Microvascular skin coverage in wounds that expose the Achilles tendon

Baltazar Barrera-Mera, Israel Salgado-Adame, Obed Horacio Grajeda-Chávez, Jazmín Danaé Chávez-Hernández, Cuauhtémoc Aguilar-Barragán, Ana Lilia Abundez-Pliego, Yuri Jiménez-Caprielova, Leonel Dalain Hernández-Arteaga, Román Alberto de la Rosa Llergo, José Enrique Pérez-López, Alan Isaac Valderrama-Treviño


Achilles tendon rupture is one of the most frequent tendon ruptures. Surgical intervention is the best option, but it has a high rate of complications leading to skin infections and necrosis. Extensive and aggressive debridement is necessary, producing tendon exposure and large skin defects. There are many alternatives for the skin coverage of the Achilles tendon, like sequential closures, vacuum assisted closure, local flaps, regional flaps, and more recently and efficiently microsurgery flaps. Skin defects in the Achilles tendon region have many peculiarities in comparison with other parts of the body: it is a zone that is always under mechanical stress due to footwear, this is why it must be highly resistant but thin. Its coverage must have sensitive properties, endure tendon gliding and allow early rehabilitation. Sometimes tendon reinforcement or creation or a neo tendon will be needed. For fulfilling these requirements free flaps by microsurgery are the only option in 90% of the cases. In this review article, we analyze three of the most frequently used free flaps in reconstructive medicine for complex Achilles tendon defects; free radial forearm flap, free radial forearm flap with vascularized flexor carpi radialis tendon and free anterolateral thigh (ALT) flap with vascularized fascia lata. This choice will be determined by the number of tissues involved, size of the defect, etiology of the defect, overall condition of the affected extremity and quality of neighboring tissues.


Achilles tendon surgery, Microsurgery, Free radial forearm flap, Vascularized flexor carpi radialis tendon, Free anterolateral thigh flap, Skin coverage, flap, Compound defect, Composed flaps

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Yang X, Meng H, Quan Q, Peng J, Lu S, Wang A. Management of acute Achilles tendon ruptures: a review. None Joint Res. 2018;12:561-9.

Jandali Z, Lam M, Merwart B, Mohring B, Geil S, Muller K, et al. Predictors of clinical outcome after reconstruction of complex soft tissue defects involving the Achilles tendon with the composite anterolateral thigh flap with vascularized fascia lata. J Reconstr Microsurg. 2018;2:632-4.

Innocenti M, Innocenti A, Ghezzi S, Delcroix L. Achilles region soft tissue defects: a reconstructive algorithm based on a series of 46 cases. J Reconstr Microsurg. 2017;3:40-7.

Huttunen TT, Kannus P, Rolf C, Tsai L, Mattila V. Acute achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012. Am J Sports Med. 2014;10:2419-23.

Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;4:791-9.

Deng S, Sun Z, Zhang C, Chen G, Li J. Surgical treatment versus conservative management for acute Achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. J Foot anke surg. 2017;8:1236-43.

Ozkaya U, Parmaksizoglu AS, Kabukcuoglu Y, Sokucu S, Basilgan S. Open minimally invasive Achilles tendon repair with early rehabilitation: functional results of 25 consecutive patients. Injury. 2009;7:669-72.

Houtmeyers P, Opsomer D, Van Landuyt K, Monstrey S. Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata. J Reconstr Microsurg. 2012;7:205-9.

Chun K, Margoles S, Birnbaum J. Radial forearm free flap for salvage of Achilles-tendon repair wounds. J Reconstr Microsurg. 2000;519-23.

Banegas-Ruiz R, Valderrama-Treviño AI, Rivas-Montero JA, Gómez-Mendoza FF, García-Martínez E, Domínguez BCR, et al. Antebrachial microvascular flap for reconstruction of the pelvic limb: case report. Int J Res Med Sci. 2019;8:1952-6.

Banegas-Ruiz R, Gómez-Mendoza FF, Baca-Domínguez CR, Campos-Angulo G, Alejo-Fuentes LJ, Alejo-Fuentes LF, et al. Reverse-flow anterolateral thigh flap for knee soft-tissue reconstruction: case report. Int J Res Med Sci. 2019;9:3914-6.

Ki S, Wha S, Hwan Y, Tae K. The composite anterolateral thigh flap for Achilles tendon and soft tissue defect reconstruction with tendon repair by fascia with double or triple folding technique. Microsurgery. 2015;10:615-21.

Nazerali R, Hakimi M, Giza E, Sahar D. Single-stage reconstruction of Achilles tendon rupture with flexor hallucis longus tendon transfer and simultaneous free radial fasciocutaneous forearm flap. Ann Plast Surg. 2013;10:416-8.

Acarturk TO, Tuncer U, Aydogan LB, Dalay AC. Median artery arising from the radial artery: its significance during harvest of a radial forearm free flap. J Plast Reconstr Aesthet Surg. 2008;11:5-8.

Hoo Y, Nam W, Cha I, Jun H. Revisiting radial forearm free flap for successful venous drainage. Maxillofacial Plastic and reconstructive surgery. 2017;1:14.

Marchesi A, Parodi P, Brioschi M, Riccio M, Perrotta E, Colombo M, et al. Soft-tissue defects of the Achilles tendon region: Management and reconstructive Ladder. Review of the Literature. Injury. 2016;3:47:S14753.

Sato R, Hibino N, Yamano M, Yoshioka S, Terai T, Kenichiro K, et al. One stage reconstruction for re rupture of Achilles Tendon with soft tissue infections: using an anterolateral thigh flap incorporating a vascularized muscle flap and a strip of iliotibial tract. J Hand Microsurg. 2018;2:105-8.

Innocenti M, Tani M, Carulli C, Ghezzi S, Raspanti A, Menichini G. Radial forearm flap plus flexor carpi radialis tendon in Achilles Tendon reconstruction: Surgical Technique, functional results, and gait analysis. Microsurgery. 2015;9:608-14.

DeFazio M, Han K, Lorio M, Attinger C, Steinberg J, Kim P, et al. Combined free tissue transfer for the Management of Composite Achilles defects: functional outcomes and patient satisfaction following thigh-based vascularized reconstruction with a neo tendon construct. J Reconstr Microsug. 2014;4:431-40.

Soons J, Rakhorst H, Ruettermann M, Luijsterburg A, Bos P, Zophel O. Reconstruction of defects involving the Achilles Tendon and local Soft Tissues: A quick solution for a Lingering problem. Bone Joint J. 2015;2:215-20.

Dun R. Grafts and Flaps. Surgery. 2006;27-32.

Jakubietsz R, Jakubietz D, Gruenert J, Schmidit R, Meffert R, Jakubietz M. Reconstruction of soft tissue defects of the Achilles tendon with rotation flaps, pedicled propeller flaps and free perforator flaps. Microsurgery. 2010;2:608-13.

Cheol-Hann K, Min-Seong T, Chang-Yong C, Sang-Gue K, Yong-Bae K. A single-stage reconstruction of a complex Achilles wound with modified free composite lateral arm flap. J Reconstr microsurg. 2008;1:127-30.

Ehrl D, Heidekrueger P, Schmitt A, Liska F, Ninkovic M, Giunta R, et al. The anterolateral thigh flap for Achilles Tendon reconstruction: Functional Outcomes. Plast Reconstr Surg. 2019;11:1772-83.