Peroneus Brevis Tendon Transfer for Chronic Achilles Tendon Ruptures 20

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is gently pulled through the inferior peroneal retinaculum, thereby retaining the muscle’s blood supply from the intermuscular septum. The peroneus brevis tendon is then woven through the ends of the ruptured Achilles tendon, passing through small coronal incisions in the distal stump, and then through similar incisions in the proximal stump. The tendon of plantaris, if present, can also be harvested to augment the repair if there is a large gap. This technique is described in detail below.

Indications and Contraindications

A delay in presentation of Achilles tendon rupture of greater than 8 weeks results in fi lling up of the gap between the ruptured ends with fi brous non- functional scar that needs excision. If the gap with the ankle in maximum plantarfl exion is between 5 and 9 cm, peroneus brevis transfer can be utilized.

We do not use this technique if the gap between the ruptured ends of the Achilles tendon is greater than 8 cm, or the ipsilateral peroneus brevis has been used for other reconstructive procedures around the ankle (for example, for reconstruction in lateral instability).

Preoperative Assessment

The diagnosis of chronic, delayed rupture can be difﬁ cult.^6,9 Scar tissue may have replaced the gap between the proximal and distal ends of the Achilles tendon, thereby obscuring the gap

Introduction/Historical Perspective

The Achilles tendon is the most commonly ruptured tendon in the human body.¹ Complete rupture of the Achilles tendon can be experienced both by sedentary patients and athletes,¹ and is especially common in middle-aged men who occasionally participate in sports.^2–5

In acute ruptures, often a snapping sensation is felt in the posterior aspect of the ankle, with the patient then experiencing difﬁ culty with weight bearing on the affected side. There is often a palpable gap between the ruptured tendon ends.⁶ However, this may not be the case with chronic ruptures that present after a delay, which can prove more difﬁ cult to diagnose and manage.⁶

The management of chronic Achilles tendon ruptures is usually different from that of acute rupture, as the tendon ends have retracted. The blood supply to this area is poor, and the tendon ends have to be freshened to allow healing. Due to the increasing gap, primary repair is generally not possible as oppose to primary repair is generally possible.

Peroneus brevis tendon transfer for rupture of the Achilles tendon was popularized by Perez- Teuffer.⁷ In the original technique, the harvested peroneus brevis tendon was passed through a transosseous drill hole in the calcaneus. Subse- quently, Turco and Spinella⁸ modiﬁ ed the technique by passing the peroneus brevis tendon through the distal stump of the Achilles tendon.

McClelland et al.⁶ described approaching the Achilles tendon medially, and delivering the Achilles tendon through the posteromedial wound. The distally transsected peroneal tendon

Peroneus Brevis Tendon Transfer for Chronic Achilles Tendon Ruptures

Jonathan S. Young, Murali K. Sayana, D. McClelland, and Nicola Maffulli

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182 J.S. Young et al.

typically palpable in acute ruptures. Moreover, pain and swelling associated with acute ruptures may be absent.

Clinically, the Simmonds¹⁰ and Matles¹¹ tests may assist in making the diagnosis in delayed Achilles tendon rupture. Occasionally, even these tests may be of dubious interpretation, and imaging may need to be considered.^12–14 Ultraso- nography of a delayed rupture typically demon- strates an acoustic vacuum with thick irregular edges.^12,13 Magnetic resonance imaging shows generalized high signal intensity on T2 weighted images. On T1 weighted images, the rupture will appear as a disruption of the signal within the tendon substance.¹⁴

Clinical examination is performed, encompass- ing the abovementioned clinical tests, ﬁ tness for anesthesia, and neurovascular status of the limb, paying particular attention to the sural nerve.

Once the diagnosis is conﬁ rmed, the patient is counseled regarding the technique and risks involved and informed consent is obtained. At our institution, general anesthesia is preferred for this procedure.

