WWW.WOUNDCAREJOURNAL.COM 79 ADVANCES IN SKIN & WOUND CARE • MARCH 2005 Martin I. Newman, MD, is Consulting Staff, Division of Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, FL. Daniel N. Ronel, MD, is in private practice at New Mexico Plastic Surgery, Albuquerque, NM. David S. Levine, MD, is Assistant Attending Orthopaedic Surgeon, Hospital for Special Surgery, New York, NY. Lloyd B. Gayle, MD, FACS, is Associate Professor of Clinical Surgery, Division of Plastic Surgery, New York-Presbyterian Hospital, New York, NY. Complex wounds arising from repair of the Achilles tendon present a significant clinical dilemma. These wounds often involve not only the skin, but also the subcutaneous tissues, muscles, and tendons. An established protocol for reconstruc- tion of these complex injuries is lacking, although several case reports and case series have been published in recent years outlining options for repair. This article presents a clinical sce- nario that has not been previously reported: a complex Achilles tendon and posterior compartment defect resulting from debridement of an infected graft 17 years after initial placement for repair of a spontaneous tendon rupture. The illustrations show use of a latissimus dorsi free flap in a single-stage repair of tendon and soft tissue with split-thickness skin graft cover- age. The discussion explains the benefits of this option in the reconstruction of the particular and similar complex defects. Case History Presentation A 75-year-old man presented to an outside hospital 17 years after an atraumatic, spontaneous right Achilles tendon rupture that was repaired initially with a carbon-fiber graft. On presen- tation, the patient complained of a 1-month history of progres- sive right lower-extremity edema and low-grade fever, which culminated in several days of spontaneous seropurulent drainage from a punctum in the midcalf region. The patient denied antecedent trauma. The skin over the calf was erythe- matous, edematous, and slightly tender on admission. After incision and drainage of the soft tissues, a 2-week course of intravenous antibiotics, local wound care, and bedrest were prescribed. When the wound failed to heal, the patient was transferred to another institution for further evaluation. The patient presented at the second institution with a 5-cm open wound overlying his calf; surrounding erythema was minimal. The wound bed had a thin layer of pale fibrotic tissue. The foot was not edematous and had palpable dorsalis pedis and posterior tibialis pulses. The patient’s medical history included a coronary artery bypass graft 3 years previously. He had no history of myocardial infarction, and a stress test per- formed 18 months earlier was negative. Current medications included aspirin and metoprolol. Hospital course Operative exploration of the foot revealed large purulent col- lections throughout the posterior compartment. The entire contents of the superficial posterior compartment were excised and the Achilles tendon was debrided to the level of the calcaneus, resulting in a 7-cm  16-cm defect (Figures 1 and 2). The wound was packed open with vancomycin-impregnated sponges. Intraoperative cultures confirmed infection with Enterobacter cloacae, and the antibiotic regimen was adjusted appropriately. Benign scar tissue was found on pathologic examination. A magnetic resonance angiogram of the leg veri- fied normal vasculature with an intact plantar arch; a second exploration 48 hours later confirmed that further debridement was not needed. Ten days after debridement, the defect was reconstructed in a single stage by free transfer of the contralateral latissimus dorsi muscle with split-thickness skin graft coverage. Using standard microsurgical techniques, the thoracodorsal artery and vein were sutured end-to-end to the posterior tibialis artery and a vena comitans, respectively. The humeral tendi- nous portion of the latissimus muscle was attached to the dis- tal remnant of the Achilles tendon with absorbable sutures, and the inferior portion of the latissimus fascia was sutured to the proximal remnant of the tendon. The remainder of the latissimus muscle was inset to the edges of the wound with absorbable sutures. The muscle was covered with a split- thickness skin graft (Figures 3 and 4). The donor site was closed primarily without tension over a suction drain. The postoperative course was essentially unremarkable, and the patient was discharged after 6 days. Ten weeks postopera- tively, the wounds were well healed (Figures 5 and 6), and the patient was able to bear full weight on the affected limb; he has regained full functional plantar flexion and dorsiflexion (Figures 7, 8, and 9). Discussion The Achilles tendon is among the most commonly injured ten- dons in the human body. 1 The incidence of Achilles injuries is increasing, which can be attributed to a greater number of active older adults. 2,3 Other factors, such as trauma, may play a role in the rising number of Achilles tendon disruptions. 4 Management of a Complex Achilles Wound Martin I. Newman, MD; Daniel N. Ronel, MD; David S. Levine, MD; and Lloyd B. Gayle, MD, FACS Case Report