21 Free Gracilis Tendon Transfer for Chronic Rupture of the Achilles Tendon

Jonathan S. Young, Wayne B. Leadbetter, and Nicola Maffulli

Introduction Management

Chronic ruptures of the Achilles tendon are asso- Management of a chronic Achilles tendon rupture ciated with both functional and operative morbid- is more diffi cult than acute rupture. Generally, an 1,8 ity.1 Various methods are described to manage open procedure must be carried out. Surgery this condition.1–4 The tendon of gracilis has requires the tendon edges to be freshened, and, as recently been used to reconstruct the Achilles they will be retracted, a large gap will thus be tendon.5,6 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 Diagnosis tendon has been used.15 A proximal-to-distal V-Y advancement of the gastrocnemius tendon has Although diagnosis is straightforward for also been described.3 experienced surgeons,7 and most Achilles tendon Mann et al.2 described the use of a fl exor digi- ruptures are promptly diagnosed,1,7,8 fi rst examin- torum longus (FDL) graft in seven patients. Six of ing physicians may miss up to 20% of such the seven patients had an excellent result, and one injuries.9 The diagnosis of chronic rupture can a fair result. There were no re-ruptures at an be more diffi cult,1,10 as fi brous scar tissue may average follow-up of 39 months. have replaced the gap between the proximal and More recently, the tendon of fl exor hallucis distal ends of the Achilles tendon, and therefore longus (FHL) has been used. FHL has a long the gap palpable in acute ruptures is no longer tendon that allows bridging of large Achilles present. There may also be less pain and tendon defects.4 Wapner et al.4 reported 7 swelling. patients managed with this technique. The Clinically, the Simmonds11 and Matles12 tests tendon of FHL was woven through the ruptured help aid the diagnosis in both acute and delayed Achilles tendon ends. The distal end of FHL rupture, but even these tests may be of dubious was tenodesed to the tendon of FDL of the second interpretation, and imaging may have to be toe. Three patients had an excellent result, three used.8,13,14 Ultrasonography of a neglected rupture a good result, and one a fair result. Each will reveal an acoustic vacuum with thick irregu- patient developed a “small but functionally insig- lar edges.8,13 Magnetic resonance imaging will nifi cant loss in range of motion in the involved reveal generalized high signal intensity on T2 ankle and great toe.” This may be important in weighted images. On T1 weighted images, the athletic individuals, in whom the loss of push- rupture will appear as a disruption of the signal off from the hallux may cause diffi culty when within the tendon substance.14 sprinting.

188 21. Free Gracilis Tendon Transfer for Chronic Rupture of the Achilles Tendon 189

