Hybrid Total Achilles Tendon Reconstruction Combining Acellular Dermal Matrix Placement and Free Latissimus Dorsi Flap Coverage: A Report of Two Cases

Reconstruction of complex Achilles tendon defects involving both the tendon and the overlying soft tissues represents a challenging scenario for plastic surgeons. In this report, we present an innovative technique of hybrid total Achilles tendon reconstruction combining acellular dermal matrix placement to restore the full-thickness continuity of the tendon and free latissimus dorsi (LD) flap coverage to allow graft integration and simultaneously resurface the soft tissue defect, ultimately leading to lower limb salvage. Between August 2023 and February 2024 two patients received microsurgical hybrid reconstruction of complex defects, measuring 10 × 10 cm and 17 × 14 cm, respectively, involving the lower third of the leg and the Achilles tendon region, due to trauma with multiple previous failed surgeries and sarcoma resection. The full-thickness continuity of the tendon was reconstructed by use of an XCM BIOLOGIC Tissue Matrix (DePuy Synthes, Johnson & Johnson), measuring 6 and 10 cm long, respectively, folded in a three-layered tridimensional structure to recreate the shape and function of a new tendon. Subsequently, a free myo-cutaneous LD flap, was used to wrap and revascularize the neo-tendon and resurface the soft tissue defect. In both patients the flaps healed uneventfully, and neo-tendon integration was documented by MRI examination. The follow-up was uneventful. Long-term functional evaluation showed almost normal tendon excursion with both patients walking without assistance. The proposed hybrid approach may be a good alternative and innovative solution for the reconstruction of complex Achilles tendon defects consequent to trauma or oncological resection. Such results are more than promising for future studies on large series of patients.