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Minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization
© The Author(s). 2016
- Received: 16 July 2015
- Accepted: 25 May 2016
- Published: 3 June 2016
Plantaris tendon, peronus brevis tendon and flexor hallucis longus tendon augmentation, commonly used in Achilles tendon rupture, often lead to weakening of injured foot and they require the immobilization after the surgery. It is essential to develop the technique, which gives no such limitation and allows for immediate functional improvement.
We present our method of minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization.
Posterolateral and posteromedial portals were made approximately 3 cm above the posterosuperior part of the calcaneus to clean the area of the Achilles tendon endoscopically. Then the hamstrings are harvested and prepared for the “Endobutton” system. A midline incision of the skin is performed approximately 1 cm above the posterosuperior part of the calcaneus to approach to the posterosuperior part of the calcaneus. Then under fluoroscopy the calcaneus was drilled through using K-wire. The distal end of the graft equipped with an Endobutton loop was entered into the drilled tunnel in the calcaneus. Later, 8 consecutive skin incisions are performed. Proximal ends of the graft were brought out through the native Achilles tendon reaching medial and lateral skin incisions. The final step was to transfer and tie the graft ends through the most proximal skin incision.
This minimally invasive, endoscopic technique allows reconstruction of the Achilles tendon using semitendinosus and gracilis tendons with Endobutton stabilization and can be used in so-called “difficult”, resistant cases as a “salvage procedure”.
- Achilles tendon
- Neglected rupture
- Achilles endoscopy
- Achilles reconstruction
The Achilles tendon ruptures constitute a common clinical problem . Changes that occur due to the aging process also increase exposure to possible damage . The Achilles tendon rupture causes sudden and severe pain in the acute phase, and if left untreated, can cause muscle weakness, resulting in worsened physical functionality of the patient .
Rupture is defined as chronic if it is present at least for 4–6 weeks [4, 5]. Cases of chronic rupture of the Achilles tendon do not respond effectively to conservative treatment and therefore they require repair utilising graft . The indications for surgical management of neglected Achilles tendon ruptures include weakness of the triceps surae complex, functional lengthening of the gastrocnemius–soleus complex, and an apropulsive gait . Treatment of neglected the Achilles tendon ruptures, or re-ruptures, often involves considerable technical problems. The most common are: an enlarged gap (>3 cm) between the tendon ends, preventing end to end stapling, scarring of the tendon stumps and adjacent parts, shortening of the rear calf muscle groups, loss of muscle contractility forming the Achilles tendon and problems with wound healing . Due to these reasons, the surgical treatment of chronic damages differs from the treatment of acute Achilles tendon damage.
It has been confirmed that open technical procedures for the treatment of ruptures of the Achilles tendon lead to postoperative wound complications because of the fragility and limited vascularization of the skin , and also they can increase the risk of the infection and morbidity . Thus, minimally invasive techniques have been developed [11–16], however they are technically demanding .
Typical methods of repairing neglected Achilles tendon damage are augmentation of the plantaris tendon, peroneus brevis tendon and flexor hallucis longus tendon. Tendon transfer techniques are being commonly used, yet often result in permanent functional complications. Flexor hallucis longus transfer involves a decrease of hallux flexion strength [14, 18]. The loss of foot eversion strength associated with the transfer of the peroneus brevis tendon is little, however, subjective reduction in foot strength may occur [15, 16]. Use of turn down flaps is also widely used in neglected Achilles tendon ruptures. In cases of large gap (more than 3 cm) it requires large interference in the proximal stump, which often lacks in quality and needs additional reinforcement . Additionally patient is exposed to wound healing problems due to large skin incision and Achilles tendon exposure.
We present our method of minimally invasive, endoscopic Achilles tendon reconstruction for patients with neglected tendon rupture, with end gap over 3 cm. In our technique we use semitendinosus and gracilis tendons transfer with Endobutton stabilization.
