was set at within
the rst seven days from injury [12]. At denitive soft tissue
closure, their protocol was based on gentamicin 1.5 mg/kg IV plus
vancomycin 1 g IV or teicoplanin 800 mg IV. Our protocol is usually
based on teicoplanin IV and amikacin IV; in case of positive
cultures, a targeted antibiotic therapy is started as soon as possible
[13].
HBOT
In 2011 Sieg et al. evaluated the effects of systemic supplemental oxygen therapy (SOT) and hyperbaric oxygen therapy (HBOT) on
tendon healing in a rat tendon model. The results indicated that
intermittent HBOT or SOT did not signicantly increase the healing
of tendon repairs [14]. Conversely, Kuran et al. in 2012 demonstrated that HBOT in Wistar albino rats created a positive
histological and biomechanical effect on tendon healing after
Achilles tendon repair [15]. Histopathological study showed the
amount of brosis was signicantly higher in the HBOT group than
in the control group. Inammation and vascularisation were
signicantly higher in the steroid administration group than in the
no-steroid group. There was a signicant difference in the
biomechanical properties of the groups in terms of maximum
force, stiffness, elastic modulus and maximum allowable stress.
From an extensive Cochrane review performed by Eskes et al.,
HBOT appears benecial in patients with crush injuries, showing
improved wound healing and less adverse outcomes, such as
necrosis or the need for additional surgical procedures [16].
Furthermore, HBOT appears to improve the take of split-skin grafts.
On the other hand, complete wound healing is the most patientrelevant outcome. Hence, incomplete graft take, leading to a mere
reduction in wound size, is not very meaningful. These ndings are
supported by those of previous reviews by Goldman and Wang
et al. [17,18]. Finally, HBOT also seems to be useful in free ap
reconstructions, enabling an increase of oxygen supply over the
entire ap after HBOT [19]. In such settings, HBOT is used only in
cases where wound healing is delayed, particularly in diabetic
patients, or as a salvage procedure in free ap reconstruction.
Once the wound is clean and the cultural swabs are negative,
soft-tissue coverage can be performed.
Soft-tissue reconstruction
There is evidence that early soft-tissue coverage (<72 hours)
provides better outcome for the patient than delayed coverage
(>72 hours) [20]. However, early reconstruction is not always
possible in trauma settings due to logistical constraints, concurrent
injuries that require more urgent attention, and the need for
debridement.
Stable multilayer coverage (skin, subcutaneous tissue, fascia
and tendon) has to be provided in most cases. Several publications
describing various methods of reconstruction are available: this
multiplicity of techniques may reect that there is no best method.
The reconstructive ladder is a concept that is still a mainstay in
plastic surgery and guides decisions in the repair strategy for soft
tissue defects. The ladder comprises the ranking of reconstruction
techniques by progressive complexity and lesion and has been
evolving since its rst description by Mathes and Nahai. The ladder
includes closure by primary, secondary intention, skin graft and

