Safety of One-Stage Reconstruction of Achilles Tendon and Soft Tissue Defects Resulting from Infection After Achilles Tendon Repair using Flexor Hallucis Longus Tendon Transfer and Reverse Sural Artery Flap

Abstract

Background

Infection after Achilles tendon (AT) repair can lead to defects in both the tendon and the surrounding soft tissue. In such cases, a two-stage surgical approach is generally adopted, with soft tissue reconstruction performed initially, followed by secondary tendon reconstruction. A reverse sural artery flap (RSAF) after AT repair is not commonly performed due to potential damage to the flap pedicle. This study aims to evaluate the clinical outcomes of simultaneous flexor hallucis longus tendon (FHLT) transfer and RSAF to treat soft tissue and tendon defects resulting from infection after AT repair.

Patients and methods

We reviewed 20 patients who had undergone one-stage reconstruction of AT and soft tissue defects resulting from infection after AT repair using FHLT transfer and RSAF between October 2012 and October 2022, with a minimum of a 1-year postsurgical follow-up. Surgical outcomes were assessed based on the success of the flap, recurrence of infection, and tendon re-rupture. Clinical evaluation included visual analog scale (VAS) score, ankle range of motion, and patient-reported components of the American Orthopaedic Foot and Ankle Society (AOFAS) score (maximum of 68 points).

Results

All flaps were successful. The mean size of the flap was 7.2×4.1 cm². There was no recurrence of infection or tendon re-rupture. The mean VAS and AOFAS scores were 0.5 and 64.6, respectively. The mean ankle joint range of motion was 13.5° for dorsiflexion and 35° for plantar flexion.

Conclusion

One-stage reconstruction with FHLT transfer and RSAF is a safe and effective surgical method in patients with tendon and soft tissue defects after AT repair.

Zusammenfassung

Hintergrund

Eine Infektion nach einer Reparatur der Achillessehne (AT) kann zu Defekten sowohl an der Sehne als auch am umgebenden Weichteilgewebe führen. In solchen Fällen wird in der Regel eine zweizeitige Operation durchgeführt, bei der zuerst das Weichteilgewebe rekonstruiert wird, gefolgt von einer sekundären Sehnenrekonstruktion. Ein umgekehrter Suralarterienlappen (RSAF) nach einer AT-Reparatur wird wegen der möglichen Beschädigung des Lappenstiels in der Regel nicht durchgeführt. Ziel dieser Studie ist es, die klinischen Ergebnisse des gleichzeitigen Transfers der Flexor hallucis longus-Sehne (FHLT) und der RSAF zur Behandlung von Weichteil- und Sehnendefekten infolge einer Infektion nach einer AT-Reparatur zu überprüfen.

Patienten und methoden

Wir untersuchten 20 Patienten, die sich zwischen Oktober 2012 und Oktober 2022 einer einzeitigen Rekonstruktion von AT und infektionsbedingten Weichteildefekten nach einer AT-Reparatur mittels FHLT-Transfer und RSAF unterzogen hatten, mit einer Nachbeobachtungszeit von mindestens 1 Jahr nach der Operation. Die chirurgischen Ergebnisse wurden anhand des Erfolgs des Lappens, des Wiederauftretens einer Infektion und einer erneuten Sehnenruptur bewertet. Die klinische Bewertung umfasste den VAS score, den Bewegungsumfang des Knöchels und die vom Patienten angegebenen Komponenten des AOFAS scores (American Orthopedic Foot and Ankle Society) (maximal 68 Punkte).

Ergebnisse

Alle Lappen waren erfolgreich. Die durchschnittliche Größe des Lappens betrug 7,2×4,1 cm². Es kam weder zu einem Wiederauftreten einer Infektion noch zu einer erneuten Sehnenruptur. Die mittleren VAS und AOFAS scores betrugen 0,5 bzw. 64,6. Der mittlere Bewegungsumfang des Sprunggelenks betrug 13,5° für die Dorsalflexion und 35° für die Plantarflexion.

Schlussfolgerung

Die einzeitige Rekonstruktion mit FHLT-Transfer und RSAF ist eine sichere und effektive Operationsmethode bei Patienten mit Sehnen- und Weichteildefekten nach einer Achillessehnenreparatur.

Keywords

flexor hallucis longus tendon transfer - reverse sural artery flap - infection - one-stage reconstruction

Schlüsselwörter

Achilles tendon - Achillessehne - Infektion - Pathologie - Flexor hallucis longus-Sehnentransfer - einzeitige Rekonstruktion

Publication History

Received: 27 May 2025

Accepted: 03 August 2025

Article published online:
21 October 2025

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