Original Article With Video Illustration
Endoscopic-Assisted Achilles Tendon Reconstruction With Free Hamstring Tendon Autograft for Chronic Rupture of Achilles Tendon: Clinical and Isokinetic Evaluation Ossama El Shazly, M.D., Maged M. Abou El Soud, M.D., Ph.D., Dalia M. E. El Mikkawy, M.D., Ibrahim El Ganzoury, M.D., and Ayman Mohamed Ibrahim, M.D.
Purpose: To evaluate the clinical and functional outcome of endoscopic-assisted reconstruction of chronic ruptures of the Achilles tendon using free hamstring tendon autograft. Methods: We present a case series of 15 patients who had chronic ruptures of the Achilles tendon (>6 weeks earlier) and underwent endoscopic-assisted reconstruction with a free hamstring autograft. The graft loop was passed through and fixed to the proximal stump of the tendon. The graft was then passed through suture to the distal stump and finally inserted into a tunnel in the anterior calcaneus to the Achilles tendon insertion and fixed with an bioabsorbable interference screw. The mean follow-up period was 27 months (SD, 3 months; range, 24 to 33 months). All patients underwent magnetic resonance imaging preoperatively, immediately postoperatively, and at follow-up 2 years postoperatively. All patients were functionally evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score for the hindfoot preoperatively and postoperatively. Calf muscle power was evaluated by isokinetic strength testing at 2 years’ follow-up. Results: The mean size of the gap on preoperative magnetic resonance imaging was 49 mm (SD, 9 mm). The mean preoperative AOFAS score was 32.6 (SD, 7.5). There was a statistically significant improvement in the postoperative AOFAS score after 2 years to 90.8 (SD, 3.54) (P < .05). The mean time of return to all daily activities (except running and other sports) was 12.6 weeks (SD, 1.39 weeks). Isokinetic testing showed a nonsignificant deficit ( .05, nonsignificant; P < .05, significant; and P < .01, highly significant.
Results The study was conducted during the period from June 2008 until January 2013. Twenty-three patients were treated by the described technique. Eight patients were excluded because they missed a follow-up visit or had undergone previous interventions (e.g., skin graft or debridement), whereas 15 patients fulfilled the inclusion criteria. There were 12 men (80%) and 3 women (20%). The mean follow-up period of the 15 patients was 27 months (SD, 3 months; range, 24 to 33 months). The mean age was 37.7 years (SD, 6.8 years; range, 27 to 51 years). Ten cases involved the right Achilles tendon, whereas 5 cases involved the left. The duration of symptoms before surgery ranged from 7 to 26 weeks, with a mean duration of 13.5 5.56 weeks. Before they presented to us, 7 patients (46%) were misdiagnosed by a general practitioner as having a sprained ankle whereas 8 patients (54%) had received inadequate treatment by casting in the form of early weight bearing and improper positioning of the cast. The initial mechanism of injury was direct trauma in 6 patients (40%) and sudden dorsiflexion in 9 (60%). The mean size of the gap on preoperative MRI studies was 49 mm (SD, 9 mm). The mean
preoperative AOFAS score was 32.6 (SD, 7.5). There was a statistically significant improvement in the postoperative AOFAS score after 2 years to 90.8 (SD, 3.54; range, 85 to 96; P < .05). The mean time of return to full activity (all daily activities except running and other sports) was 12.6 weeks (SD, 1.39 weeks). Postoperative MRI showed successful bridging of the gap by the gracilis graft, which was seen fixed to the calcaneus through the calcaneal tunnel. Follow-up MRI performed after 2 years showed fusion of the graft to the previous stump of the Achilles tendon. The reconstructed tendon showed the absence of a gap and presence of homogeneous signal intensity, with no intratendinous fluid intensity or discontinuity of the fibers. The tendon was seen attached to the calcaneus with no evidence of bone marrow edema or fluid collection, and the calcaneal tunnel was almost obliterated (Fig 6). Isokinetic testing showed a nonsignificant deficit (6 cm) were treated with free semitendinosus tendon graft. The authors reported a good clinical outcome, with significant improvement in the AOFAS score and Achilles Tendon Rupture Score from 70 5 and 32 6, respectively, preoperatively to 92 5 and 89 4, respectively, postoperatively. However, deep venous thrombosis developed in 1 patient in their study, and 2 patients had superficial infections. Miskulin et al.8 performed a functional assessment of 5 cases of neglected rupture of the Achilles tendon treated by peroneus brevis transfer using isokinetic testing. They reported significant improvement in the postoperative peak torque when compared with the preoperative torque. However, there was a nonestatistically significant difference between the involved and uninvolved sides postoperatively because of the small number of patients included in their study. In our study isokinetic testing was the only objective way to assess the tendon graft power. We believe that the results of isokinetic testing in our study are directly related to graft reconstruction rather than postoperative immobilization. Although the outcomes of operative treatment and nonoperative treatment of acute Achilles ruptures are essentially similar at 2 years, this is actually not applicable in cases of chronic rupture. As documented by many reports, there is no role for nonoperative treatment of chronic rupture of the Achilles tendon. Thus these results are directly related to the procedure that we performed. Recently, flexor hallucis longus transfer was described for the treatment of a neglected rupture of the Achilles tendon. In this technique, the tendon is fixed to the calcaneal tunnel by a bioabsorbable screw. Yeoman et al.21 reported the results of 11 patients treated by this technique. All patients in their study showed improvement in the AOFAS score and Short Form 36 score after 6 months postoperatively.