Fascia lata grafts,16 plantaris,17 and synthetic residual gap. Scar tissue in both the proximal and materials18 have also been used in the management distal stumps is excised to reach viable tendon. of neglected ruptures of the Achilles tendon. If the gap produced is greater than 6 cm despite Perez-Teuffer19 popularized the use of the pero- maximal plantarfl exion of the ankle and traction neus brevis. Turco and Spinella20 used a similar on the Achilles tendon stumps, we proceed to technique, but passed the peroneus brevis tendon harvest the tendon of gracilis. A vertical 2.5- to 3- through the distal stump of the Achilles tendon. cm longitudinal incision is made over the tibial McClelland and Maffulli1 used a similar technique, tuberosity, and should be centred over the distal but they approached the Achilles tendon through insertion of the pes anserinus (where the gracilis a curvilinear medial incision, thus minimizing the tendon inserts). There is a constant venous plexus risk of sural nerve injury. lying at the distal end of the wound, and care More recently, we used the tendon of gracilis as should be taken to diathermy this. Using a small a free graft to bridge the gap in chronic ruptures.5,6 swab attached to an artery clip, dissection deep to We report the details of this technique. 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 Preoperative Assessment margin of the pes anserinus into the sartorious fascia. Care is taken to avoid damage to the saphe- nous nerve. Through this incision, Mackenrodt The patient is assessed, a full history is collected, scissors are introduced and opened so as to split clinical examination is carried out, and fi tness for and produce a window within the superior border anesthesia and the neurovascular status of the of the sartorious, allowing for access to the tendon limb are assessed, paying particular attention to of gracilis. the sural nerve. The diagnosis of chronic rupture The gracilis tendon lies more superiorly than may be diffi cult and require further imaging. the neighboring tendon of semitendinosus. It can Written informed consent is taken. The patient be retrieved with the aid of a curved Moynihan should be aware of wound problems, neurovascu- clip (Fig. 21.1). The tendon is brought into the lar damage, altered sensation around the gracilis wound and distal traction on the tendon is harvest site, calf wasting, weakness of ankle imposed. An open-ended tendon stripper is used fl exion, and the risk of failure of surgery and of to harvest the tendon (Fig. 21.2).21 anesthesia. 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 Operative Technique scalpel blade in the substance of the distal stump of the Achilles tendon in a medial-to-lateral direc- With the patient prone and both feet dangling tion. The gracilis tendon is then pulled proximally from the end of the operating table, the affected and through a small incision in the substance of leg and ankle is prepped and draped. A single dose the proximal stump of the Achilles tendon in a of a fi rst-generation cephalosporin is adminis- lateral-to-medial direction through the proximal tered at induction of anesthesia. The limb is stump (Fig. 21.4). The gracilis tendon is sutured exsanguinated and a thigh tourniquet is infl ated to the Achilles tendon at each entry and exit point to 250 mmHg. A 12- to 15-cm longitudinal, slightly using 3-0 Vicryl (Polyglactin 910 braided absorb- curvilinear skin incision is made medial and ante- able suture, Johnson & Johnson, European Logis- rior to the medial border of the tendon. The tics Centre, 66 Rue de la Fusee, B-1130 Bruxelles, paratenon, if not disrupted, is incised longitudi- Belgium). The repair is tensioned to greater than nally in the midline for the length of the skin inci- the physiological equinus present in the opposite sion. The Achilles tendon is thus exposed. Gentle ankle. When present, the tendon of plantaris can continuous traction is applied so that the proxi- be harvested with the tendon stripper, left attached mal stump of the ruptured tendon is further deliv- distally (Fig. 21.5), and used to reinforce the ered into the wound, allowing the lowest possible reconstruction (Fig. 21.6). 190 J.S. Young et al.

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. 21. Free Gracilis Tendon Transfer for Chronic Rupture of the Achilles Tendon 191

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. 192 J.S. Young et al.

Interrupted 4-0 Vicryl reabsorbable sutures are ing exercises.22 Cycling and swimming are started used for the subcutaneous fat, and the skin is eight weeks after surgery if the wound is healthy. closed with interrupted 4.0 Ethilon (Ethicon, Patients are prompted to increase the frequency Johnson & Johnson, European Logistics Centre, of their self-administered exercise program, and 66 Rue de la Fusee, B-1130 Bruxelles, Belgium), or are allowed to return to their sports in the fi fth with subcuticular 3-0 Vicryl. The tourniquet is postoperative month. defl ated, the wound is dressed, and a below-knee plaster-of-Paris cast is applied with the patient prone. Complications