Operative Technique

The patient is placed prone with feet protruding over the edge of the operating table. Both legs are prepped and draped, allowing intraoperative

comparison to adjust the tension of the reconstruction. If considered necessary, a tourniquet is applied to the thigh of the affected leg, the leg exsanguinated, and the tourniquet inﬂ ated to 250 mmHg. A 10- to 12-cm longitudinal skin incision is made just medial to the medial border of the Achilles tendon, and sharp dissection is carried out through the subcutaneous fat layer (Fig. 20.1).

The Achilles tendon is exposed using a longitudinal incision of the paratenon in the midline for the length of the skin incision. Scar tissue is debrided from the ends of the Achilles tendon, which are freshened by sharp dissection, deﬁ ning the defect between the freshened ends. The proximal and distal stumps are gently dissected out and mobilized.

Through the base of the wound, the deep fascia overlying the deep fl exor compartment and the lateral compartment containing the peronei muscles can be seen. The internervous plane lies between the peroneus brevis (supplied by the superfi cial peroneal nerve) and the fl exor hallucis longus (supplied by the tibial nerve). The muscle belly of the peroneus brevis passes from the midline medially and under the tendon of the peroneus longus to lie anterior to it and adjacent to the posterior aspect of the lateral malleolus.

The tendons of the peroneus longus and brevis can be distinguished from each other at this level as the peroneus brevis muscle extends more distally than that of the peroneus longus. The deep

FIGURE 20.1 Incision over the medial edge of the Achilles tendon.

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fascia overlying the peroneal tendons is incised, and the peroneal tendons are mobilized.

The peroneus brevis passes around the posterior aspect of the lateral malleolus and above the peroneal trochlea to insert onto the styloid process of the base of the ﬁ fth metatarsal.

Both peroneal tendons are tethered both at the lateral malleolus and the peroneal trochlea by the superior peroneal retinaculum and the inferior peroneal retinaculum, respectively. A 2.5- cm longitudinal incision is made over the base of the ﬁ fth metatarsal (Fig. 20.2). The peroneus brevis tendon is identiﬁ ed, and a stay suture is placed in the distal end of the peroneus brevis tendon, which is then detached from its insertion and mobilized proximally. The tendon is then delivered through the posteromedial wound using gentle continuous traction as it is pulled through the inferior peroneal retinaculum (Fig. 20.3). In this fashion, the tendon of the peroneus brevis retains its blood supply from the intermuscular septum.

The peroneus brevis tendon is woven through the Achilles tendon ends. It is fi rst passed from lateral to medial through the distal Achilles tendon stump via coronal incisions medially and laterally in the Achilles tendon (Fig. 20.4). The edges of the coronal incisions in the Achilles tendon are sutured to the peroneus brevis tendon to prevent the transferred peroneus brevis tendon from pulling out of the Achilles. The tendon is then passed through the proximal stump from medial to lateral with the ankle plantarfl exed to achieve the correct tension relative to the uninvolved extremity. A comparison is made with the contra- lateral limb to confi rm tension is equal. The peroneal tendon is sutured to the Achilles tendon stumps using 3/0 Vicryl (Ethicon, Edinburgh, UK, EH11 4HE) (Fig. 20.5). This is usually suffi cient, but, if there is a large defect, the plantaris tendon may be utilized to reinforce the reconstruction (Fig. 20.6).

Hemostasis is achieved. In most patients with delayed ruptures of the Achilles tendon, the FIGURE 20.2 Incision over the base fifth metatarsal enabling identification of the distal end of the peroneus brevis tendon.

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FIGURE 20.3 Peroneus brevis tendon being delivered into the posteromedial wound with gentle traction.

FIGURE 20.4 Passing peroneus brevis tendon through the ends of the Achilles tendon.

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FIGURE 20.5 End result of sutured peroneus brevis graft in situ.

FIGURE 20.6 Plantaris tendon used to augment the reconstruction.

paratenon is either not present or not viable. If present, one can generally manage to close it over the proximal stump using 2/0 Vicryl. Reapproxi- mation of the paratenon over the distal portion of the reconstruction is often not possible. The skin is closed with a continuous 2/0 subcuticular Vicryl suture. Steristrips (3M Healthcare St Paul, MN, USA) are applied, and the wound is dressed.

