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Endoscopic-Assisted Achilles Tendon Reconstruction With Free Hamstring Tendon Autograft for Chronic Rupture of Achilles Tendon: Clinical and Isokinetic Evaluation
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 (<10%) between the involved and uninvolved plantar flexors and dorsiflexors with regard to peak torque, average power, and total work. Conclusions: Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon autograft 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. Level of Evidence: Level IV, therapeutic cases series.
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hronic rupture of the Achilles tendon is a challenging problem. The rupture is considered neglected when there is a delay in diagnosis or treatment for at least 4 weeks after injury.1,2 It is estimated that approximately 20% of all Achilles tendon ruptures are misdiagnosed initially.3,4 Chronic Achilles tendons may manifest because of the patient’s delay in seeking medical attention, misdiagnosis, or conservative treatment
From the Orthopedic Department (O.E.S., M.M.A.E.S., I.E.G.), Department of Physical Medicine, Rheumatology, and Rehabilitation (D.M.E.E.M.), and Radiology Department (A.M.I.), Ain Shams University, Cairo, Egypt. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received July 26, 2013; accepted February 13, 2014. Address correspondence to Ossama El Shazly, M.D., Orthopedic Department, Ain Shams University, Cairo, Egypt. E-mail: ossama_elshazly@yahoo. com Ó 2014 by the Arthroscopy Association of North America 0749-8063/13518/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.019
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failure.5 When Achilles tendon ruptures are not treated promptly, retraction and degeneration of the tendon can occur and the gap between the ruptured ends will eventually fill with fibrotic scar tissue, which will result in impairment of the Achilles tendon function and a marked degree of disability.6,7 There is no role for conservative treatment in chronic ruptures of the Achilles tendon, and the treatment is mainly surgical.8 End-to-end repair is possible if the rupture gap is less than 2.5 cm. However, in most instances, reconstruction of the tendon is required.9 Several surgical methods of reconstruction have been described, including local tissue augmentation with plantaris tendon; V-Y advancement for the gastrocnemius muscle; turndown procedures; local tendon transfer (peroneus brevis, flexor digitorum longus, flexor hallucis longus); free tissue transfer (fascia lata or hamstring tendon graft); tendon allografts; and recently, the use of synthetic materials.4,6-8,10-12 The most serious and common complications of the aforementioned techniques are wound complications,
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such as deep infection (2.3%), wound breakdown and superficial infection (9%), non-cosmetic scar (13.1%), and plastic coverage for significant soft-tissue defects (2%).13-15 These complications are related to the paucity of soft-tissue vascularity in this area. Although minimally invasive procedures are commonly used for the treatment of acute ruptures, there are very few reports in the literature describing minimally invasive surgery for chronic ruptures.2,13 The purpose of this study was to evaluate the clinical and functional outcome of endoscopic-assisted reconstruction of chronic ruptures of the Achilles tendon using a free hamstring autograft. We hypothesized that the results of this technique would be equal to the published results of open techniques with a lower rate of soft-tissue complications.
Methods This is a prospective case series study on 15 patients who had chronic ruptures of the Achilles tendon and were treated by endoscopic-assisted reconstruction with free hamstring tendon graft. The inclusion criteria were a rupture of the Achilles tendon that had been neglected for more than 6 weeks and the presence of a gap of more than 3 cm on magnetic resonance imaging (MRI). Patients were excluded if there were any signs of infection, if they had undergone any prior surgery, or if they did not complete 2 years’ follow-up. We evaluated the patients clinically by taking a thorough history and performing a physical examination. All patients reported an inability to stand on their tiptoes and significant disability during climbing stairs. The Thompson test was positive in all cases, and the palpable defect in the Achilles tendon was determined. Preoperative MRI was obtained, and the rupture gap was measured by MRI in all cases. Preoperative functional evaluation was performed with the American Orthopaedic Foot & Ankle Society (AOFAS) scale for the ankle. Surgical Technique A pneumatic thigh tourniquet was applied. The patient was placed in the prone position, a sandbag was
Fig 1. Graft harvest and preparation. (A) Harvesting of left semitendinosus tendon through transverse medial popliteal incision. (B) Preparation of double loop and measurement of its length. (C) Measurement of size of double loop.
