188
21
Management
Management of a chronic Achilles tendon rupture is more diffi cult than acute rupture. Generally, an open procedure must be carried out.1,8 Surgery requires the tendon edges to be freshened, and, as they will be retracted, a large gap will thus be produced. Various techniques have been described to bridge the gap.
A strip of the superfi cial part of the tendinous portion of the proximal stump of the Achilles tendon has been used.15 A proximal-to-distal V-Y advancement of the gastrocnemius tendon has also been described.3
Mann et al.2 described the use of a fl exor digi- torum longus (FDL) graft in seven patients. Six of the seven patients had an excellent result, and one a fair result. There were no re-ruptures at an average follow-up of 39 months.
More recently, the tendon of fl exor hallucis longus (FHL) has been used. FHL has a long tendon that allows bridging of large Achilles tendon defects.4 Wapner et al.4 reported 7 patients managed with this technique. The tendon of FHL was woven through the ruptured Achilles tendon ends. The distal end of FHL was tenodesed to the tendon of FDL of the second toe. Three patients had an excellent result, three a good result, and one a fair result. Each patient developed a “small but functionally insig- nifi cant loss in range of motion in the involved ankle and great toe.” This may be important in athletic individuals, in whom the loss of push- off from the hallux may cause diffi culty when sprinting.
Introduction
Chronic ruptures of the Achilles tendon are asso- ciated with both functional and operative morbid- ity.1 Various methods are described to manage this condition.1–4 The tendon of gracilis has recently been used to reconstruct the Achilles tendon.5,6
Diagnosis
Although diagnosis is straightforward for experienced surgeons,7 and most Achilles tendon ruptures are promptly diagnosed,1,7,8 fi rst examin- ing physicians may miss up to 20% of such injuries.9 The diagnosis of chronic rupture can be more diffi cult,1,10 as fi brous scar tissue may have replaced the gap between the proximal and distal ends of the Achilles tendon, and therefore the gap palpable in acute ruptures is no longer present. There may also be less pain and swelling.
Clinically, the Simmonds11 and Matles12 tests help aid the diagnosis in both acute and delayed rupture, but even these tests may be of dubious interpretation, and imaging may have to be used.8,13,14 Ultrasonography of a neglected rupture will reveal an acoustic vacuum with thick irregu- lar edges.8,13 Magnetic resonance imaging will reveal 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
Free Gracilis Tendon Transfer for Chronic Rupture of the Achilles Tendon
Jonathan S. Young, Wayne B. Leadbetter, and Nicola Maffulli
Fascia lata grafts,16 plantaris,17 and synthetic materials18 have also been used in the management of neglected ruptures of the Achilles tendon.
Perez-Teuffer19 popularized the use of the pero- neus brevis. Turco and Spinella20 used a similar technique, but passed the peroneus brevis tendon through the distal stump of the Achilles tendon.
McClelland and Maffulli1 used a similar technique, but they approached the Achilles tendon through a curvilinear medial incision, thus minimizing the risk of sural nerve injury.
More recently, we used the tendon of gracilis as a free graft to bridge the gap in chronic ruptures.5,6 We report the details of this technique.
Preoperative Assessment
The patient is assessed, a full history is collected, clinical examination is carried out, and fi tness for anesthesia and the neurovascular status of the limb are assessed, paying particular attention to the sural nerve. The diagnosis of chronic rupture may be diffi cult and require further imaging.
Written informed consent is taken. The patient should be aware of wound problems, neurovascu- lar damage, altered sensation around the gracilis harvest site, calf wasting, weakness of ankle fl exion, and the risk of failure of surgery and of anesthesia.
Operative Technique
With the patient prone and both feet dangling from the end of the operating table, the affected leg and ankle is prepped and draped. A single dose of a fi rst-generation cephalosporin is adminis- tered at induction of anesthesia. The limb is exsanguinated and a thigh tourniquet is infl ated to 250 mmHg. A 12- to 15-cm longitudinal, slightly curvilinear skin incision is made medial and ante- rior to the medial border of the tendon. The paratenon, if not disrupted, is incised longitudi- nally in the midline for the length of the skin inci- sion. The Achilles tendon is thus exposed. Gentle continuous traction is applied so that the proxi- mal stump of the ruptured tendon is further deliv- ered into the wound, allowing the lowest possible
residual gap. Scar tissue in both the proximal and distal stumps is excised to reach viable tendon.
If the gap produced is greater than 6 cm despite maximal plantarfl exion of the ankle and traction on the Achilles tendon stumps, we proceed to harvest the tendon of gracilis. A vertical 2.5- to 3- cm longitudinal incision is made over the tibial tuberosity, and should be centred over the distal insertion of the pes anserinus (where the gracilis tendon inserts). There is a constant venous plexus lying at the distal end of the wound, and care should be taken to diathermy this. Using a small swab attached to an artery clip, dissection deep to the fat is carried out both medially and superiorly.