628
O. EL SHAZLY ET AL.
Few reports have described a minimally invasive approach for the management of chronic ruptures. Bertelli et al.2 described a percutaneous technique for neglected ruptures of the Achilles tendon with a mean time from rupture of 14 weeks. Although they reported excellent results with a mean postoperative AOFAS score of 99, a high satisfaction rate, and no reruptures, they did not show how they dealt with scar tissue and large gaps through their percutaneous technique. In addition, they applied their technique in an elderly group of patients (mean age, 74 years; age range, 65 to 82 years). Our study examined a minimally invasive technique that minimizes postoperative wound complications. The role of endoscopy is to clear the retrocalcaneal space for easy passage of the graft and for debridement of scar tissue. In our technique the gap is bridged by double-loop graft that is fixed in the proximal stump and distal stump by percutaneous sutures and fixed to the calcaneus by a bioabsorbable screw. This triple fixation provides strength to the graft and allows incorporation of the graft into the original stump as proved by follow-up MRI. The relative anterior location of the calcaneal tunnel to the insertion of the Achilles tendon is necessary to avoid posterior wall blowout of the tunnel. Although it may have a theoretical impact on the power and range of plantar flexion, isokinetic testing in our cases showed a nonsignificant deficit between the involved and uninvolved limbs. Limitations The main limitation of our study was the small number of cases (17 cases) because of the paucity of cases with the described condition. In addition, the absence of a control group made a comparison with standard techniques impossible. Another limitation is the use of the AOFAS score for functional evaluation, which lacks patient-derived outcome measures, as well as measurements of patient satisfaction. However, the recently developed and more specific scoring systems were not available when we started this study.
Conclusions Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon graft for chronic ruptures of the Achilles tendon showed good to excellent results in all patients. Isokinetic testing showed a nonsignificant deficit between the involved and uninvolved sides at 2 years’ follow-up.
References 1. Gabel S, Manoli A. Neglected rupture of the Achilles tendon. Foot Ankle Int 1994;15:512-517. 2. Bertelli R, Gaiani L, Palmonari M. Neglected rupture of the Achilles tendon treated with a percutaneous technique. Foot Ankle Surg 2009;15:169-173.