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applied under the operative leg, and the ankle was placed off the edge of the table. Graft Harvest and Preparation. A 3-cm transverse skin incision was made on the medial side of the popliteal crease. The deep fascia was incised, and the medial hamstring tendons were exposed. The semitendinosus tendon was dissected, and a tendon stripper was used to detach the tendon proximally at the musculotendinous junction. The stripper was turned in the other direction to detach the tendon from it distal attachment. The graft was prepared and tensioned on the tendon board, and the tendon was cleaned of soft tissue. The peripheral 3 cm of the tendon was augmented by No. 2 nonabsorbable double-braided Ethibond sutures (Ethicon, Somerville, NJ), and the size of the double loop was measured (Fig 1). Portal Placement. Four portals were used: 2 superior and 2 inferior. The superior portals were located on each side of the Achilles tendon 3 cm above the palpable gap. First, the skin was incised by a No. 11 knife blade; then, the portal was dilated with a small mosquito forceps. In patients with large gaps, care was taken during creation of the superolateral portal to avoid injury to the sural nerve. The sural nerve crosses the lateral border of the Achilles tendon about 10 cm from its insertion.16 In such cases, the skin incision at the superolateral border was enlarged, and retraction of the sural nerve was performed by use of nerve tape (Fig 2). The inferior portals were located 1 cm above the insertion, on each side of the Achilles tendon. Hindfoot Endoscopy. The next step was hindfoot endoscopy. This was performed for clearance of the retrocalcaneal space of fibrous tissue and debridement of the scar tissue. The 4-mm endoscope was inserted from the inferolateral portal while a 3.5-mm full-radius shaver blade was applied through the inferomedial portal. Care was taken during hindfoot endoscopy to avoid
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Fig 2. Left hindfoot, posterior view, showing location of superior and inferior portals. The sural nerve (yellow line) crosses the lateral border at 9.8 cm above the insertion. The inset shows isolation and retraction of the sural nerve through the superolateral portal.
injury to the posteromedial neurovascular bundle. During all steps, crossing the medial border of the flexor hallucis longus tendon was carefully avoided. Shaving was stopped when the posterior process of the talus and superior surface of the calcaneus were clearly exposed. Creation of Calcaneal Tunnel. A C-guide (usually used for anterior cruciate ligament reconstruction) was used to make localization of the tunnel easier. The angle of the guide was adjusted to 65 . The sharp tip of the guide was inserted through the inferolateral portal and fixed on the calcaneal surface 10 mm anterior to the insertion of the Achilles tendon. The other end of the guide was placed on the center of the heel. The guide pin was inserted first; then, the anterior cruciate ligament reamer was used, according to the size of graft, to create the calcaneal tunnel. On the basis of a previous anatomic and radiologic study, this tunnel will have 3 to 4 mm of bone thickness in the posterior wall17 (Fig 3). Graft Passage. A small vascular clamp was passed from the superolateral portal to the superomedial portal deep to the Achilles tendon. The substance of the tendon was felt superficial to the clamp, and a guide pin with an eyelet threaded with No. 1 Prolene suture (Ethicon) was then passed horizontally to create a track in the substance of the Achilles tendon. The track was further dilated by moving the pin in the proximal and distal directions. Then, the guide pin was removed, and the Prolene suture was passed horizontally in the same track. The Ethibond suture on one end of the graft was tied to the Prolene suture passing through the Achilles
Fig 3. Intraoperative lateral X-ray projection showing creation of calcaneal tunnel. The inset shows the location of the guide pin at 10 mm from the insertion of the Achilles tendon; this will leave a 3- to 4-mm-thick posterior wall for the tunnel, as shown on the sagittal computed tomography scan cut.
