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Less invasive Achilles tendon reconstruction
© Carmont and Maffulli; licensee BioMed Central Ltd. 2007
Received: 10 May 2007
Accepted: 26 October 2007
Published: 26 October 2007
The optimal management of chronic ruptures of the Achilles tendon is surgical reconstruction. Reconstruction of the Achilles tendon using peroneus brevis has been widely reported. Classically, these procedures involve relatively long surgical wounds in a relatively hypovascular area which is susceptible to wound breakdown.
We describe our current method of peroneus brevis reconstruction for the Achilles tendon using two para-midline incisions.
This technique allows reconstruction of the Achilles tendon using peroneus brevis preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of previous surgery.
Acute Achilles tendons ruptures may be managed either operatively or non-operatively. However, generally 6 weeks following a rupture a direct repair opposing the tendon ends becomes increasingly difficult. Over time, scar tissue forms, the muscles atrophy with disuse, and the tendon ends weaken. Chronic and neglected Achilles tendon ruptures are debilitating: their optimal management is surgical . Operative procedures for reconstruction of the Achilles tendon include flap tissue turn down using one [2–4] and two flaps , local tendon transfer [6–9], and autologous hamstring tendon harvesting . All of these techniques use a single longitudinal incision for exposure. Following these procedures, complications, especially wound breakdown and infection (9%), are not infrequent, are probably related to the paucity of the soft tissue vascularity, and may require plastic surgical procedures to cover significant soft tissue defects [11–14].
We previously described our open technique to allow full exposure for late reconstruction of chronic Achilles tendon tears using peroneus brevis . We describe our current method, using less invasive surgery than an open reconstruction. Our technique uses two para-midline incisions preserving skin integrity over the site most prone to wound breakdown.
The patient is positioned prone with a calf tourniquet. Skin preparation is performed in the usual fashion, and sterile drapes are applied. Pre-operative anatomical markings include the palpable tendon defect, both malleoli, and the base of the fifth metatarsal.
Post operatively, patients are allowed to weight bear as comfort allows with the use of elbow crutches. It would be unusual for a patient to weight bear fully at this stage. After 2 weeks, the back shell is removed, and physiotherapy is commenced with the front shell in situ preventing dorsiflexion of the ankle, focusing on proprioception, plantar-flexion of the ankle, inversion and eversion. During this period of rehabilitation the patient is permitted to weight bear as comfort allows with the front shell in situ although full weight bearing rarely occurs on account of balance difficulties and patients usually still require the assistance of a single elbow crutch as this stage. The front shell may be finally removed after 6 weeks. We do not use a heel raise after removal of the cast, and patients normally regain a plantigrade ankle over a couple of weeks.
The use of peroneus brevis for reconstruction of chronic Achilles tendon tears is well established . Achilles tendon reconstruction with peroneus brevis is advantageous in patients involved in sports , leaving minimal or no objective plantar flexion weakness following the procedure , and minimal re-rupture rates . Peroneus brevis fulfils many of the essential criteria for tendon transfer . The tendon has an acceptable strength of 116.2 N/mm, cross sectional area of 19.5 cm2 and an elastic modulus of 149.7 N/mm2, compared to an ultimate tensile load of 1724 N [20–22], has similar line of pull, is in phase, has adequate excursion, and is expendable. It is also easily identified distally inserting into the tubercle of the base of the fifth metatarsal, whereas at this level the tendon of peroneus longus has already passed within its groove on the plantar aspect of the cuboid .
Reconstruction techniques include passing the tendon through a tunnel drilled through the calcaneus  and a tenotomy in the proximal Achilles tendon stump , and through tenotomies in the distal and the proximal tendon stumps as an open procedure [9, 24]. These techniques use relatively long longitudinal incisions, and wound breakdown may occur. In our hands the open technique had a 9% superficial infection rate . In many instances, reconstructive procedures for the Achilles tendon have incorporated plastic surgical flap procedures to facilitate skin closure [11, 13, 14].
Following surgery, the ankle is kept in equinus to prevent disruption of the reconstruction. Vascularity of the soft tissues is maximal at 20° of plantar flexion, and at 40° of plantar flexion the blood supply of the skin is reduced by 49% . Therefore, the tightness of the repair may influence wound healing.
In patients with chronic ruptures, the skin over the gap retracts over several weeks, and remains so until the operation. In open surgery, this skin is incised, and is then stretched out in a relatively acute fashion to accommodate the reconstructed tendon. Therefore, following the reconstruction, the skin over the gap may well be stretched so much that vascular supply is impaired .
The reconstructed gastro-soleus Achilles tendon complex will stretch with increased loading and range of movement exercises during rehabilitation .
Preservation of skin cover during reconstruction procedures is clearly an advantage, as the skin is not injured by the operation, and protects the reconstruction beneath. As with all surgery performed through less invasive incisions, this procedure is technically demanding. Careful incision placement is required together with skin retraction to allow visualisation of the tendon ends and to permit the reconstruction. The technique is designed to preserve skin cover of the reconstruction site, and, although reconstruction is always risky, it may extend the indications for surgery in groups prone to wound complications such as vasculopaths and diabetics.
This technique allows reconstruction of the Achilles tendon using peroneus brevis preserving skin integrity, and can be especially used to reconstruct the Achilles tendon in the presence of previous surgery.
We thank the Department of Medical Illustration for their help with this research. The patient has given their written consent for the photographs used.
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