3. Maffulli N. Clinical tests in sports medicine: More on Achilles tendon. Br J Sports Med 1996;30:250. 4. Lee DK. Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures. J Foot Ankle Surg 2007;46:451-455. 5. Thermann H, Hüfner T, Tscherne H. Achilles tendon rupture. Orthopade 2000;29:235-250 (in German). 6. Tako M, Ochi M, Nato K, Uchio Y, Matsusaki M, Oae K. Repair of neglected Achilles tendon rupture using gastrocnemius flaps. Arch Orthop Trauma Surg 2003;123:471-474. 7. Lepow GM, Green JB. Reconstruction of a neglected Achilles tendon rupture with an Achilles tendon allograft: A case report. J Foot Ankle Surg 2006;45:351-355. 8. Miskulin M, Miskulin A, Klobucar H, Kuvalja S. Neglected rupture of the Achilles tendon treated with peroneus brevis transfer: A functional assessment of 5 cases. J Foot Ankle Surg 2005;44:49-56. 9. Maffulli N, Ajis A. Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am 2008;90:1348-1360. 10. Maffulli N, Leadbetter WB. Free gracilis tendon graft in neglected tears of the Achilles tendon. Clin J Sport Med 2005;15:56-61. 11. Barber FA, McGarry JE, Herbert MA, Anderson RB. A biomechanical study of Achilles tendon repair augmentation using GraftJacket matrix. Foot Ankle Int 2008;29:329-333. 12. Park YS, Sung KS. Surgical reconstruction of chronic Achilles tendon ruptures using various methods. Orthopedics 2012;35:e213-e218. 13. 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: 2304-2312. 14. Ademoglu Y, Ozerkan F, Ada S, et al. Reconstruction of skin and tendon defects from wound complications after Achilles tendon rupture. J Foot Ankle Surg 2001;40:158-165. 15. Wilkins R, Bisson LJ. Operative versus nonoperative management of acute Achilles tendon ruptures: A quantitative systematic review of randomized controlled trials. Am J Sports Med 2012;40:2154-2160. 16. Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int 2000;21:475-477. 17. El Shazly O, Abou Elsoud MM, Desouky A. Endosopic achilles tendon augmentation with a graft loop anatomic and radiologic study. Foot Ankle Surg 2011;17:173-177. 18. Jacoby SM. Isokinetics in rehabilitation. In: Prentice WE, Voight ML, eds. Techniques in musculoskeletal rehabilitation. New York: McGraw-Hill, 2001;153-166. 19. 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;94:906-910. 20. Sarzaeem MM, Lemraski MM, Safdari F. Chronic Achilles tendon rupture reconstruction using a free semitendinosus tendon graft transfer. Knee Surg Sports Traumatol Arthrosc 2012;20:1386-1391. 21. Yeoman TF, Brown MJ, Pillai A. Early post-operative results of neglected tendo-Achilles rupture reconstruction using short flexor hallucis longus tendon transfer: A prospective review. Foot (Edinb) 2012;22:219-223.
Endoscopic-Assisted Achilles Tendon Reconstruction With Free Hamstring Tendon Autograft for Chronic Rupture of Achilles Tendon: Clinical and Isokinetic Evaluation Ossama El Shazly, M.D., Maged M. Abou El Soud, M.D., Ph.D., Dalia M. E. El Mikkawy, M.D., Ibrahim El Ganzoury, M.D., and Ayman Mohamed Ibrahim, M.D.
Purpose: To evaluate the clinical and functional outcome of endoscopic-assisted reconstruction of chronic ruptures of the Achilles tendon using free hamstring tendon autograft. Methods: We present a case series of 15 patients who had chronic ruptures of the Achilles tendon (>6 weeks earlier) and underwent endoscopic-assisted reconstruction with a free hamstring autograft. The graft loop was passed through and fixed to the proximal stump of the tendon. The graft was then passed through suture to the distal stump and finally inserted into a tunnel in the anterior calcaneus to the Achilles tendon insertion and fixed with an bioabsorbable interference screw. The mean follow-up period was 27 months (SD, 3 months; range, 24 to 33 months). All patients underwent magnetic resonance imaging preoperatively, immediately postoperatively, and at follow-up 2 years postoperatively. All patients were functionally evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score for the hindfoot preoperatively and postoperatively. Calf muscle power was evaluated by isokinetic strength testing at 2 years’ follow-up. Results: The mean size of the gap on preoperative magnetic resonance imaging was 49 mm (SD, 9 mm). The mean preoperative AOFAS score was 32.6 (SD, 7.5). There was a statistically significant improvement in the postoperative AOFAS score after 2 years to 90.8 (SD, 3.54) (P < .05). The mean time of return to all daily activities (except running and other sports) was 12.6 weeks (SD, 1.39 weeks). Isokinetic testing showed a nonsignificant deficit ( .05, nonsignificant; P < .05, significant; and P < .01, highly significant.