S149

aps and has been progressively modied to incorporate several

major advances in wound healing and repair, such as the use of
negative-pressure wound therapy and dermal matrices [21]. As
shown in the literature, aps are the currently accepted treatment
to repair wounds to this area. Numerous kinds of aps are
available, including local, perforator and free aps.
In this review, the authors show an up-to-date reconstructive
ladder that considers the advantages, negative points, and surgical
indications of the reported techniques for the reconstruction of
Achilles tendon region defects. The review covers the last thirty
years of English literature on PubMed.
This reconstructive ladder should be considered as the basis in
the reconstruction, and possible techniques that are enriching the
management of this difcult area should not be underestimated
(Table 1). Each technique has its own indication according to the
size and depth of the defect, the structures exposed, and local
considerations, such as vascular status, presence of previous scars
and availability of regional aps. In many cases, different solutions
are theoretically possible, but are restricted to one or two
procedures by local or general conditions.
Split thickness skin graft, Vacuum-Assisted Closure (VAC) and dermal
substitutes
In case of moderate-to-large supercial wounds without
tendon involvement, a split thickness skin graft is the simplest
solution. Nonetheless, there is a paucity of literature about using
skin grafts on the Achilles tendon: this may be mainly a
consequence of the frequent presence of an inappropriate recipient
bed over the tendon. Conditions for skin graft failure include:
avascular surface of tendons without paratenon, soft tissue
congestion, bone exposure, irregular local anatomy and insufcient vascular network. Also, a skin graft may restrict Achilles
tendon movement or be poorly resistant to the strong wear and
tear that is always present in this area. For these concerns,
physicians tend to exclude this reconstructive possibility. However,
wound care may lead to granulation tissue over the tendon:
mechanical or enzymatic debridement of the tendon, negativepressure wound therapy, dermal matrices and oral antibiotics in
case of infection can alter a recipient bed to one that can be closed
by skin graft. VAC therapy has been applied to exposed Achilles
tendon: the use of negative-pressure therapy in a three-case series
was effective in preparing the wound bed for closure with skin
graft in the preoperative period, as well as a dressing for the graft in
the postoperative period [22]. As part of the soft-tissue reconstruction process, the use of negative-pressure wound therapy has
an important role as a bridge before denitive reconstruction, but
even that is apropos only after adequate debridement has been
accomplished [23]. Negative-pressure wound therapy can accelerate wound healing by increasing local tissue perfusion, decreasing
tissue oedema and, in the short-term, decreasing the bacterial load
[24]. There is no question that the frequency of dressing changes
can be reduced with negative-pressure wound therapy, which
reduces patient discomfort, lessens the work burden on nursing
staff, and minimises the risk of wound desiccation. In the literature
there is also the rst documented case using Matriderm and
simultaneous overlying split skin grafts for burn wound closure on
exposed Achilles tendon [25]. Attinger et al. conducted a
retrospective study of 45 patients with 49 wounds with closure
by secondary intention, skin grafting, and reconstruction with a
ap or free aps [26]. The efcacy of each procedure was not
signicantly different. The overall wound-healing rate was 96% and
the limb salvage rate was 98% in diabetic patients. The authors
concluded that a prepared wound bed is the best predictor of
wound closure even with skin grafting in Achilles tendon ulcers
[27]. Although a rate of wound complications of 25% after skin

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Table 1
Reconstructive ladder of Achilles tendon region soft-tissue defects.
Wound complexity

Wound size

Simple wound without bone or tendon exposure or Small defects

with exposed tendon with intact paratenon
(diameter < 2 cm)
Moderate to large defects
(more than 2 cm diameter)
Complex wound with bone and/or tendon exposure Small defects
with injured paratenon
(diameter < 2 cm)
Moderate defects (24 cm
diameter)

Technique

Advantages

Secondary closure with dressing changes

Direct closure with skin graft, with/without
previous VAC therapy or dermal substitutes
Local rotational aps
V-Y advancement aps
Propeller perforator aps
Bipedicled aps
Propeller perforator aps
Distally-based peroneus brevis ap
Lateral supramalleolar ap
Lateral calcanear artery ap

Large defects (48 cm

diameter)

Massive defects
(diameter > 8 cm)

In case of microsurgical
contraindications
Otherwise

In case of general
microsurgical
contraindications

In case of local
microsurgical
contraindications
Otherwise

grafting was reported, in most of the cases the recurrences healed

by secondary intention. There was no difference in the success of
the technique between diabetic and non-diabetic patients. The rate
of complications indicates that elderly individuals who are poor
candidates for free-tissue transfer secondary to their comorbidity
and are less active are the therapeutic target of skin grafting. Other
positive experiences with hyaluronic acid devices and allogeneic
keratinocytes in the Achilles tendon region have been reported
with satisfactory results [28,29].
Local aps
The composition of regional aps may vary: fasciocutaneous,
myocutaneous, adipofascial and muscular aps can be harvested
when the complexity of tissue loss does not allow skin grafting. The
main problem with local aps is that they involve neighbouring
tissues that may have been damaged, and may lead to signicant
donor-site morbidity or poor cosmesis due to bulky dimensions of
the ap. When Achilles tendon is to be repaired, local aps do not
usually provide adequate tendon-like tissue.
The most reported and popular ap is the distally-based sural
fasciocutaneous ap, which is supplied by the perforating vessels
accompanying the sural nerve on the posterior part of the leg
[3032]. The easy dissection of the ap, ample soft tissue, and
reliable blood supply that did not compromise a major artery of the
lower extremity make this ap the rst and preferred reconstructive choice for Achilles tendon exposure. The combination of the
distally-based sural fasciocutaneous ap with gracilis tendon