tendon, and the graft was passed from medial to lateral through the substance of the proximal Achilles tendon stump (Fig 4A). Next, the graft ends were retrieved from the corresponding inferior portals by means of a small vascular clamp passing from the inferior portal to the corresponding superior portal (Fig 4B). Finally, the graft ends were retrieved from the calcaneal tunnel under endoscopic control. A Prolene loop was inserted from the calcaneal tunnel to the retrocalcaneal space. Under endoscopic control, the loop was grasped and delivered from the medial-inferior portal. The medial Ethibond suture of the graft was tied through the loop, and the loop was pulled out of the tunnel so that the Ethibond suture and the medial graft end would exit from the tunnel. The same steps were repeated on the other side so that we could obtain both graft ends exiting from the tunnel. By this step, the graft loop was passing through the substance of the proximal stump of the Achilles tendon and through the calcaneal tunnel distally (Fig 4C). Fixation of Graft. The graft loop was fixed first to the proximal stump by means of percutaneous locking stitches. The needle of a No. 2-0 braided absorbable suture was inserted through the superior portal deep to the tendon to exit from the skin at the midline of the Achilles tendon. Then, the needle was turned subcutaneously to exit from the superior portal again. The stitch was tied subcutaneously; thus the graft loop became locked to the tendon at this point. Another locking stitch was taken on the other side through the other superior portal. Next, the graft was fixed to the calcaneal tunnel by a biodegradable interference screw according to the size of
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Fig 4. Left foot, posterior view. (A) The graft is passed through the proximal stump through superior portals. (B) The graft ends are retrieved from the inferior portal. (C) Under endoscopic control, the graft ends are retrieved through the calcaneal tunnel.
the tunnel. The surgeon achieved fixation while applying manual tension on the graft and the ankle was placed in a neutral position. Additional fixation was achieved by applying multiple locking sutures to the distal stump using the same technique described for the proximal locking sutures. Finally, closure of the portals was performed (Fig 5; Video 1, available at www.arthroscopyjournal. org). Postoperatively, a bulky dressing was applied and the ankle was immobilized by a posterior splint in 30 of plantar flexion for 2 weeks. At 2 weeks postoperatively, the skin stitches were removed and the ankle was then immobilized with a hinged foot and ankle orthosis fixed in 30 of plantar flexion for 1 month. At 6 weeks, the brace was fixed in the neutral position and the patient was allowed full weight bearing. Isotonic Achilles exercises and proprioceptive training were started at 8 weeks. Loading exercises and stretching Achilles exercises were started at 12 weeks. Running and sportsrelated exercises were allowed after 16 weeks. We performed functional evaluation at 24 months using the AOFAS score for the hindfoot. In addition, we performed objective evaluation of tendon function using isokinetic strength testing. Postoperative isokinetic muscle strength assessment was performed for the ankle dorsiflexors and plantar flexors in all patients at 2 years’ follow-up by use of a standard protocol on the isokinetic Biodex System 3 (Biodex Medical Systems, Shirley, NY).18 Data for the normal side were obtained as control
Fig 5. (A) The graft is fixed distally to the calcaneal tunnel by a bioabsorbable screw. The inset shows an endoscopic view of the doublebundle graft after fixation in the calcaneal tunnel. (B) Closure of portals after reconstruction of tendon.
