RECENT ADVANCES IN THE RECONSTRUCTION OF COMPLEX ACHILLES TENDON DEFECTS DANIEL N. RONEL, M.D., F.A.A.P.,* MARTIN I. NEWMAN, M.D., LLOYD B. GAYLE, M.D., F.A.C.S., and LLOYD A. HOFFMAN, M.D., F.A.C.S. Large, complex lower-extremity defects in the region of the Achilles tendon occur when tendon loss or disruption is complicated by damage to surrounding structures, including soft tissue, vessels, or bone. The surgical approach to these complex defects has evolved from simple amputation to the recognition that satisfactory reconstruction has three components: functional reconstruction of the tendon, importation of vascularized soft tissue, and skin coverage. Many techniques have been developed to address these difficult reconstructive goals, which often require multiple procedures or complicated single-stage operations. Microsurgical advances have begun to reduce the complexity of Achilles tendon region reconstruction, and excellent results can be obtained which restore function, form, and cosmesis with minimal morbidity. ª 2003 Wiley-Liss, Inc. The incidence of Achilles tendon rupture has increased over the past several decades in the Western world, co- inciding with the increasing percentage of active middle- aged and elderly members of the population. 1 Surgical or nonsurgical therapy is selected by considering factors such as the anatomical and functional extent of the Achilles defect, whether surrounding tissues are affect- ed, the patient’s level of activity, and comorbid condi- tions. In 1575, Ambroise Pare at the Hotel-Dieu in Paris described a nonsurgical treatment for Achilles tendon rupture that consisted of strapping bandages dipped in wine and spices to the lower leg. Surgery was first ad- vocated as the treatment of choice for Achilles tendon ruptures 350 years later, also by surgeons at the Hotel- Dieu. 2 Early surgical procedures simply repaired the tendon primarily and did not address the problem of deficiency in length. Over the past several decades, techniques were developed to improve the quality of Achilles tendon repair, including the V-Y advancement flap, autotransplantation of fascia lata strips, trans- plantation of cadaver ligament, transfer of regional tendons, and implantation of Marlex mesh or carbon fiber prosthetics. 1,3À6 COMPLEX ACHILLES TENDON REGION DEFECTS An Achilles tendon defect in the setting of large tissue loss is a more difficult problem than simple repair of a ruptured or lacerated tendon. Successful reconstruction must include tendon repair sufficient to provide strength, durability, and tension, a soft-tissue cushion thick en- ough to protect the area but thin enough to permit normal footwear, and a skin cover strong enough to withstand the repetitive friction and shearing forces of ambulation. 3 The defects are often contaminated with bacteria and require the importation of vascularized tissue to supply components of the immune system, as well as antibiotics. In some cases, limited surgical treat- ment simply with skin-flap coverage and scar formation can achieve acceptable functional results. 7 The availability of local muscle, skin, or fascia to cover tissue defects in the lower leg is limited. The early surgical treatment of complex injuries to the Achilles area involved multiple-stage procedures, long hospital courses, and a relatively high incidence of postoperative complications, especially the formation of fibrous ad- hesions impairing gliding of the reconstructed tendon. It is widely accepted that the arcs of rotation and vascular supply of the gastrocnemius and soleus muscles preclude their use in the distal third of the foreleg. Intrinsic foot muscles are too small. Plantar flaps of adequate size would hinder ambulation. Dermal turnover flaps are unreliable, and a dorsalis pedis flap would leave an unacceptable donor-site defect. Flaps that require the sacrifice of either the dorsalis pedis or posterior tibialis artery circulation would place at great risk the remain- ing blood flow to the foot. 8 Despite these limitations, procedures have been de- veloped that combine functional tendon repair and skin coverage. They are particularly suitable for hospitals where the infrastructure for microsurgery is not availa- ble. One option combines the thick skin of the medial plantar flap with a tensor fascia lata tendon graft, and can reduce friction from shoes on the repaired area, es- pecially in distal lesions. 9 Another combination proce- dure replaces the Achilles tendon with a free fascia lata graft, covers it with a gastrocnemius flap turned down from above, and provides skin coverage with a local Division of Plastic Surgery, New York-Presbyterian Hospital, New York, NY *Correspondence to: Daniel N. Ronel, M.D., Division of Plastic Surgery, New York-Presbyterian Hospital; 525 East 68th St. Room P-719, Box 115, New York, NY 10021. E-mail: dronelmd@yahoo.com Received 10 March 2003; Accepted 24 March 2003 Published online 30 December 2003 in Wiley InterScience (www.interscience. wiley.com). DOI: 10.1002/micr.10191 ª 2003 Wiley-Liss, Inc.