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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.
- Achilles Tendon
- Sural Nerve
- Plantar Flexion
- Achilles Tendon Rupture
- Wound Breakdown
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.
- Leslie HD, Edwards WH: Neglected ruptures of the Achilles tendon. Foot Ankle Clin. 2005, 10 (2): 357-370. 10.1016/j.fcl.2005.01.009.View ArticlePubMedGoogle Scholar
- Lee YS, Lin CC, Chen CN, Chen SH, Liao WY, Huang CR: Reconstruction for neglected Achilles tendon rupture: the modified Bosworth technique. Orthopedics. 2005, 28 (7): 647-650.PubMedGoogle Scholar
- Christiansen LB: Rupture of the Achilles tendon: analysis of 57 cases. Acta Chir Scand. 1953, 106: 50-60.Google Scholar
- Silfverskiold N: Uber die subkutaneous totale Achillessehnenruptur und deren behander. Acta Chir Scand. 1941, 84: 393-Google Scholar
- Amer O, Lindholm A: Subcutaneous rupture of the Achilles tendon. A study of ninety two cases. Acta Chir Scand. 1959, 239: 1-51.Google Scholar
- Dekker M, Bender J: Results of surgical treatment of rupture of the Achilles tendon with the use of the plantaris tendon. Arch Chir Neerl. 1977, 29 (1): 39-45.PubMedGoogle Scholar
- Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R: Repair of chronic Achilles tendon rupture with flexor hallucis longus. Foot Ankle. 1993, 14 (8): 443-9.View ArticlePubMedGoogle Scholar
- Wilcox DK, Bohay DR, Anderson JG: Treatment of chronic Achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int. 2000, 21 (12): 1004-10.PubMedGoogle Scholar
- McClelland D, Maffulli N: Neglected rupture of the Achilles tendon: reconstruction with peroneus brevis transfer. Surgeon. 2004, 2 (4): 209-13.View ArticlePubMedGoogle Scholar
- Maffulli N, Leadbetter WB: Free gracilis tendon graft in neglected tears of the Achilles tendon. Clin J Sport Med. 2005, 15 (2): 56-61. 10.1097/01.jsm.0000152714.05097.ef.View ArticlePubMedGoogle Scholar
- Ademoglu Y, Ozerkan F, Ada S, Bora A, Kaplan I, Kayalar M, Kul F: Reconstruction of skin and tendon defects from wound complications after Achilles tendon rupture. J Foot Ankle Surg. 2001, 40 (3): 158-65.View ArticlePubMedGoogle Scholar
- Kumta SM, Maffulli N: Local flap coverage for soft tissue defects following open repair of Achilles tendon rupture. Acta Orthop Belg. 2003, 69 (1): 59-66.PubMedGoogle Scholar
- Dabernig J, Shilov B, Schumacher O, Lenz C, Dabernig W, Schaff J: Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fascia latae flap. J Plas Recon & Aesth Surg. 2006, 59: 142-147. 10.1016/j.bjps.2005.07.011.View ArticleGoogle Scholar
- Attinger CE, Ducic I, Hess CL, Basil A, Abbruzzesse M, Cooper P: Outcome of skin graft versus flap surgery in the salvage of the exposed Achilles tendon in diabetics versus non diabetics. Plast Reconstr Surg. 2006, 117 (7): 2460-7. 10.1097/01.prs.0000219345.73727.f5.View ArticlePubMedGoogle Scholar
- Webb J, Moorjani N, Radford M: Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int. 2000, 21 (6): 475-7.PubMedGoogle Scholar
- Turco V, Spinella AJ: Peroneus brevis transfer for Achilles tendon rupture in athletes. Orthop Rev. 1988, 17 (8): 822-4. 827-8.PubMedGoogle Scholar
- Pintore E, Barra V, Pintore R, Maffulli N: Peroneus brevis transfer in neglected tears of the Achilles tendon. J Trauma. 2001, 50 (1): 71-8.View ArticlePubMedGoogle Scholar
- Gallant GG, Massie C, Turco VJ: Assessment of eversion and plantarflexion strength after repair of Achilles tendon rupture using peroneus brevis tendon transfer. Am J Orthop. 1995, 24 (3): 257-61.PubMedGoogle Scholar
- Fenton CF, Gilman RD, Jassen M, Dollard M, Smith GA: Criteria for selected major tendon transfers in podiatric surgery. J Am Podiatry Assoc. 1983, 73 (11): 561-8.View ArticlePubMedGoogle Scholar
- Attarian DE, McCrackin HJ, Devito DP, McElhaney JH, Garrett WE: A biomechanical study of human lateral ankle ligaments and autogenous reconstructive grafts. Am J Sports Med. 1985, 13 (6): 377-81. 10.1177/036354658501300602.View ArticlePubMedGoogle Scholar
- Bohnsack M, Surie B, Kirsch IL, Wulker N: Biomechanical properties of commonly used autogenous transplants in the treatment of chronic lateral ankle instability. Foot Ankle Int. 2002, 23 (7): 661-4.View ArticlePubMedGoogle Scholar
- Datta B, Turner A, Neil M, Maffulli N, Walsh WR: Mechanical properties of human flexor hallucis longus, peroneus brevis and tendo Achilles tendons. 2006, Presented at ESSKA Congress, InnsbruckGoogle Scholar
- Williams A, Newell RLM, Davies MS, Collins P: The pelvic girdle and lower limb. Grays Anatomy. Edited by: Standring S. 2005, London: Elsevier, Chapter 114:Google Scholar
- Pérez Teuffer A: Traumatic rupture of the Achilles Tendon. Reconstruction by transplant and graft using the lateral peroneus brevis. Orthop Clin North Am. 1974, 5 (1): 89-93.PubMedGoogle Scholar
- Turco VJ, Spinella AJ: Achilles tendon ruptures-peroneus brevis transfer. Foot Ankle. 1987, 7 (4): 253-9.View ArticlePubMedGoogle Scholar
- Poynton AR, O'Rourke K: An analysis of skin perfusion over the Achilles tendon in varying degrees of plantar flexion. Foot Ankle Int. 2001, 22 (7): 572-4.PubMedGoogle Scholar
- Myerson MS: Disorders of the Achilles tendon, Chapter 10-1. Reconstructive Foot and Ankle Surgery. 2005, Philadelphia: Elsevier SaundersGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/8/100/prepub