data. The test protocol chosen comprised concentricconcentric contractions with test speeds of 60 /s and 120 /s with 5 test repetitions. The test protocol was explained to the patient, and there was a 5-minute warmup period before starting the test. Visual feedback was provided. The following data were obtained from the test: peak torque (in newton meters), peak torque/body weight (as a percent), maximum repetition total work (in joules), and average power (in watts). The deficit between the normal and operative sides was detected for all these parameters. According to the Biodex System 3 scale, deficits of 1% to 10% are considered nonsignificant whereas deficits of 11% to 25% are considered significant and require rehabilitation and deficits greater than 25% are considered functional impairment and require revision.18 Postoperative MRI was obtained in the immediate postoperative period and at 1 year of follow-up. We used a 1.5-T MRI system (Signa Horizon; GE Medical Systems, Milwaukee, WI) with a commercially available quadrature cervical spinal coil or knee coil. Statistical Analysis The collected data were revised, coded, tabulated, and introduced onto a personal computer using SPSS software (SPSS for Windows, version 15.0.1; SPSS, Chicago, IL). Data were presented and a suitable analysis was performed according to the type of data obtained for each parameter. Analytic statistical analysis for isokinetic test
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Fig 6. MRI study. (A) Preoperative sagittal MRI cut showing chronic rupture of Achilles tendon with 5-cm gap. (B) Immediate postoperative MRI cut showing semitendinosus graft (arrow heads) bridging defect, passing through proximal stump, and fixed to calcaneal tunnel. (C) MRI cut at 2 years’ follow-up showing incorporation of graft into old stumps with absence of gap and presence of homogenous signal intensity, as well as no discontinuity of fibers.
readings was performed with the Student t test to assess the statistical significance of the difference between the involved and uninvolved limbs. The analysis-of-variance test was used to assess the statistical significance of the difference between preoperative and postoperative AOFAS scores. The post hoc test was used for comparisons of all possible pairs of group means. The level of significance (P value) was ranked as follows: P > .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 (<10%) between the involved and uninvolved plantar flexors and dorsiflexors at 120 /s and 60 /s in peak torque, average power, and total work (Table 1). With regard to complications, paresthesia developed at the distribution of the sural nerve in 1 case and resolved spontaneously after 6 months. There were no cases of infection or deep venous thrombosis.
Discussion Treatment of a neglected rupture of the Achilles tendon is a challenging problem for both the orthopaedic surgeon and the patient. For the surgeon, there are many technical difficulties that are usually encountered, including the presence of a tendon gap, tendon fraying, tendon retraction, and disruption of the blood supply of the tendon
*Deficit is determined as follows: (Uninvolved side e Involved side)/Uninvolved side.
Uninvolved Involved Deficit* (%) Uninvolved Involved Deficit* (%) Uninvolved Involved Deficit* (%) Uninvolved Involved Deficit* (%) 28.4 27.6 2.8 32.4 31.8 1.8 20.8 20.5 1.4 23.2 23 0.8 27.2 26.1 31.2 30.9 20 19.4 3 22.3 21.9 1.7 10.5 9.8 6.6 15.4 15.2 1.2 8.6 8.4 2.3 13.3 13 2.2 13.0 12.7 2.3 18.3 17.9 2.1 12.9 12.6 2.3 21.8 21.5 1.3 36.3 35.7 1.6 66.1 65.6 0.7 61.3 61 0.4 110.4 109.8 0.5 Peak torque (N-m) Peak torque/body weight (%) Maximum repetition total work (J) Average power (W) Total work (J)
Table 1. Isokinetic Testing Results
Mean Plantar Flexion at 60 /s
Mean Dorsiflexion at 60 /s
Mean Plantar Flexion at 120 /s
Mean Dorsiflexion at 120 /s
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during surgery. For the patient, there is a relatively high risk of postoperative wound complications, in addition to tendon adhesion and stiffness.13-15 When the defect is larger than 2.5 cm, reconstruction of the defect is needed by graft augmentation.9 Maffulli and Leadbetter10 treated 21 patients with a neglected rupture of the Achilles tendon by open reconstruction using free gracilis tendon graft. They concluded that the technique is safe but technically demanding and carries a risk of complications. They reported superficial wound infections in 5 patients (23.8%) and a significant decrease in the calf muscle circumference and strength at the end of follow-up. In 2012 Maffulli et al.19 reported the long-term results of their technique; on the basis of the results of treatment of chronic tears of the Achilles tendon with free gracilis tendon grafting, they concluded that patients retained good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference. In a study performed by Sarzaeem et al.,20 11 patients with chronic rupture of the Achilles tendon with a large gap (>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.