Results The study was conducted during the period from June 2008 until January 2013. Twenty-three patients were treated by the described technique. Eight patients were excluded because they missed a follow-up visit or had undergone previous interventions (e.g., skin graft or debridement), whereas 15 patients fulfilled the inclusion criteria. There were 12 men (80%) and 3 women (20%). The mean follow-up period of the 15 patients was 27 months (SD, 3 months; range, 24 to 33 months). The mean age was 37.7 years (SD, 6.8 years; range, 27 to 51 years). Ten cases involved the right Achilles tendon, whereas 5 cases involved the left. The duration of symptoms before surgery ranged from 7 to 26 weeks, with a mean duration of 13.5 5.56 weeks. Before they presented to us, 7 patients (46%) were misdiagnosed by a general practitioner as having a sprained ankle whereas 8 patients (54%) had received inadequate treatment by casting in the form of early weight bearing and improper positioning of the cast. The initial mechanism of injury was direct trauma in 6 patients (40%) and sudden dorsiflexion in 9 (60%). The mean size of the gap on preoperative MRI studies was 49 mm (SD, 9 mm). The mean
preoperative AOFAS score was 32.6 (SD, 7.5). There was a statistically significant improvement in the postoperative AOFAS score after 2 years to 90.8 (SD, 3.54; range, 85 to 96; P < .05). The mean time of return to full activity (all daily activities except running and other sports) was 12.6 weeks (SD, 1.39 weeks). Postoperative MRI showed successful bridging of the gap by the gracilis graft, which was seen fixed to the calcaneus through the calcaneal tunnel. Follow-up MRI performed after 2 years showed fusion of the graft to the previous stump of the Achilles tendon. The reconstructed tendon showed the absence of a gap and presence of homogeneous signal intensity, with no intratendinous fluid intensity or discontinuity of the fibers. The tendon was seen attached to the calcaneus with no evidence of bone marrow edema or fluid collection, and the calcaneal tunnel was almost obliterated (Fig 6). Isokinetic testing showed a nonsignificant deficit (6 cm) were treated with free semitendinosus tendon graft. The authors reported a good clinical outcome, with significant improvement in the AOFAS score and Achilles Tendon Rupture Score from 70 5 and 32 6, respectively, preoperatively to 92 5 and 89 4, respectively, postoperatively. However, deep venous thrombosis developed in 1 patient in their study, and 2 patients had superficial infections. Miskulin et al.8 performed a functional assessment of 5 cases of neglected rupture of the Achilles tendon treated by peroneus brevis transfer using isokinetic testing. They reported significant improvement in the postoperative peak torque when compared with the preoperative torque. However, there was a nonestatistically significant difference between the involved and uninvolved sides postoperatively because of the small number of patients included in their study. In our study isokinetic testing was the only objective way to assess the tendon graft power. We believe that the results of isokinetic testing in our study are directly related to graft reconstruction rather than postoperative immobilization. Although the outcomes of operative treatment and nonoperative treatment of acute Achilles ruptures are essentially similar at 2 years, this is actually not applicable in cases of chronic rupture. As documented by many reports, there is no role for nonoperative treatment of chronic rupture of the Achilles tendon. Thus these results are directly related to the procedure that we performed. Recently, flexor hallucis longus transfer was described for the treatment of a neglected rupture of the Achilles tendon. In this technique, the tendon is fixed to the calcaneal tunnel by a bioabsorbable screw. Yeoman et al.21 reported the results of 11 patients treated by this technique. All patients in their study showed improvement in the AOFAS score and Short Form 36 score after 6 months postoperatively.
628
O. EL SHAZLY ET AL.
Few reports have described a minimally invasive approach for the management of chronic ruptures. Bertelli et al.2 described a percutaneous technique for neglected ruptures of the Achilles tendon with a mean time from rupture of 14 weeks. Although they reported excellent results with a mean postoperative AOFAS score of 99, a high satisfaction rate, and no reruptures, they did not show how they dealt with scar tissue and large gaps through their percutaneous technique. In addition, they applied their technique in an elderly group of patients (mean age, 74 years; age range, 65 to 82 years). Our study examined a minimally invasive technique that minimizes postoperative wound complications. The role of endoscopy is to clear the retrocalcaneal space for easy passage of the graft and for debridement of scar tissue. In our technique the gap is bridged by double-loop graft that is fixed in the proximal stump and distal stump by percutaneous sutures and fixed to the calcaneus by a bioabsorbable screw. This triple fixation provides strength to the graft and allows incorporation of the graft into the original stump as proved by follow-up MRI. The relative anterior location of the calcaneal tunnel to the insertion of the Achilles tendon is necessary to avoid posterior wall blowout of the tunnel. Although it may have a theoretical impact on the power and range of plantar flexion, isokinetic testing in our cases showed a nonsignificant deficit between the involved and uninvolved limbs. Limitations The main limitation of our study was the small number of cases (17 cases) because of the paucity of cases with the described condition. In addition, the absence of a control group made a comparison with standard techniques impossible. Another limitation is the use of the AOFAS score for functional evaluation, which lacks patient-derived outcome measures, as well as measurements of patient satisfaction. However, the recently developed and more specific scoring systems were not available when we started this study.