A curved retractor is inserted, and a curved inci- sion, 1 cm in length, is made along the superior margin of the pes anserinus into the sartorious fascia. Care is taken to avoid damage to the saphe- nous nerve. Through this incision, Mackenrodt scissors are introduced and opened so as to split and produce a window within the superior border of the sartorious, allowing for access to the tendon of gracilis.
The gracilis tendon lies more superiorly than the neighboring tendon of semitendinosus. It can be retrieved with the aid of a curved Moynihan clip (Fig. 21.1). The tendon is brought into the wound and distal traction on the tendon is imposed. An open-ended tendon stripper is used to harvest the tendon (Fig. 21.2).21
Once the tendon is freed of fat and muscle fi bers (Fig. 21.3), it is passed through a small transverse incision produced by a number 11 scalpel blade in the substance of the distal stump of the Achilles tendon in a medial-to-lateral direc- tion. The gracilis tendon is then pulled proximally and through a small incision in the substance of the proximal stump of the Achilles tendon in a lateral-to-medial direction through the proximal stump (Fig. 21.4). The gracilis tendon is sutured to the Achilles tendon at each entry and exit point using 3-0 Vicryl (Polyglactin 910 braided absorb- able suture, Johnson & Johnson, European Logis- tics Centre, 66 Rue de la Fusee, B-1130 Bruxelles, Belgium). The repair is tensioned to greater than the physiological equinus present in the opposite ankle. When present, the tendon of plantaris can be harvested with the tendon stripper, left attached distally (Fig. 21.5), and used to reinforce the reconstruction (Fig. 21.6).
FIGURE 21.1 Gracilis tendon prior to removal from pes anserinus.
FIGURE 21.2 Extraction of gracilis with tendon stripper.
FIGURE 21.3 Free gracilis tendon.
FIGURE 21.4 Plantaris tendon.
FIGURE 21.5 Weaving of gracilis tendon through the Achilles tendon stumps.
FIGURE 21.6 Repaired Achilles tendon using gracilis and plantaris.
Interrupted 4-0 Vicryl reabsorbable sutures are used for the subcutaneous fat, and the skin is closed with interrupted 4.0 Ethilon (Ethicon, Johnson & Johnson, European Logistics Centre, 66 Rue de la Fusee, B-1130 Bruxelles, Belgium), or with subcuticular 3-0 Vicryl. The tourniquet is defl ated, the wound is dressed, and a below-knee plaster-of-Paris cast is applied with the patient prone.
Postoperative Care
Postoperatively, the injured leg is elevated until discharge. Patients are discharged the day after surgery, after having been taught to use crutches by an orthopedic physiotherapist.8 Thrombo- prophylaxis is provided with Fragmin, 2,500 units (Deltaparin Sodium, Pharmacia and Upjohn, Roma, Italy) subcutaneously once daily, or with 150 mg of acetylsalicylic acid orally daily, until removal of the cast. When the cast has dried, patients are encouraged to mobilize with the use of crutches, under the direction of a physiothera- pist. Patients are allowed to bear weight on the operated leg as tolerated, but are told to keep the operated leg elevated as much as possible for the fi rst two postoperative weeks.22
The cast is removed two weeks after the opera- tion, and a synthetic anterior below-knee slab is applied, with the foot in gravity equinus.1 The syn- thetic slab is secured to the leg with three or four removable Velcro (Velcro USA Inc., Manchester, NH, USA) straps for four weeks. Patients are encouraged to weight bear on the operated limb as soon as comfortable, and to gradually progress to full weight bearing. The patients are seen by a trained physiotherapist, who teaches them 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 unstrapping the two most distal Velcro straps. Patients are given an appointment six weeks from the operation, when the anterior slab is removed.
Patients mobilize the ankle with physiotherapy guidance. They are allowed to weight bear as able, and perform gradual stretching and strengthen-
ing exercises.22 Cycling and swimming are started eight weeks after surgery if the wound is healthy.
Patients are prompted to increase the frequency of their self-administered exercise program, and are allowed to return to their sports in the fi fth postoperative month.
Complications
Wound infection, breakdown, and scar problems are a documented risk in open repairs of the Achilles tendon,1,8 given the tenuous blood supply in this area.23 There is also the theoretical risk of infection and wound breakdown to the donor gracilis tendon site. In our series,5 fi ve patients had a superfi cial infection of the Achilles tendon surgical wound. They were managed conserva- tively with oral antibiotics following a microbiol- ogy swab to ascertain sensitivity, were asked to keep the leg elevated at all times, and healed uneventfully by the 18th postoperative week. At the sixth postoperative month, two patients com- plained of hypersensitivity of the surgical wounds.