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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 (<10%) between the involved and uninvolved plantar flexors and dorsiflexors with regard to peak torque, average power, and total work. Conclusions: Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon autograft 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. Level of Evidence: Level IV, therapeutic cases series.
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hronic rupture of the Achilles tendon is a challenging problem. The rupture is considered neglected when there is a delay in diagnosis or treatment for at least 4 weeks after injury.1,2 It is estimated that approximately 20% of all Achilles tendon ruptures are misdiagnosed initially.3,4 Chronic Achilles tendons may manifest because of the patient’s delay in seeking medical attention, misdiagnosis, or conservative treatment
From the Orthopedic Department (O.E.S., M.M.A.E.S., I.E.G.), Department of Physical Medicine, Rheumatology, and Rehabilitation (D.M.E.E.M.), and Radiology Department (A.M.I.), Ain Shams University, Cairo, Egypt. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received July 26, 2013; accepted February 13, 2014. Address correspondence to Ossama El Shazly, M.D., Orthopedic Department, Ain Shams University, Cairo, Egypt. E-mail: ossama_elshazly@yahoo. com Ó 2014 by the Arthroscopy Association of North America 0749-8063/13518/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.019
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failure.5 When Achilles tendon ruptures are not treated promptly, retraction and degeneration of the tendon can occur and the gap between the ruptured ends will eventually fill with fibrotic scar tissue, which will result in impairment of the Achilles tendon function and a marked degree of disability.6,7 There is no role for conservative treatment in chronic ruptures of the Achilles tendon, and the treatment is mainly surgical.8 End-to-end repair is possible if the rupture gap is less than 2.5 cm. However, in most instances, reconstruction of the tendon is required.9 Several surgical methods of reconstruction have been described, including local tissue augmentation with plantaris tendon; V-Y advancement for the gastrocnemius muscle; turndown procedures; local tendon transfer (peroneus brevis, flexor digitorum longus, flexor hallucis longus); free tissue transfer (fascia lata or hamstring tendon graft); tendon allografts; and recently, the use of synthetic materials.4,6-8,10-12 The most serious and common complications of the aforementioned techniques are wound complications,
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such as deep infection (2.3%), wound breakdown and superficial infection (9%), non-cosmetic scar (13.1%), and plastic coverage for significant soft-tissue defects (2%).13-15 These complications are related to the paucity of soft-tissue vascularity in this area. Although minimally invasive procedures are commonly used for the treatment of acute ruptures, there are very few reports in the literature describing minimally invasive surgery for chronic ruptures.2,13 The purpose of this study was to evaluate the clinical and functional outcome of endoscopic-assisted reconstruction of chronic ruptures of the Achilles tendon using a free hamstring autograft. We hypothesized that the results of this technique would be equal to the published results of open techniques with a lower rate of soft-tissue complications.
Methods This is a prospective case series study on 15 patients who had chronic ruptures of the Achilles tendon and were treated by endoscopic-assisted reconstruction with free hamstring tendon graft. The inclusion criteria were a rupture of the Achilles tendon that had been neglected for more than 6 weeks and the presence of a gap of more than 3 cm on magnetic resonance imaging (MRI). Patients were excluded if there were any signs of infection, if they had undergone any prior surgery, or if they did not complete 2 years’ follow-up. We evaluated the patients clinically by taking a thorough history and performing a physical examination. All patients reported an inability to stand on their tiptoes and significant disability during climbing stairs. The Thompson test was positive in all cases, and the palpable defect in the Achilles tendon was determined. Preoperative MRI was obtained, and the rupture gap was measured by MRI in all cases. Preoperative functional evaluation was performed with the American Orthopaedic Foot & Ankle Society (AOFAS) scale for the ankle. Surgical Technique A pneumatic thigh tourniquet was applied. The patient was placed in the prone position, a sandbag was
Fig 1. Graft harvest and preparation. (A) Harvesting of left semitendinosus tendon through transverse medial popliteal incision. (B) Preparation of double loop and measurement of its length. (C) Measurement of size of double loop.
