Coverage of distal lower extremity soft tissue defects and unstable scars over the Achilles tendon

Introduction: Coverage of the exposed Achilles tendon requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic resu lt for the distal lower extremity. Various local flaps and free flaps have been described for reconstruction of small and large defects. Small defects can be closed with local tissue, whereas free flap coverage may be necessa ry for coverage of large defects. Methods: From July 1993 to September 1998 14 patients between the age of 15 and 74 years (mean 47 years; 3 female, 1 1 male) underwent free flap coverage for the exposed Achilles tendon due to primary trauma, chronic wounds or tumors. The mean duration of follow-up w as 33.3 months. The defect size ranged from 8 x 8 to 25 x 28 cm. Results: S ix parascapular flaps (three with a vascularized scapular fascial extension ), four radial forearm flaps and four latissimus dorsi flaps (one combined with free serratus fascia) were used for soft tissue coverage over the Achi lles tendon. Thirteen flaps survived. In one case a parascapular flap had t o be removed due to venous thrombosis and a free latissimus dorsi flap was used as secondary salvage procedure. The donor site morbidity was acceptabl e for most patients after flag harvesting in the subscapular region and als o satisfactory in the forearm region. Average active range of motion in the upper ankle joint was 15-0-40 degrees for extension/flexion. All patients were satisfied with the functional and aesthetic result. Conclusion: Soft t issue coverage over the exposed Achilles tendon requires an optimal solutio n for each patient to achieve an aesthetically pleasing result and acceptab le function. Microvascular free flaps can be used to reconstruct medium and large defects and to provide gliding tissue for the Achilles tendon. The c omplication rate of microvascular flaps is comparable with that of local fl aps.