Postoperative Management

Elevation of the operated limb on a Braun frame is recommended overnight, and the patient should have regular neurovascular observations. Follow-

ing review by a physiotherapist, the patient is generally discharged the day following surgery. A full below-knee cast is applied with the ankle in physiological equinus and retained for two weeks until review in an outpatient clinic. Patients are advised to keep the operated limb elevated as much as possible to minimize swelling. They are allowed to weight bear on the operated leg as tolerated, for the ﬁ rst two weeks until seen in the clinic, when the cast is split and the wounds are inspected. A synthetic anterior below-knee slab is ﬁ tted with the ankle in physiological equinus. The slab is secured to the leg with three or four removable Velcro (Velcro USA Inc., Manchester, NH, USA) straps for four weeks. At this stage, the patients

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are encouraged to weight bear on the operated limb as tolerated, gradually progressing to full weight bearing. The patients are seen by a trained physiotherapist and taught to perform gentle mobilization exercises of the ankle, isometric contraction of the gastrocsoleus complex, and gentle concentric contraction of the calf muscles. Patients are encouraged to perform mobilization of the involved ankle several times per day after unstrap- ping the two most distal Velcro straps.¹⁵ Patients are given an appointment six weeks from the operation, when the anterior slab is removed and the wound is again inspected.

Once the cast is removed, patients are referred for more intensive physiotherapy. They are allowed to begin gentle exercise such as swim- ming and cycling at eight weeks following surgery but are restricted from running for an additional four to six weeks and limited from return to sports until four to ﬁ ve months from time of surgery.

Results

We have treated 22 Achilles tendon ruptures with delayed presentation using this technique.¹⁶ All of these patients were satisﬁ ed with the procedure.

Despite subjective patient satisfaction, objective evaluation demonstrated greater loss of isokinetic strength variables at high speeds and greater loss of calf circumference when compared with patients undergoing open repair of fresh Achilles tendon ruptures.

Complications

Damage to the sural nerve, wound complications, and re-rupture are all risks with surgical reconstruction of chronic rupture of the Achilles tendon.

The medial longitudinal incision helps avoid damage to the sural nerve.⁶

Longitudinal incisions used in open repair of the Achilles tendon are typically performed through poorly vascularized skin,¹⁷ introducing the potential for poor wound healing. This risk can be reduced by careful handling of tissues and by maintaining thick skin ﬂ aps throughout the procedure.⁶ Even minor areas of wound dehis-

cence may take a long time to heal. Wounds that break down need coverage, as tendons left exposed undergo desiccation and secondary adhesions.¹⁸ Occasionally, local or free fl ap coverage may be required. Local fl ap coverage can be in the form of medial plantar fl ap, posterior tibial reverse fl ow fl ap, or peroneal reverse fl ow island fl ap, depend- ing on the site of the defect.¹⁹ This is advantageous in restricting the morbidity of the leg originally operated on, and, if a local fl ap fails, a free fl ap can still be considered.¹⁸ Wound complications over the Achilles tendon warrant aggressive, early management.

Re-ruptures are rare: Perez-Teuffer⁷ and Pintore et al.¹⁶ reported no re-ruptures in their series of peroneal reconstructions of chronic Achilles ruptures. Patients must be cautioned about the risk of re-rupture and should allow the reconstructed tendon adequate time to heal in the duration of postoperative recovery.

Possible Concerns/Future of the Technique

This technique generally provides a good functional outcome, with minimal complications as long as good postoperative care is administered.

The postoperative management in these patients is the same as that we have recently described following open repair of acute Achilles tendon ruptures.²⁰ Accelerated rehabilitation programs have been advocated,²¹ but the priority in these challenging patients is to restore adequate muscle-tendon unit function without compromising skin healing.²²

As the peroneus brevis is utilized to reconstruct the Achilles tendon, the peroneus longus becomes the sole evertor of the foot, and continues to maintain the transverse arch. Gallant et al.

assessed eversion and plantarﬂ exion strength after repair of Achilles tendon rupture using peroneus brevis tendon transfer and found mild objective eversion and plantarﬂ exion weakness.

