Semitendinosus tendon augmentation for a large defect after Achilles tendon rupture: two case reports

Good outcomes at mid-term following the reconstruction of chronic Achilles tendon rupture with semitendinosus allograft

PURPOSE

Chronic Achilles tendon rupture is commonly treated surgically, yet there are limited available data on tendon allografts for Achilles tendon reconstruction. The purpose of this study was to evaluate the patient-reported outcomes of chronic Achilles tendon rupture reconstructed with semitendinosus allograft.

METHODS

A total of 34 patients (30 males and 4 females, average age 36.1 ± 6.8 years ranging from 25 to 50 years) who underwent Achilles tendon reconstruction with semitendinosus allograft from 2011 to 2015 were identified for this retrospective study. The American Orthopedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Achilles tendon total rupture score (ATRS), and Tegner score were evaluated preoperatively and at final follow-up.

RESULTS

A total of 33 patients (97.1%) were followed up for a median time of 53 (range 24-80) months. The median AOFAS score increased from 50 (5-75) to 100 (86-100), the median VISA-A score increased from 23 (5-59) to 94 (52-100), the median ATRS score increased from 22.5 (6-67) to 99 (84-100), and the median Tegner score increased from 1 (0-3) to 4 (3-9).

CONCLUSIONS

Reconstruction of chronic-ruptured Achilles tendon with semitendinosus allograft offers satisfactory patient-reported results with low risk of re-rupture and complications. This technique could be considered an effective alternative for chronic ruptures of the Achilles tendon.

LEVEL OF EVIDENCE

Case series, Level IV.

Reconstruction of Myerson type III chronic Achilles tendon ruptures using semitendinosus tendon and gracilis tendon autograft

BACKGROUND

Reconstruction of Myerson type III (defect size more than 5 cm) chronic Achilles tendon ruptures (CATRs) is a surgical challenge due to its large Achilles tendon defect. This study aims to describe our operative technique for Myerson type III CATR and its clinical outcomes.

PATIENTS AND METHODS

From May 2012 to April 2015, we treated seven patients (6 males, 1 female) with Myerson type III CATR using semitendinosus tendon and gracilis tendon autograft. The mean age was 47.3 years (range: 37-56). Patients were followed for a mean time of 31.3 months. All patients' defect size between Achilles ends after debridement was more than 5 cm and hence classified as Myerson type III. The clinical outcomes were evaluated by visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Achilles tendon total rupture score (ATRS), and the Short Form 36 (SF-36).

RESULTS

All patients reported good postoperative clinical outcomes. The average AOFAS score increased from 54.29 points (range: 46-65 points) preoperatively to 97.57 points (range: 90-100 points) at last follow-up. The average ATRS increased from 51.43 points (range: 40-61 points) preoperatively to 92.71 points (range: 83-100 points) at last follow-up. And the average VAS for pain was 0 at the last follow-up. The mean value of SF-36 physical increased from 32.14 points (range: 25-35 points) to 90 points (range: 80-95 points). And the mean value of SF-36 mental was improved from 37.14 points (range: 32-40 points) to 90.86 points (range: 84-96 points).

CONCLUSIONS

Semitendinosus tendon combined gracilis tendon autograft is a safe and effective technique in the reconstruction of Myerson type III CATR.

Tendon allograft for treatment of chronic Achilles tendon rupture: A systematic review

BACKGROUND

To summarize available evidence and determine if tendon allograft is an effective treatment for chronic Achilles tendon rupture.

METHODS

A search was performed in the PubMed, Web of Science, Embase and Cochrane Database from 1960 to April 2017 to identify relevant articles. Predefined inclusion and exclusion criteria were applied to identify all eligible articles.

RESULTS

Total 186 articles were identified through our systematic search. Of these, 9 publications met the inclusion criteria. Five studies were case reports; three were case series; and one were expert opinion. Of a total 35 patients, 34 underwent Achilles tendon allograft repair and 1 peroneus brevis tendon allograft reconstruction. All patients experienced good clinical and functional results, but most reports used non-validated outcome measures.

CONCLUSIONS

The evidence suggests that tendon allograft offers favorable outcomes in patients with chronic Achilles tendon rupture. However, randomized controlled trials which use validated functional outcome measures are required to determine effectiveness of this intervention.

LEVEL OF EVIDENCE

Level V, systematic review of Level IV and V studies.

Endoscopy-Assisted Achilles Tendon Reconstruction With a Central Turndown Flap and Semitendinosus Augmentation

BACKGROUND

The objective of this study was to report the results of a new minimally invasive Achilles reconstruction technique and to assess the perioperative morbidity, medium- to long-term outcomes, and functional results.

