In the reconstructive ladder, a 6 × 8 cm full-thickness wound over the Achilles tendon with exposed tendon is to be reconstructed. Which reconstructive option is most appropriate when the wound cannot be skin grafted due to exposed avascular tendon?

• A Split-thickness skin graft directly over the paratenon
• B Simple primary closure with vertical mattress sutures
• C Negative pressure wound therapy (NPWT) alone until tendon is re-covered by granulation
• D Pedicled sural artery flap or reverse sural flap for coverage of the distal leg/heel ✓

Explanation

Exposed avascular structures (bone, tendon, cartilage, neurovascular bundles) cannot be covered by split-thickness skin grafts, which require a vascular bed (granulation tissue or paratenon) for graft take. The reverse sural artery flap (distally-based sural flap) is the workhorse flap for coverage of the distal one-third of leg, Achilles tendon, and heel, utilizing the reverse flow of the sural artery via perforator connections to the peroneal artery. It provides well-vascularized fasciocutaneous tissue that can survive on exposed tendon. Free flaps (e.g., anterolateral thigh or gracilis) are escalated to if local flap options are unavailable. NPWT alone does not generate granulation over avascular tendon.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.