Wound infection, breakdown, and scar problems Postoperative Care are a documented risk in open repairs of the Achilles tendon,1,8 given the tenuous blood supply Postoperatively, the injured leg is elevated until in this area.23 There is also the theoretical risk of discharge. Patients are discharged the day after infection and wound breakdown to the donor surgery, after having been taught to use crutches gracilis tendon site. In our series,5 fi ve patients 8 by an orthopedic physiotherapist. Thrombo- had a superfi cial infection of the Achilles tendon prophylaxis is provided with Fragmin, 2,500 units surgical wound. They were managed conserva- (Deltaparin Sodium, Pharmacia and Upjohn, tively with oral antibiotics following a microbiol- Roma, Italy) subcutaneously once daily, or with ogy swab to ascertain sensitivity, were asked to 150 mg of acetylsalicylic acid orally daily, until keep the leg elevated at all times, and healed removal of the cast. When the cast has dried, uneventfully by the 18th postoperative week. At patients are encouraged to mobilize with the use the sixth postoperative month, two patients com- of crutches, under the direction of a physiothera- plained of hypersensitivity of the surgical wounds. pist. Patients are allowed to bear weight on the They were counseled to rub hand cream over the operated leg as tolerated, but are told to keep the wounds several times a day, and all were asymp- operated leg elevated as much as possible for the tomatic by the next visit. One patient developed a 22 fi rst two postoperative weeks. hypertrophic scar in the area of the Achilles The cast is removed two weeks after the opera- tendon surgical wound as it rubbed against the tion, and a synthetic anterior below-knee slab is shoe, and was not pleased with the appearance of 1 applied, with the foot in gravity equinus. The syn- the operative scar. Other early complications thetic slab is secured to the leg with three or four include wound hematoma and sural nerve sensory removable Velcro (Velcro USA Inc., Manchester, defi cit from intraoperative injury. Medial posi- NH, USA) straps for four weeks. Patients are tioning of the incision helps to reduce sural nerve encouraged to weight bear on the operated limb injury.1 Re-rupture is one of the most important as soon as comfortable, and to gradually progress late complications.1,19 Deep vein thrombosis is to full weight bearing. The patients are seen by a also a documented risk. Arner and Lindholm24 trained physiotherapist, who teaches them to reported two DVTs in 86 patients following open perform gentle mobilization exercises of the repair of the Achilles tendon. No patients in our ankle, isometric contraction of the gastrocsoleus series5 sustained a re-rupture or developed a DVT. complex, and gentle concentric contraction of the Also, functionally all patients were able to walk on calf muscles. Patients are encouraged to perform tiptoes, and no patient used a heel lift or walked mobilization of the involved ankle several times with a visible limp. per day after unstrapping the two most distal Velcro straps. Patients are given an appointment six weeks from the operation, when the anterior Results slab is removed. Patients mobilize the ankle with physiotherapy Twenty-one patients were managed with this guidance. They are allowed to weight bear as able, technique. The delay in presentation varied from and perform gradual stretching and strengthen- 2 to 9 months following the rupture.5 The outcome 21. Free Gracilis Tendon Transfer for Chronic Rupture of the Achilles Tendon 193 of surgical management was rated using a four- 2. Mann RA, Holmes GB, Seale KS, Collins DN. point scale.25 Most patients were satisfi ed with the Chronic rupture of the Achilles tendon: A new procedure; only two were classifi ed as having an technique of repair. J Bone Joint Surg 1991; excellent result, although 15 of our 21 patients 73-A:214–219. achieved a good result. 3. Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon: Treatment by V-Y tendinous The maximum calf circumference was signifi - fl ap. J Bone Joint Surg 1975; 57-A:253–255. cantly decreased in the operated leg both at pre- 4. Wapner KL, Pavlock GS, Hecht PJ, Naselli F, sentation and at latest follow-up. Walther R. Repair of chronic Achilles tendon Patients were able to perform at least 10 single- rupture with Flexor hallucis longus tendon trans- leg heel lifts on the affected leg by discharge, and fer. Foot Ankle 1993; 14:443–449. four patients were able to perform at least 60 5. Maffulli N, Leadbetter WB. Free Gracilis Tendon single-leg heel lifts on the affected leg. All patients graft in neglected tears of the Achilles tendon. Clin had returned to their pre-injury working occupa- J Sport Med 2005; 15(2):56–61. tion. Of the 21 patients included in this study, 15 6. Young J, Sayana, MK, Maffulli, N, Leadbetter WB. had returned to their leisure activities. Of these 15, Technique of free gracilis tendon transfer for fi ve of the seven patients who played tennis delayed rupture of the Achilles tendon. Techniques Foot Ankle Surg 2005; 4(3):148–153. returned to playing doubles. Three patients who 7. DiStefano VJ, Nixon JE. Achilles tendon rupture: played squash were able to return to training, Pathogenesis, diagnosis and treatment by a modi- but did not plan to return to competition. Four fi ed pullout wire technique. J Trauma 1972; 12(8): patients returned to bowling, and the remaining 671–677. three returned to golf, although not with the same 8. Maffulli N. Rupture of the Achilles tendon. J Bone frequency as before the injury. Of the whole group Joint Surg Am 1999; 81-A:1019–1036. of 21 patients, six were sedentary and only walked 9. Maffulli N. Clinical tests in sports medicine: More their dogs and performed gardening. They on Achilles tendon. Br J Sports Med 1996; 30:250. reported no problems in these activities. 10. Maffulli N. The clinical diagnosis of subcutaneous The operated limb showed a lower peak torque tear of the Achilles tendon: A prospective study in than the nonoperated one, but the patients did not 174 patients. Am J Sports Med 1998; 26:266–270. 11. Simmonds FA. The diagnosis of the ruptured Achil- perceive this decrease in strength as hampering les tendon. Practitioner 1957; 179:56–58. their daily or leisure activities. 12. Matles AL. Rupture of the tendo Achilles: Another diagnostic sign. Bull Hosp Joint Dis 1975; 36:48– 51. Conclusions 13. Maffulli N, Dymond NP, Capasso G. 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