Distally-based
sural ap
Gracilis muscle
ap
Anterior
serratus muscle
ap
Radial forearm
ap
ALT ap
Tensor fascia
lata muscle ap
Groin ap
EPAP ap

Dermal
substitutes
Dermal
substitutes
Cross-leg aps
Latissimus
dorsi ap
ALT ap

Short operating time

Short operating time
Minor donor site morbidity
Short operating time
Minor donor site morbidity
In case of bilateral previous scars at
distal third of the leg or oedema
Safe blood supply
In case of bilateral previous scars at
distal third of the leg
Short operating time
Long wounds
Dead-space lling
Thin coverage

Thin coverage
Minor donor site morbidity
Thin coverage
Possibility of composite ap
Thin coverage.
Possibility of local or cross-leg ap
type
No donor site morbidity, but only for
clean wounds
No donor site morbidity, but only for
clean wounds
Last salvage procedure
Dead-space lling
Minor donor site morbidity

allograft has been described in a case report when correction of

Achilles tendon was necessary, avoiding a free composite ap.
Baumeister et al. described the outcome of the reverse sural ap in
patients with several comorbidities, including diabetes mellitus
and vascular insufciency. Diabetes mellitus was identied as an
important risk factor for ap failure, being associated with a veto six-fold increased necrosis rate and incidence of complications,
such as painful neuromas and donor-site tissue defect. Nonetheless, a high clinical success rate of the reverse sural ap was
reported in high-risk patients [33]. If the Achilles tendon defect
extends so far laterally that it compromises the pedicle of the sural
ap, the ap is no longer a reconstructive possibility [34].
Grishkevich described the use of a proximally-based sural ap
for defects over the Achilles region and heel: good results were
achieved in 14 out of 16 patients in this case-series. The most
important limitation for this technique is previous local surgical
procedures that may have damaged the sural nerve, thereby
putting the ap vascularisation at risk [35].
The lateral supramalleolar ap is a fasciocutaneous ap raised
from the lateral aspect of the lower leg and elevated as a distallybased pedicled ap. This ap is nourished by the perforating
branch of the peroneal artery and does not involve the sacrice of a
major vascular axis. No necrosis of the ap was reported in eight
case-series used for Achilles tendon coverage [36]. Touam et al.
conducted a comparative study between sural and lateral supramalleolar aps and concluded that the former ap is more secure,
and the latter ap should be considered when the sural ap
viability is a concern, as previously exposed [37].

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A series of four patients were treated using a lateral calcaneal

artery ap transfer [38]. A long-term follow-up documented
complete survival of the aps; therefore, these aps may be an
alternative among the fasciocutaneous aps.
Local aps include the medial plantar and dorsalis pedis aps:
these regional aps are supplied by major vascular pedicles, which
places the distal foot at great risk of low blood ow. The size of
these aps also limits their indications [39,40].
In a case report a bipedicle fasciocutaneous ap was elevated:
the reconstructive strategy involved longitudinal incisions to save
axial cutaneous perforators and followed the orientation of the
most widely used incisions for tendon reconstruction, avoiding
additional scars that in this area can result in poor ankle mobility
[41]. Fumarola et al. described a reconstructive method of
repairing tendon rupture with a free fascial graft followed by
coverage with a fascio-aponeurotic ap from the gastrocnemius
muscle [42].
Muscular aps require the sacrice of the muscle involved and
additional skin grafting for coverage; they are traditionally
indicated for infected receiving sites as they have large vascularisation, which acts as a carrier for antibiotics and cellular
immunity. Muscular aps reported for Achilles tendon coverage
include: distally pedicled peroneus brevis muscle ap, extensor
digitorum brevis muscle ap, and abductor halluces [43,44,45]. A
distal soleus adiposal pull-through composite ap has also been
reported [46].
Most of the local aps, except for the distally-based sural ap,
are presented in the literature as case reports or short clinical
series and share some clinical characteristics, such as relative
operative difculty, important donor-site morbidity, sometimes
requiring skin grafts, and limited surgical indications (i.e. small-tomoderate defects only).
Propeller perforator ap
Perforator aps are based on cutaneous, small-diameter vessels
that take their origin from a main pedicle and perforate the fascia
or muscle to supply the skin vascular network. Dissection of a local
perforator ap can provide excellent results for colour, texture, and
thickness of the tissues involved that are really similar to those of
the receiving area. Perforator aps avoid signicant donor site
morbidity, preserving the underlying muscles and major arteries.
Although microsurgical dissection is necessary for local perforator
aps, a microvascular anastomosis is not required. Perforator aps
can be elevated on perforating vessels derived from all three major
vessels of the leg: peroneal, anterior tibial or posterior tibial artery.
Peroneal and posterior tibial artery derived-aps are the most
reported ones for the coverage of the Achilles tendon region.
Among these, propeller perforator aps are the most common.
The term propeller perforator ap denes an island ap with an
axial rotation. It can be rotated from an angle that ranges from 90
to 180 . It is usually not necessary to rotate beyond 180 , as it can
be simply rotated in the remaining directions. The angle between
the proximal long axis of the ap and the defect determines the
direction of rotation. The use of the posterior tibial perforator ap
for Achilles tendon coverage was reported successfully, even
among diabetic patients [47,48].
Jakubiets et al. adopted an algorithm that involved rstly
mapping the proximal perforators of the peroneal and tibial
vessels; if no suitable perforator for a 180 propeller ap was found
during the intervention, a free peroneal artery perforator ap was
elevated from the ipsilateral lower extremity [49].
Propeller aps have been demonstrated to be necessary tools
for soft tissue defect in patients with peripheral arterial obstructive
disease because of their high operative security, easy surgical act,
and low complications rate [50].

