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

Abstract Background: Open segmental Achilles tendon defects with simultaneous soft-tissue loss are exceptionally uncommon in young children. Gross contamination may preclude immediate reconstruction, whereas extensive tendon loss may make primary repair impossible. Management requires coordinated restoration of tendon continuity and vascularized posterior ankle coverage. Case presentation: A 7-year-old Colombian boy of Mestizo ethnicity sustained a contaminated crush-avulsion injury to the posterior right ankle after entrapment in a sugarcane mill. Surgical exploration revealed extensive posterior ankle soft-tissue loss, complete Achilles tendon disruption, plant-material contamination, and segmental tendon loss. Two surgical irrigation and debridement procedures and interim negative-pressure wound therapy were performed. The initial deep-tissue culture yielded methicillin-susceptible Staphylococcus aureus , and the repeat culture showed no growth after 48 hours. Definitive debridement left an approximately 8-cm gap between viable tendon remnants, precluding tension-free primary repair. Achilles tendon continuity was restored using a free semitendinosus interposition autograft with local triceps surae aponeurotic augmentation, and coverage was achieved with a reverse sural fasciocutaneous flap. Partial distal flap loss involving full-thickness skin and subcutaneous tissue developed postoperatively without tendon or neurovascular exposure and healed over 4 months with conservative wound care. At 6 months, the flap provided stable coverage; ankle motion measured 20° of dorsiflexion and 45° of plantar flexion; plantar-flexion strength was Medical Research Council grade 4/5; calf compression elicited plantar flexion; and the child walked independently without an observable limp. Return to age-appropriate play was reported without limitation by the patient or caregiver. Conclusions: This case illustrates the staged orthoplastic management of a contaminated pediatric Achilles tendon defect with major soft-tissue loss. Early follow-up demonstrated clinical continuity of the reconstructed Achilles mechanism and functional ambulation despite partial distal flap loss. Surveillance through growth remains necessary to assess graft length, strength recovery, donor-site morbidity, sensory consequences, and flap integrity.