METHODS

Our series was comprised 14 patients (11 men and 3 women), with a mean age of 45.6 years at surgery. Each patient had a chronic Achilles tendon rupture. The mean interval from rupture to surgery was 5.5 months (range, 2-10). The mean total follow-up was 30.1 months (range, 12-78). All patients were operated with a central turndown flap augmented with free semitendinosus tendon graft and percutaneous sutures in a minimally invasive approach assisted by endoscopy. The patients underwent retrospective assessment by clinical examination, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, and the Achilles Tendon Total Rupture Score (ATRS). Paired t tests were used to assess the preoperative and postoperative AOFAS scores, ATRS scores, and ankle range of motion.

RESULTS

The length of the defect ranged from 3 to 8 cm (mean, 5.1), while the length of the turndown flap ranged from 8 to 13 cm (mean, 10.1). The mean AOFAS score improved from 64.5 points preoperatively to 96.9 points at last follow-up. The mean ATRS score improved from 49.4 preoperatively to 91.4 points at last follow-up. None of the patients developed a wound complication. No patient had a rerupture or sural nerve damage.

CONCLUSION

All patients in our study had a favorable outcome with no complications. We believe that with this triple-repair technique, one can achieve a strong and robust repair such as in open surgery while at the same time reducing the incidence of complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Chronic Achilles tendon rupture reconstructed using hamstring tendon autograft

BACKGROUND

Chronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and augmentation methods are challenging when the defect exceeds 5-6 cm, especially if the distal stump is grossly tendinopathic.

METHODS

We describe our method of Achilles tendon reconstruction with ipsilateral semitendinosis autograft and interference screw fixation in a patient with chronic rupture, a 9 cm defect and gross distal tendinopathy.

RESULTS

Patient reported outcome measures consistently demonstrated improved health status at 12 months post surgery: MOXFQ-Index 38-25, EQ5D-5L 18-9, EQ VAS 70-90 and VISA-A 1-64. The patient was back to full daily function, could single leg heel raise and was gradually returning to sport. No complications or adverse events were recorded.

CONCLUSION

Reconstruction of chronic tears of the Achilles tendon with large defects and gross tendinopathy using an ipsilateral semitendinosis autograft and interference screw fixation can achieve satisfactory improvements in patient reported outcomes up to 1 year post-surgery.

Use of the semitendinosus tendon for foot and ankle tendon reconstructions

Objective

To demonstrate the results obtained from foot and ankle tendon reconstructions using the tendon of the semitendinosus muscle. The clinical results, the patient's degree of satisfaction and complications in the graft donor and recipient areas were evaluated.

Methods

This was a retrospective study in which the medical files of 38 patients who underwent this surgical procedure between 2006 and 2010 were surveyed. The functional results from this technique, the complications in the donor and recipient areas and the patients’ degree of satisfaction were evaluated.

Results

Three patients presented complications in the recipient area (skin necrosis); one patient showed complications in the donor area (pain and insensitivity); and all patients had satisfactory functional results, with complete range of motion.

Conclusion

The semitendinosus muscle is a good option for treatments for foot and ankle tendon injuries.

Semitendinosus Tendon Autograft for Reconstruction of Large Defects in Chronic Achilles Tendon Ruptures

BACKGROUND

Chronic Achilles tendon ruptures are associated with considerable functional morbidity. When treated operatively, debridement of degenerated tendon ends may create large defects. Various procedures to reconstruct large defects have been described. We present a simple technique in which an autologous semitendinosus tendon graft is used to reconstruct defects larger than 5 cm in chronic Achilles tendon ruptures. The purpose of this study was to describe our operative technique and its functional outcome.

METHODS

Achilles ruptures of more than 6 weeks duration were considered for the study. We treated 35 patients (20 males, 15 females) with symptomatic chronic Achilles tendon ruptures. The mean age was 47.4 years (range, 30 to 59). The smallest defect that we had reconstructed was 5 cm, and the largest was 9 cm in length. The average follow-up duration was 30.7 months (range, 20 to 42). Postoperatively, the strength of gastrocsoleus was measured by manual muscle testing (MMT) in non-weight-bearing and weight-bearing positions.

RESULTS

All operated patients showed satisfactory functional outcome, good soft tissue healing, and no reruptures. The preoperative weight-bearing MMT of 2/5 improved to 4/5 or 5/5 postoperatively. In all patients, postoperative non-weight-bearing MMT was 5/5. All patients returned to their prerupture daily activity.