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Lateral retromalleolar perforatorbased ap was introduced by

Chang et al. [51]. Their anatomical study on cadavers revealed the
presence of usually two to three retromalleolar cutaneous
perforators arising from the terminal part of the peroneal artery
in the lateral retromalleolar space. The clinical application in ve
cases showed that the lateral retromalleolar perforator is constant
and reliable for the elevation of a lower pivot point, distally-based
ap.
The peroneal artery perforators are predictable and secure for
the elevation of a perforator-based ap. The selected perforating
vessels depend on the position of the soft tissue loss, varying from
4.5 to 18 cm above the tip of the lateral malleolus. Lu et al. classied
pedicled peroneal artery perforator aps into ve types: (A)
propeller ap, (B) peninsular ap, (C) advancement ap, (D)
proximally-based island ap and (E) distally-based island ap [52].
The peninsular ap type emerged as the rst ap of choice for
Achilles tendon coverage, due to the perforator-plus concept: it not
only has dual arterial nourishment from a perforator plus random
supply from its base, but also two veins-drainage.
The peroneal artery is not the dominant blood supply to the
foot. Fibular fracture is a contraindication for peroneal-based
perforator aps. The peroneal cutaneotendinous ap can be
transferred on the perforating vessels. If the ap does not reach
the receiving site, the peroneal vascular branch is divided, and the
ap can be elevated on the peroneal vessels as a distally-based ap
[53].
In 2010 Ruan et al. described the extended peroneal artery
perforator ap (EPAP ap), which was based on the perforator
dissection and further dissection of the peroneal artery conducted
proximally up to its origin or distally up to the communicating
branch with the anterior tibial artery [54]. In their study,
12 patients with soft tissue defects of the lower extremity
underwent reconstruction using the EPAP ap. The blood supply
to the EPAP ap was sufcient to sustain a 23  15 cm fasciocutaneous island on a single perforator, for a recipient area from the
proximal knee to distal forefoot. All 12 aps survived completely.
They performed the distally-based ap successfully in cases with
only one intact additional main vessel besides the peroneal artery.
Proof of patency and forward ow past the ankle of at least one of
either the anterior or posterior tibial artery on Doppler ultrasound
examination assured presence and patency of sufcient distal
communicating branches.
Tissue expansion
Up to now, only two patients with complicated Achilles tendon
ruptures have been treated using expansion to enable tendon
reconstruction, to guarantee healing with good tissues and to avoid
tension on skin closure [55]. Tissue expansion was revealed to be
an effective option in patients with complex Achilles tendon
defects. No major complications were reported. Donor site
morbidity was also absent.
Free aps
Free tissue transfer is usually reserved for large or massive
defects. The authors think that assessment of the vascular integrity
of the extremity through a computed tomographic angiography
(CTA) or magnetic resonance angiography (MRA) or classic
angiography is mandatory before planning any free ap reconstruction. We usually prefer to perform the vascular anastomosis
on the non-dominant vessel for foot circulation. In case of injury to
a main vascular trunk, we anastomose the free ap on the proximal
stump of the injured trunk, leaving intact other undamaged
vessels. Sometimes, vein grafting is required to keep the vascular
anastomosis out of the zone of injury.