The surgery is routinely performed under spinal anesthesia. The patient lay in prone position with the pneumatic tourniquet applied at the midthigh at a fixed pressure of 250 mmHg, in order to obtain ischemia within the surgical field.
An approximately 3 cm incision is made just below the knee on the inside and top part of the tibia to make the semitendinosus and gracilis tendons visible. Harvested grafts are cleaned and hemmed with an Ethibond 2 thread (Ethicon, USA). Afterwards the hamstring graft is prepared for the Endobutton system (Smith & Nephew, USA). Both tendons are grouped together and folded in half creating a bundle of 4 (the length of about 10 cm, from 7 mm to 9 mm thick, provided with an Endobutton loop system). The length of the loop is chosen according to the total length of the calcaneus bone tunnel to obtain an intracalcaneal graft length of a minimum 1.5 cm.
Preparation of the tunnel in the calcaneus
Restoring the Achilles tendon continuity
After releasing the tourniquet and hemostatic control, wounds are sutured. Afterwards, a Jones dressing is performed with 10° of plantar flexion.
Patients are discharged on the day after surgery after being instructed by a physiotherapist about using crutches and rehabilitation for the first 2 weeks. We do not use any immobilisation neither orthosis. Thromboprophylaxis is provided with Fraxiparine (nadroparin calcium, GlaxoSmithKline) 0.6 ml administered subcutaneously once a day. Partial weight bearing is allowed immediately after the surgery and full weight bearing after 2 weeks if tolerated. There are no limitations in the active range of motion of the operated foot. A follow-up postoperative x-ray is obtained at 2 weeks post-surgery.
The main findings of the present study is that our new method of minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization can be a treatment option for patients with neglected Achilles rupture with the end gap over 3 cm.
Treating neglected Achilles tendon rupture is challenging, and there is still a scientific debate over the surgical approach (open or percutaneous), suture repair method and suture type . Conventional operative treatments for chronic damages of the Achilles tendon are plantaris tendon, peroneus brevis tendon and flexor hallucis longus tendon augmentation [13–16]. Turn down flaps is also widely used in neglected Achilles tendon . All of these techniques use a single longitudinal incision for exposure. Following these procedures, complications, especially wound breakdown and infection, are not infrequent. They are probably related to the paucity of the soft tissue vascularity, and they may require plastic surgical procedures to cover significant soft tissue defects . Moreover, following these procedures, complications, especially foot strength weakening is observed [13–16]. In our opinion we should avoid to weaken, already injured and weakened foot, and surgeons should try to use grafts harvested anatomically placed away from the foot. That is why, following this concept of using hamstring graft for chronic Achilles reconstructions seems to be the ideal resolution.
Indications and contraindications for minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization
- neglected Achilles ruptures with end gap > 3 cm
- neglected partial damage (>50 %) resulting from Achilles tendon dysfunction
- failure of previous conservative and surgical treatment
- metabolic disorders
Minimally invasive technique of Achilles reconstruction limits the risk of damaging surrounding tissue when it is compared to open techniques . Suturing the Achilles tendon with the Bunnel suture is widely used [13, 23]. Such approach provides adequate tensile strength and it can be implemented into percutaneous technique. The use of the hamstring autograft was proven to be safe and effective in reducing autoimmune reactions [23–26].
Advantages of minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization
- fast and simple procedure
- minimal risk of wound healing complications
- no weakening of injured foot
- minimal risk of donor site morbidity
- very fast functional improvement
- no need of immobilization, no need of orthosis use
Pitfalls in minimally invasive, endoscopic Achilles tendon reconstruction using semitendinosus and gracilis tendons with Endobutton stabilization
- entry point in calcaneal tunnel should be properly localized it minimize the risk of calcaneal fracture and clash of Achilles tendon with shoes
- distal end of calcaneal tunnel should be located anterior to plantar fascia attachment, where the posterior-bottom calcaneus cortex is thick
- be aware of sural nerve damage (we advise larger skin incision number 8 to visualize the nerve)
We acknowledge that this paper is a technical note, and no data about clinical results of our patients are presented. However, we would like to inform that our preliminary results are very encouraging and we plan to analyze the long-term outcomes of this technique. This will be the subject of future research projects.
