SLR - May 2012 - Linda S. Oh
Reference: Lapidus, L., Ray, B., & Hamberg, P. (2012). Medial Achilles Tendon Island Flap - A Novel Technique to Treat Reruptures and Neglected Ruptures of the Achilles Tendon. International Orthopaedics, 2012
Scientific Literature Review
Reviewed by: Linda S. Oh, DPM
Residency Program: Cambridge Health Alliance, Cambridge, MA
Podiatric Relevance:
Surgical management and reconstruction of neglected ruptures and reruptures of the Achilles tendon is strongly recommended. The literature describes a number of technically demanding procedures that carry an overall high risk of complications; one of which is wound complication. This article describes a new technique to bridge rupture gaps using a low profile tendon island flap, which is simple in its approach and has the added benefit of preserving local vascularity.
Methods:
A total of nine patients were included in the case series; six males and three females with the median age of 59 years. Three patients presented with neglected ruptures, three presented with delayed diagnosis, and three presented with reruptures of the Achilles tendon. Of the three reruptures, one occurred after conservative care, one occurred after a primary end-to-end repair and one occurred after a repair using a turn down flap. In all cases, the defect in the Achilles tendon measured 3-8cm with the foot in a neutral position. The time of rupture to the final reconstructive procedure was an average of three months
The operative technique consisted of a posterior medial incision made down to the level of the tendon. The scar tissue between the ruptured proximal and distal ends was removed and debrided. A flap was marked out with the muscle under tension from the midline of the proximal tendon end and going proximally up the midline. The mark was then turned perpendicular over to the medial side of the gastrocnemius aponeurosis. This distance to the bridge added up to approximately 2cm. The island flap was divided sharply taking care not to go deeper than proper tendon tissue and the proximal island flap was advanced distally until the gap was bridged. The tendon was sutured end-to-end with a modified Kessler suture using 0 PDS suture. The proximal tendon was then tacked over the midline to its lateral counterpart with 2.0 PDS suture. The patient was placed in a below knee cast with the ankle in equinus.
Results:
All nine patients scored good or excellent overall in satisfaction with no occurrences of infection or reruptures. One patient reported persistent post-activity swelling of the leg and three out of nine patients reported slight calf muscle weakness not affecting activities of daily living. All patients reported normal walking function, and all but three patients returned to various recreational activities. The activity level in the three patients was reduced to long walks.
Conclusions:
There are currently no evidenced based guidelines for an optimal technique in repairing these types of Achilles injuries. The main vascular supply of the Achilles tendon enters through the anterior paratenon, with the proximal portion of the tendon supplied by the recurrent branch of the posterior tibial artery. The described method avoids surgical dissection anterior to the proximal aspect of the tendon – which in turn is used as the island flap and therefore beneficial in maintaining vascular viability to the flap site. Surgical methods crossing the midline to the lateral side on the proximal gasctronemius aponeurosis risk damage to the neurovascular structures overlying the gastrocnemius myotendinous junction. These structures run from midline to the lateral aspect of the Achilles tendon and are capable of carrying large pedicled flaps on the foot. Bulkier flap augmentation procedures do produce better pull out strength than end-to-end suturing alone, but the increase in strength is balanced against the risk of wound issues with retraction of the skin over the rupture site. End to end suturing alone has been recommended if the resected tendon gap is less than 2.5cm. The V-Y tendon alignment procedure has been a concern for elongations for covering gaps greater than 4-5cm. With the medial Achilles tendon island flap, a gap up to 5-6cm may be covered with little limitations; three of the patients demonstrated a rupture gap of 7-8cm but were still able to recover with this method. Limitations of this study include the low number of patients, the absence of long term assessments, and the subjectivity of the data reflecting functional results.