Staged orthoplastic reconstruction of an 8-cm open Achilles tendon defect after crush trauma in a 7-year-old child: a case report

Technical Summary: Staged Orthoplastic Reconstruction of an 8-cm Open Achilles Tendon Defect in a Pediatric Patient

Problem Statement
Open segmental Achilles tendon defects accompanied by simultaneous soft-tissue loss are exceptionally rare in young children. Unlike adult degenerative ruptures, pediatric injuries often result from high-energy mechanisms such as crush trauma. The specific challenge addressed in this case involves a contaminated, 8-cm segmental defect of the Achilles tendon in a 7-year-old child, complicated by extensive posterior ankle soft-tissue loss and gross contamination with plant material. Standard primary repair was deemed impossible due to the inability to approximate viable tendon remnants without excessive tension, and immediate definitive reconstruction was contraindicated by the contaminated wound bed.

Methodology
The authors employed a staged orthoplastic reconstruction strategy involving three distinct phases:

1. Initial Management and Debridement:

   • The patient underwent urgent surgical exploration, irrigation, and excisional debridement upon admission.
   • Nonviable tissue and foreign debris were removed. Deep-tissue cultures initially grew methicillin-susceptible Staphylococcus aureus.
   • Negative-pressure wound therapy (NPWT) was applied at −125 mmHg.
   • A second debridement was performed four days later. Repeat cultures showed no growth after 48 hours, and the wound bed was deemed clinically viable, allowing progression to reconstruction.

2. Tendon Reconstruction:

   • A longitudinal strip of local triceps surae aponeurotic tissue was mobilized but proved insufficient to bridge the 8-cm gap without tension.
   • A free semitendinosus autograft was harvested and used as an interposition graft between the viable proximal and distal Achilles tendon remnants.
   • Fixation was achieved using a locking Krackow suture configuration at both ends.
   • The construct was tensioned with the knee in full extension and the ankle at 20° of plantar flexion to restore continuity while avoiding excessive shortening.

3. Soft-Tissue Reconstruction:

   • Coverage was achieved using an 11 × 5-cm reverse sural fasciocutaneous flap.
   • The flap included a 3-cm-wide adipofascial pedicle with the pivot point 4 cm proximal to the lateral malleolus, retaining the small saphenous vein within the pedicle.
   • The secondary donor site was covered with a split-thickness skin graft.
   • Postoperative immobilization was maintained in an anterior splint at 20° of plantar flexion for two weeks.

Results

• Complications: Approximately 15 days post-reconstruction, the patient developed substantial partial distal flap loss (7 × 5 cm) involving full-thickness skin and subcutaneous tissue. Crucially, the reconstructed tendon and deep neurovascular structures remained covered. The necrotic area was managed nonoperatively with serial wound care and hydrocolloid dressings, achieving complete healing over four months without the need for flap revision.
• Functional Outcomes at 6 Months:
  • Range of Motion: 20° of dorsiflexion and 45° of plantar flexion.
  • Strength: Plantar-flexion strength was graded 4/5 on the Medical Research Council (MRC) scale.
  • Mechanism Continuity: Calf compression elicited plantar flexion, and the patient could perform a single-leg heel rise, confirming clinical continuity of the Achilles mechanism.
  • Ambulation: The patient walked independently without an assistive device or observable limp.
  • Activity: The child returned to age-appropriate play and school without limitations.
  • Scoring: The American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score improved from 29 (pre-reconstruction) to 75 at 6 months.

Key Contributions
This case report documents the successful management of a complex pediatric injury characterized by a large, contaminated segmental tendon defect and soft-tissue loss. The primary contribution is the demonstration of a staged orthoplastic approach that prioritizes wound bed preparation before definitive reconstruction. The authors detail the specific combination of a free semitendinosus interposition autograft augmented by local triceps surae aponeurotic tissue, covered by a reverse sural flap. Furthermore, the report highlights that substantial partial flap loss can be managed conservatively in the absence of tendon exposure, allowing for eventual healing without additional surgical intervention.

Significance and Claims
The authors claim that this case illustrates the feasibility of staged orthoplastic management for contaminated pediatric Achilles defects where neither tension-free primary repair nor direct soft-tissue closure is possible. The report emphasizes that early clinical continuity and functional ambulation can be achieved despite significant wound-healing morbidity (partial flap necrosis) and incomplete restoration of plantar-flexion strength.

However, the authors maintain a modest stance regarding the long-term implications. They explicitly state that a 6-month follow-up is insufficient to determine graft durability, definitive strength recovery, or adaptation to skeletal growth. The paper concludes that continued surveillance is necessary to assess potential graft elongation, donor-site morbidity, sensory consequences, and long-term flap integrity. The case serves as a descriptive report of a specific surgical sequence rather than evidence establishing the superiority of this technique over other reconstructive methods.