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Reconstructions of soft tissue defect of the posterior ankle including Achilles the tendon should take into account not only coverage but functional outcome. Various methods of tendon transfer and tendon graft have been reported as a single-stage procedure. With advances and refinements in microsurgical techniques, several free composite flaps including tendon, fascia, or nerve have been used in single-stage reconstructions of large defects in this area minimizing further damage to the traumatized leg. However, when free flap is not feasible for some reasons, this cannot be accomplished successfully. Here we present a patient with Achilles tendon and circumferential large soft tissue defect. Because of circulatory compromise of the lower extremity, free flap reconstruction could not be applied. Instead, cross-leg composite flap of the dorsalis pedis flap including the extensor hallucis brevis musle and tendon, and tendon strips of the Second, third and fourth extensor digitorum logus were employed, Functional reconstruction of the tendon and resurfacing were obtained at the same time. The flap was detached 3 weeks postoperatively, and the transplanted flap has survived without any complications. By 3 months after surgery, full weight bearing, tip-toe standing and even walking without crutch assistance was possible. When functional reconstruction with the free flap is unattainable in the large defect of the posterior ankle including the Achilles tendon, cross-leg composite island flap of dorsalis pedis flap and tendon strips of the extensor digitorum longus tendon is a viable alternative.
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