However, subjective assessment revealed no functional compromise.²³ We have not come across any hindfoot varus deformities in our patients following this reconstructive procedures. However, in the long term, hindfoot varus is a theoretical (though unencountered) possibility.

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References

1. Jozsa L, Kvist M, Balint BJ, et al. The role of recre- ational sport activity in Achilles tendon rupture: A clinical, pathoanatomical, and sociological study of 292 cases. Am J Sports Med 1989; 17:338–343.

2. Carden DG. Rupture of the calcaneal tendon: The early and late management. J Bone and Joint Surg 1987; 69-B:416–420.

3. Puddu G, Ippolito E. A classiﬁ cation of Achilles tendon disease. Am J Sports Med 1976; 4:145–150.

4. Boyden EM, Kitaoka H. Late versus early repair of Achilles tendon rupture: Clinical and biomechani- cal evaluation. Clin Orthop 1995; 317:150–158.

5. Hattrup SJ, Johnson KA. A review of the ruptures of the Achilles tendon. Foot Ankle 1985; 6:34–38.

6. McClelland D, Maffulli N. Neglected rupture of the Achilles tendon: Reconstruction with peroneus brevis tendon transfer. Surgeon 2004; 2:209–213.

7. Perez-Teuffer A. Traumatic rupture of the Achilles tendon: Reconstruction by transplant and graft using the lateral peroneus brevis. Orthop Clin North Am 1974; 5:89–93.

8. Turco V, Spinella AJ. Achilles tendon ruptures: Pero- neus brevis transfer. Foot Ankle 1987; 7:253–259.

9. Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon: A prospective study in 174 patients. Am J Sports Med 1998; 26:266–270.

10. Simmonds FA. The diagnosis of the ruptured Achil- les tendon. The Practitioner 1957; 179:56–58.

11. Matles AL. Rupture of the tendo Achilles: Another diagnostic test. Bull Hosp Joint Dis 1975; 36:48–51.

12. Maffulli N, Dymond NP, Capasso G. Ultrasono- graphic ﬁ ndings in subcutaneous rupture of Achil- les tendon. J Sports Med Phys Fitness 1989;

29:365–368.

13. Maffullli N. Rupture of the Achilles tendon. J Bone Joint Surg 1999; 81-A:1019–1036.

14. Kabbani YM, Mayer DP. Magnetic resonance imaging of tendon pathology about the foot and ankle: Part I. Achilles tendon. J Am Podiatr Med Assoc 1993; 83:418–420.

15. McClelland D, Maffulli N. Percutaneous repair of ruptured Achilles tendon. J Royal Coll Surg Edin 2002; 41:613–618.

16. Pintore E, Barra V, Pintore R, et al. Peroneus brevis tendon transfer in neglected tears of the Achilles tendon. J Trauma 2001; 50:71–78.

17. Haertsch PA. The blood supply of the skin of the leg: A post-mortem investigation. Br J Plast Surg 1981; 34:470–477.

18. Leung PC, Hung LK, Leung KS. Use of medial plantar ﬂ ap in soft tissue replacement around the heel region. Foot Ankle 1988; 8:327–330.

19. Kumta SM, Maffulli N. Local ﬂ ap coverage for soft tissue defects following open repair of Achilles tendon rupture. Acta Orthop Belg 2003;

69:59–66.

20. Maffulli N, Tallon C, Wong J, et al. Early weight- bearing and ankle mobilization after open repair of acute midsubstance tears of the Achilles tendon.

Am J Sports Med 2003; 31:692–700.

21. Kangas J, Pajala A, Siira P, et al. Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: A prospective, randomized, clinical study. J Trauma 2003; 54:1171–1180.

22. Coutts A, MacGregor A, Gibson J, et al. Clinical and functional results of open operative repair for Achilles tendon rupture in a non-specialist surgical unit. J R Coll Surg Edin 2002; 47:753–762.

23. Gallant GG, Massie C, Turco VJ. Assessment of eversion and plantar ﬂ exion strength after repair of Achilles tendon rupture using peroneus brevis tendon transfer. Am J Orthop. 1995; 24(3):257–

261.