Conclusions Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon graft for chronic ruptures of the Achilles tendon showed good to excellent results in all patients. Isokinetic testing showed a nonsignificant deficit between the involved and uninvolved sides at 2 years’ follow-up.
References 1. Gabel S, Manoli A. Neglected rupture of the Achilles tendon. Foot Ankle Int 1994;15:512-517. 2. Bertelli R, Gaiani L, Palmonari M. Neglected rupture of the Achilles tendon treated with a percutaneous technique. Foot Ankle Surg 2009;15:169-173.
3. Maffulli N. Clinical tests in sports medicine: More on Achilles tendon. Br J Sports Med 1996;30:250. 4. Lee DK. Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures. J Foot Ankle Surg 2007;46:451-455. 5. Thermann H, Hüfner T, Tscherne H. Achilles tendon rupture. Orthopade 2000;29:235-250 (in German). 6. Tako M, Ochi M, Nato K, Uchio Y, Matsusaki M, Oae K. Repair of neglected Achilles tendon rupture using gastrocnemius flaps. Arch Orthop Trauma Surg 2003;123:471-474. 7. Lepow GM, Green JB. Reconstruction of a neglected Achilles tendon rupture with an Achilles tendon allograft: A case report. J Foot Ankle Surg 2006;45:351-355. 8. Miskulin M, Miskulin A, Klobucar H, Kuvalja S. Neglected rupture of the Achilles tendon treated with peroneus brevis transfer: A functional assessment of 5 cases. J Foot Ankle Surg 2005;44:49-56. 9. Maffulli N, Ajis A. Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am 2008;90:1348-1360. 10. Maffulli N, Leadbetter WB. Free gracilis tendon graft in neglected tears of the Achilles tendon. Clin J Sport Med 2005;15:56-61. 11. Barber FA, McGarry JE, Herbert MA, Anderson RB. A biomechanical study of Achilles tendon repair augmentation using GraftJacket matrix. Foot Ankle Int 2008;29:329-333. 12. Park YS, Sung KS. Surgical reconstruction of chronic Achilles tendon ruptures using various methods. Orthopedics 2012;35:e213-e218. 13. 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: 2304-2312. 14. Ademoglu Y, Ozerkan F, Ada S, et al. Reconstruction of skin and tendon defects from wound complications after Achilles tendon rupture. J Foot Ankle Surg 2001;40:158-165. 15. Wilkins R, Bisson LJ. Operative versus nonoperative management of acute Achilles tendon ruptures: A quantitative systematic review of randomized controlled trials. Am J Sports Med 2012;40:2154-2160. 16. Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int 2000;21:475-477. 17. El Shazly O, Abou Elsoud MM, Desouky A. Endosopic achilles tendon augmentation with a graft loop anatomic and radiologic study. Foot Ankle Surg 2011;17:173-177. 18. Jacoby SM. Isokinetics in rehabilitation. In: Prentice WE, Voight ML, eds. Techniques in musculoskeletal rehabilitation. New York: McGraw-Hill, 2001;153-166. 19. 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;94:906-910. 20. Sarzaeem MM, Lemraski MM, Safdari F. Chronic Achilles tendon rupture reconstruction using a free semitendinosus tendon graft transfer. Knee Surg Sports Traumatol Arthrosc 2012;20:1386-1391. 21. Yeoman TF, Brown MJ, Pillai A. Early post-operative results of neglected tendo-Achilles rupture reconstruction using short flexor hallucis longus tendon transfer: A prospective review. Foot (Edinb) 2012;22:219-223.