This technique allows for minimally invasive, endoscopic reconstruction of Achilles tendon using semitendinosus and gracilis tendons with Endobutton stabilization, and it can be a treatment option for patients with neglected Achilles tendon rupture with end gap over 3 cm, and in cases who failed of previous conservative and surgical treatment.
TP and KC-G developed this surgical technique. TP performed the surgeries. PB and KC-G took part in the surgeries. PB and MG performed literature search. KC-G prepared the figures. PB wrote the initial draft. TP, KC-G, and MG provided comments and prepare the final version of the manuscript for publication. All authors read and approved the final manuscript.
The authors declare that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article.
Consent to publish
Written informed consent was obtained from the patient for publication of these data and for publication of all accompanying images.
Ethical approval and consent to participate
The presented case was treated off-label. Due to less invasive surgery than other used methods (open reconstruction or open tendon transfer) the treatment did not require the approval of the ethics committee.
The surgeon (First Author – TP) posseses the necessary qualifications (Senior Research Fellow at the Poznań University of Medical Sciences) to carry out off-label procedures.
Polish medical law statements are provided in the attachment.
The novel procedure was explained to the patients. They had an option to choose standard care (open procedure with FHL transfer).
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- Longo UG, Ronga M, Maffulli N. Acute ruptures of the achilles tendon. Sports Med Arthrosc. 2009;17:127–38.View ArticlePubMedGoogle Scholar
- Peffers MJ, Fang Y, Cheung K, Wei TKJ, Clegg PD, Birch HL. Transcriptome analysis of ageing in uninjured human Achilles tendon. Arthritis Res Ther. 2015;17:33.View ArticlePubMedPubMed CentralGoogle Scholar
- Bertelli R, Gaiani L, Palmonari M. Neglected rupture of the Achilles tendon treated with a percutaneous technique. Foot Ankle Surg. 2009;15:169–73.View ArticlePubMedGoogle Scholar
- Hartog Den BD: Surgical strategies: delayed diagnosis or neglected Achilles’ tendon ruptures. Foot Ankle Int 2008;29:456-463.Google Scholar
- Jennings AG, Sefton GK. Chronic rupture of tendo Achillis. Long-term results of operative management using polyester tape. J Bone Joint Surg Br. 2002;84:361–3.View ArticlePubMedGoogle Scholar
- Maffulli N, Ajis A, Longo UG, Denaro V. Chronic rupture of tendo Achillis. Foot Ankle Clin. 2007;12:583–96.View ArticlePubMedGoogle Scholar
- Peterson KS, Hentges MJ, Catanzariti AR, Mendicino MR, Mendicino RW. Surgical considerations for the neglected or chronic Achilles tendon rupture: a combined technique for reconstruction. J Foot Ankle Surg. 2014;53:664–71.View ArticlePubMedGoogle Scholar
- Lapidus LJ, Ray BA, Hamberg P. Medial Achilles tendon island flap--a novel technique to treat reruptures and neglected ruptures of the Achilles tendon. Int Orthop. 2012;36:1629–34.View ArticlePubMedPubMed CentralGoogle Scholar
- Knobe M, Gradl G, Klos K, Corsten J, Dienstknecht T, Rath B, Sönmez TT, Hoeckle C, Pape H-C. Is percutaneous suturing superior to open fibrin gluing in acute Achilles tendon rupture? Int Orthop. 2015;39:535–42.View ArticlePubMedGoogle Scholar
