Single-stage Flexor Hallucis Longus transfer and Gracilis free flap cover for failed Achilles tendon repair with soft tissue defect

Published:November 22, 2022DOI:



      Reconstruction of failed Achilles tendon repair, with infection and loss of overlying skin, is a surgical challenge. This paper aims to deal with the technical considerations and study the outcome of reconstructing such defects by radical debridement and reconstruction with combined Flexor hallucis longus (FHL) transfer and free Gracilis flap cover.

      Materials and Methods

      A retrospective study of six patients with failed Achilles tendon repair with overlying skin and soft tissue loss reconstructed by FHL transfer and free Gracilis flap cover performed between January 2017 and August 2020 was done. Postoperatively they were assessed with the Mean Functional Gait Assessment score(MFGA), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, the Achilles tendon Total Rupture Score (ATRS), Modified Vancouver scar scale score (mVSS).


      All six patients reported a good gait at nine months of follow-up. The MFGA score at six months was 24.8. The mean ankle plantar flexion at nine months follow up was 39.10 . The mean nine-month postoperative AOFAS and ATRS scores were 86.33 ± 2.654 and 88.5 ± 5.54, respectively. At nine months, all the patients could perform a single-leg heel raise on the operated foot. The overall mean mVSS score was 1.41. In about 12 months the peak forefoot to hindfoot ratio matched the uninjured opposite foot.


      Simultaneous reconstruction of the Achilles tendon with FHL transfer with free Gracilis flap for coverage of overlying soft tissue loss is a good management option for failed Achilles tendon repair with overlying skin loss.


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