CONCLUSION

We present a technique that is simple, with low morbidity. We believe it is a valuable option especially when allografts are not available. It is inexpensive as suture anchors or tenodesis screws are not used. This can be a useful option if other tendons (flexor hallucis longus, peroneus brevis, etc) are not available for transfer.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Chronic Achilles tendon rupture reconstruction using a free semitendinosus tendon graft transfer

PURPOSE

The purpose of this study was to evaluate the outcomes following reconstruction of the chronic Achilles tendon ruptures with large gaps (>6 cm) using free semitendinosus tendon graft transfer.

METHODS

There were 11 consecutive patients underwent the above-mentioned surgical technique for the treatment of chronically ruptured Achilles tendon contributed in current study and were followed up prospectively for a mean of 25 ± 3 months. The intraoperative tendon defect was greater than 6 cm in all of the patients. Functional and clinical assessment was performed using The American Orthopaedic Foot and Ankle Society (AOFAS) and Achilles Tendon Rupture Score (ATRS).

RESULTS

The average AOFAS and ATRS improved significantly from 70 ± 5 and 32 ± 6 preoperatively, to 92 ± 5 and 89 ± 4 points post-operatively (P = 0.001). The range of dorsiflexion was significantly limited on the operated side (13 ± 4° vs. 17 ± 4°) (P = 0.04). All patients were able to stand on the tiptoe of injured leg, and no patient walked with a visible limp. Post-operative complications included one patient with symptomatic DVT and 2 patients with superficial infection treated nonoperatively.

CONCLUSIONS

The technique offers good clinical and functional outcomes and is safe. Reconstruction of the chronic Achilles tendon ruptures with free semitendinosus tendon graft in patients with defects greater than 6 cm is recommended.

LEVEL OF EVIDENCE

IV.

Evaluation of the hallux morbidity of single-incision flexor hallucis longus tendon transfer

BACKGROUND

Achilles tendinosis and chronic Achilles tendon ruptures are relatively frequently encountered by orthopaedic surgeons. One treatment for patients who fail to respond to conservative management involves augmentation of the repair with transfer of the flexor hallucis longus (FHL), using either a single-incision or double-incision technique. Despite the frequency of this procedure, little is known about the associated donor morbidity. We report the effects of the single-incision technique on hallux function.

MATERIALS AND METHODS

We retrospectively reviewed 48 patients who underwent a single-incision FHL tendon transfer for chronic Achilles tendon rupture or Achilles tendinosis. Twenty-two patients (mean followup, 28 months) completed the study. The average age was 56 years. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal (MTP) joint and interphalangeal (IP) joint scores, the Health Related Quality of Life Measures Short Form (SF-36). Also, the average of two pedobarographic measurements of both feet and strength testing of the FHL of both feet were recorded.

RESULTS

Decreased distal phalangeal pressure and FHL weakness were demonstrated (p < 0.05). No difference was noted in plantar pressure of the first or second metatarsal head. The high score on the AOFAS hallux MTP-IP scale demonstrated improved patient forefoot function after FHL transfer through a single-incision technique.

CONCLUSION

Flexor hallucis longus tendon transfer using a single-incision technique results in decreased flexion power at the IP joint as demonstrated by decreased distal phalangeal pulp pressure; however, this appears to be a laboratory finding as patient function remains high.

Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon

Background

Many techniques have been developed for the reconstruction of the Achilles tendon in chronic tears. In presence of a large gap (greater than 6 centimetres), tendon augmentation is required.

Methods

We present our method of minimally invasive semitendinosus reconstruction for the Achilles tendon using one para-midline and one midline incision.

Results

The first incision is a 5 cm longitudinal incision, made 2 cm proximal and just medial to the palpable end of the residual tendon. The second incision is 3 cm long and is also longitudinal but is 2 cm distal and in the midline to the distal end of the tendon rupture. The distal and proximal Achilles tendon stumps are mobilised. After trying to reduce the gap of the ruptured Achilles tendon, if the gap produced is greater than 6 cm despite maximal plantar flexion of the ankle and traction on the Achilles tendon stumps, the ipsilateral semitendinosus tendon is harvested. The semitendinosus tendon is passed through small incisions in the substance of the proximal stump of the Achilles tendon, and it is sutured to the Achilles tendon. It is then passed beneath the intact skin bridge into the distal incision, and passed from medial to lateral through a transverse tenotomy in the distal stump. With the ankle in maximal plantar flexion, the semitendinosus tendon is sutured to the Achilles tendon at each entry and exit point

Conclusion

This minimally invasive technique allows reconstruction of the Achilles tendon using the tendon of semitendinosus 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 large gap (greater than 6 centimetres).