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Free aps enable skin, fascia, muscle, bone and nerve to be

transferred in various combinations to reconstruct tissue losses. In
this way, they can provide unique possibilities for complex Achilles
tendon region defects. Their disadvantages include donor-site
morbidity that requires skin graft, increased surgical time, the use
of a major vessel of the leg, and the need for microsurgical
experience. Free aps, even if recommended as treatment of choice
by most of the reports, are evidently not suitable for every patient,
particularly those with comorbidities.
The early description of a composite ap transfer was reported
by Taylor and Townsend: they used free groin ap and external
oblique aponeurosis in combination [56].
Anterolateral thigh free ap is well reported in the literature:
the skin-fat component is adequate for wound healing, and the
fascia lata sheet was used to repair the lost Achilles tendon
segment in three patients. The drawback is constituted by the
range of the vascular pedicle. Preoperative Doppler audiometry
assessment is needed. Elevating the anterolateral thigh ap
requires great experience with perforator aps, which may reduce
its usage [57]. Inoue et al. used a lateral thigh ap transfer coupled
with fascia lata sheet to reach effective reconstruction [58].
Lee et al. harvested the latissimus dorsi muscle ap to repair the
tendon and soft tissue loss. They described a brotic change in the
muscle, transforming into a tendon-like structure [59]. An
application of the free partial latissimus dorsi musculocutaneous
ap was revealed to be an appropriate solution in ve growing
children and ankle movement was preserved [60].
Wei et al. then tried a composite free groin ap with attached
iliac bone and abdominal fascia to reconstruct the skin-aponeurosis-bone complex. The supercial circumex iliac artery, which is
the main pedicle of the groin ap, is relatively little and easily
damaged in an average patient. The excessive amount of fat can
require a successive debulking of the ap [61]. The composition of
Achilles tendon allograft and a rectus muscle free ap is another
method [62].
Free tensor fasciae latae ap is an option from the thigh from
the lateral circumex femoral artery, which may also include the
fascia lata for repair of tendon rupture, as seen in other composite
aps [63]. The lateral arm ap would be another option [64].
Methods described are tensor fasciae latae perforator ap,
fasciocutaneous infragluteal ap, and the free composite dorsalis
pedis ap [6567].
The gracilis muscle ap is a traditional ap in reconstructive
microsurgery because the muscle is completely expendable. The
muscle fascia constitutes a gliding tissue for Achilles tendon. An
extensive usage of this ap for Achilles tendon coverage has been
reported in 20 patients for small-to-large defects [68].
The advantages of composite free ap with vascularised tendon
include high resistance to infection, rapid healing, reduced
scarring, and improved tendon mobility [69].
Conclusions
Adequate debridement must precede any soft-tissue restoration. The exact timing is often difcult to understand, but it is
largely accepted that once the wound is clinically and microbiologically clean, soft-tissue reconstruction should be performed.
Accurate assessment of general conditions and local conditions
(such as presence of infections and vascular status of the injured
limb) are mandatory before the reconstructive phase. Choosing the
best treatment option follows a decisional algorithm in cascade,
each step being a restriction of the previous one. Firstly, accurate
evaluation of the defect is of utmost importance, being the main
indicator for the therapeutic option. Whenever possible, the
simplest anatomical reconstruction should be attempted. If the

particular circumstances do not allow it, the main objective is to

ensure the best functional outcome in terms of coverage stability,
range of movement (ROM) of the ankle, and shoe tting. The
optimal solution, according to the experience of the surgeon and
the wishes of the patient, is the one that implies less sacrice of the
donor site. Recent knowledge about lower limb vascularisation and
widespread introduction of the perforator-based aps indicates
these reconstructive units seem to be the most suitable for
coverage purposes for only small-to-medium size defects. The
distally-based sural ap is still the most reported technique for
moderate-to-large defects of this region. The use of free aps
should be reserved mainly for complex and wide reconstructions.
Applying principles of the reconstructive ladder may facilitate the
achievement of soft tissue coverage, a goal that is paramount in
lower extremity reconstruction.
Conict of interest
No conict of interest to disclose.
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