They were counseled to rub hand cream over the wounds several times a day, and all were asymp- tomatic by the next visit. One patient developed a hypertrophic scar in the area of the Achilles tendon surgical wound as it rubbed against the shoe, and was not pleased with the appearance of the operative scar. Other early complications include wound hematoma and sural nerve sensory defi cit from intraoperative injury. Medial posi- tioning of the incision helps to reduce sural nerve injury.1 Re-rupture is one of the most important late complications.1,19 Deep vein thrombosis is also a documented risk. Arner and Lindholm24 reported two DVTs in 86 patients following open repair of the Achilles tendon. No patients in our series5 sustained a re-rupture or developed a DVT.
Also, functionally all patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp.
Results
Twenty-one patients were managed with this technique. The delay in presentation varied from 2 to 9 months following the rupture.5 The outcome
of surgical management was rated using a four- point scale.25 Most patients were satisfi ed with the procedure; only two were classifi ed as having an excellent result, although 15 of our 21 patients achieved a good result.
The maximum calf circumference was signifi - cantly decreased in the operated leg both at pre- sentation and at latest follow-up.
Patients were able to perform at least 10 single- leg heel lifts on the affected leg by discharge, and four patients were able to perform at least 60 single-leg heel lifts on the affected leg. All patients had returned to their pre-injury working occupa- tion. Of the 21 patients included in this study, 15 had returned to their leisure activities. Of these 15, fi ve of the seven patients who played tennis returned to playing doubles. Three patients who played squash were able to return to training, but did not plan to return to competition. Four patients returned to bowling, and the remaining three returned to golf, although not with the same frequency as before the injury. Of the whole group of 21 patients, six were sedentary and only walked their dogs and performed gardening. They reported no problems in these activities.
The operated limb showed a lower peak torque than the nonoperated one, but the patients did not perceive this decrease in strength as hampering their daily or leisure activities.
Conclusions
The management of chronic subcutaneous tears of the Achilles tendon by free gracilis tendon grafting is safe but technically demanding. It affords good recovery, even in patients with a chronic rupture of two to nine months’ duration.
Such patients should be warned that they are at risk of postoperative complications, that the wasting of their calf is not likely to recover, and that their ankle plantarfl exion strength can remain reduced.
References
1. McClelland D, Maffulli N. Neglected rupture of the Achilles tendon: Reconstruction with pero- neus brevis tendon transfer. Surgeon 2004 Aug;2(4):
209–213.
2. Mann RA, Holmes GB, Seale KS, Collins DN.
Chronic rupture of the Achilles tendon: A new technique of repair. J Bone Joint Surg 1991;
73-A:214–219.
3. Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon: Treatment by V-Y tendinous fl ap. J Bone Joint Surg 1975; 57-A:253–255.
4. Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of chronic Achilles tendon rupture with Flexor hallucis longus tendon trans- fer. Foot Ankle 1993; 14:443–449.
5. Maffulli N, Leadbetter WB. Free Gracilis Tendon graft in neglected tears of the Achilles tendon. Clin J Sport Med 2005; 15(2):56–61.
6. Young J, Sayana, MK, Maffulli, N, Leadbetter WB.
Technique of free gracilis tendon transfer for delayed rupture of the Achilles tendon. Techniques Foot Ankle Surg 2005; 4(3):148–153.
7. DiStefano VJ, Nixon JE. Achilles tendon rupture:
Pathogenesis, diagnosis and treatment by a modi- fi ed pullout wire technique. J Trauma 1972; 12(8):
671–677.
8. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999; 81-A:1019–1036.
9. Maffulli N. Clinical tests in sports medicine: More on Achilles tendon. Br J Sports Med 1996; 30:250.
10. 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.
11. Simmonds FA. The diagnosis of the ruptured Achil- les tendon. Practitioner 1957; 179:56–58.
12. Matles AL. Rupture of the tendo Achilles: Another diagnostic sign. Bull Hosp Joint Dis 1975; 36:48–
51.
13. Maffulli N, Dymond NP, Capasso G. Ultrasono- graphic fi ndings in subcutaneous rupture of Achilles tendon. J Sports Med Phys Fitness 1989;
29:365–368.
14. Kabbani YM, Mayer DP. Magnetic resonance imaging of tendon pathology about the foot and ankle: Part I. Achilles tendon. J Am Podiatr Med Ass 1993; 83:418–420.
15. Bosworth DM. Repair of defects in the tendo Achil- lis. J Bone Joint Surg 1956; 38-A:111–114.
16. Bugg EI, Boyd BM. Repair of neglected rupture or laceration of the Achilles tendon. Clin Orthop 1968;
56:73–75.
17. Lynn TA. Repair of the torn Achilles tendon, using plantaris tendon as a reinforcing membrane. J Bone Joint Surg 1966; 48-A:268–272.
18. Howard CB, Winston I, Bell W, Mackie I, Jenkins DHR. Late repair of the calcaneal tendon with carbon fi bre. J Bone Joint Surg 1984; 66-B:206–
208.