- Saxena A, Maffulli N, Nguyen A, Li A. Wound complications from surgeries pertaining to the Achilles tendon: an analysis of 219 surgeries. J Am Podiatr Med Assoc. 2008;98:95–101.View ArticlePubMedGoogle Scholar
- Maffulli N, Leadbetter WB. Free gracilis tendon graft in neglected tears of the Achilles tendon. Clin J Sport Med. 2005;15:56–61.View ArticlePubMedGoogle Scholar
- Maffulli N, Spiezia F, Longo UG, Denaro V. Less-invasive reconstruction of chronic achilles tendon ruptures using a peroneus brevis tendon transfer. Am J Sports Med. 2010;38:2304–12.View ArticlePubMedGoogle Scholar
- Lee KB, Park YH, Yoon TR, Chung JY. Reconstruction of neglected Achilles tendon rupture using the flexor hallucis tendon. Knee Surg Sports Traumatol Arthrosc. 2009;17:316–20.View ArticlePubMedGoogle Scholar
- Mahajan RH, Dalal RB. Flexor hallucis longus tendon transfer for reconstruction of chronically ruptured Achilles tendons. J Orthop Surg (Hong Kong). 2009;17:194–8.Google Scholar
- Singh A, Nag K, Roy SP, Gupta RC, Gulati V, Agrawal N. Repair of Achilles tendon ruptures with peroneus brevis tendon augmentation. J Orthop Surg (Hong Kong). 2014;22:52–5.Google Scholar
- McClelland D, Maffulli N. Neglected rupture of the Achilles tendon: reconstruction with peroneus brevis tendon transfer. Surgeon. 2004;2:209–13.View ArticlePubMedGoogle Scholar
- Maffulli N, Longo UG, Spiezia F, Denaro V. Minimally invasive surgery for Achilles tendon pathologies. OAJSM. 2010;1:95–103.View ArticlePubMedPubMed CentralGoogle Scholar
- Ahmad J, Jones K, Raikin SM. Treatment of Chronic Achilles Tendon Ruptures With Large Defects. Foot Ankle Spec. 2016.Google Scholar
- Maffulli N, Longo UG, Gougoulias N, Denaro V. Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon. BMC Musculoskeletal Disord. 2008;9:100.View ArticleGoogle Scholar
- Reiman M, Burgi C, Strube E, Prue K, Ray K, Elliott A, Goode A. The utility of clinical measures for the diagnosis of achilles tendon injuries: a systematic review with meta-analysis. J Athl Train. 2014;49:820–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Gulati V, Jaggard M, Al-Nammari SS, Uzoigwe C, Gulati P, Ismail N, Gibbons C, Gupte C. Management of achilles tendon injury: A current concepts systematic review. World J Orthop. 2015;6:380–6.View ArticlePubMedPubMed CentralGoogle Scholar
- Molloy A, Wood EV. Complications of the treatment of Achilles tendon ruptures. Foot Ankle Clin. 2009;14:745–59.View ArticlePubMedGoogle Scholar
- Sadoghi P, Rosso C, Valderrabano V, Leithner A, Vavken P. Initial Achilles tendon repair strength--synthesized biomechanical data from 196 cadaver repairs. Int Orthop. 2012;36:1947–51.View ArticlePubMedPubMed CentralGoogle Scholar
- Takeuchi M, Suzue N, Matsuura T, Higashino K, Sakai T, Hamada D, Goto T, Takata Y, Nishisho T, Goda Y, Sato R, Tonogai I, Mineta K, Sairyo K. Reconstruction of chronic Achilles tendon rupture using the semitendinosus tendon: a case report. J Med Invest. 2014;61:417–20.Google Scholar
- Piontek T, Ciemniewska-Gorzela K, Szulc A, Naczk J, Wardak M, Trzaska T, Dudzinski W, Grygorowicz M. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction with autologous hamstring grafts-isokinetic assessment with control group. PLoS One. 2013;8:e82462.Google Scholar
- Maffulli N, Spiezia F, Testa V, Capasso G, Longo UG, Denaro V. Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon. J Bone Joint Surg Am. 2012;94:906–10.PubMedGoogle Scholar