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applied under the operative leg, and the ankle was placed off the edge of the table. Graft Harvest and Preparation. A 3-cm transverse skin incision was made on the medial side of the popliteal crease. The deep fascia was incised, and the medial hamstring tendons were exposed. The semitendinosus tendon was dissected, and a tendon stripper was used to detach the tendon proximally at the musculotendinous junction. The stripper was turned in the other direction to detach the tendon from it distal attachment. The graft was prepared and tensioned on the tendon board, and the tendon was cleaned of soft tissue. The peripheral 3 cm of the tendon was augmented by No. 2 nonabsorbable double-braided Ethibond sutures (Ethicon, Somerville, NJ), and the size of the double loop was measured (Fig 1). Portal Placement. Four portals were used: 2 superior and 2 inferior. The superior portals were located on each side of the Achilles tendon 3 cm above the palpable gap. First, the skin was incised by a No. 11 knife blade; then, the portal was dilated with a small mosquito forceps. In patients with large gaps, care was taken during creation of the superolateral portal to avoid injury to the sural nerve. The sural nerve crosses the lateral border of the Achilles tendon about 10 cm from its insertion.16 In such cases, the skin incision at the superolateral border was enlarged, and retraction of the sural nerve was performed by use of nerve tape (Fig 2). The inferior portals were located 1 cm above the insertion, on each side of the Achilles tendon. Hindfoot Endoscopy. The next step was hindfoot endoscopy. This was performed for clearance of the retrocalcaneal space of fibrous tissue and debridement of the scar tissue. The 4-mm endoscope was inserted from the inferolateral portal while a 3.5-mm full-radius shaver blade was applied through the inferomedial portal. Care was taken during hindfoot endoscopy to avoid
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Fig 2. Left hindfoot, posterior view, showing location of superior and inferior portals. The sural nerve (yellow line) crosses the lateral border at 9.8 cm above the insertion. The inset shows isolation and retraction of the sural nerve through the superolateral portal.
injury to the posteromedial neurovascular bundle. During all steps, crossing the medial border of the flexor hallucis longus tendon was carefully avoided. Shaving was stopped when the posterior process of the talus and superior surface of the calcaneus were clearly exposed. Creation of Calcaneal Tunnel. A C-guide (usually used for anterior cruciate ligament reconstruction) was used to make localization of the tunnel easier. The angle of the guide was adjusted to 65 . The sharp tip of the guide was inserted through the inferolateral portal and fixed on the calcaneal surface 10 mm anterior to the insertion of the Achilles tendon. The other end of the guide was placed on the center of the heel. The guide pin was inserted first; then, the anterior cruciate ligament reamer was used, according to the size of graft, to create the calcaneal tunnel. On the basis of a previous anatomic and radiologic study, this tunnel will have 3 to 4 mm of bone thickness in the posterior wall17 (Fig 3). Graft Passage. A small vascular clamp was passed from the superolateral portal to the superomedial portal deep to the Achilles tendon. The substance of the tendon was felt superficial to the clamp, and a guide pin with an eyelet threaded with No. 1 Prolene suture (Ethicon) was then passed horizontally to create a track in the substance of the Achilles tendon. The track was further dilated by moving the pin in the proximal and distal directions. Then, the guide pin was removed, and the Prolene suture was passed horizontally in the same track. The Ethibond suture on one end of the graft was tied to the Prolene suture passing through the Achilles
Fig 3. Intraoperative lateral X-ray projection showing creation of calcaneal tunnel. The inset shows the location of the guide pin at 10 mm from the insertion of the Achilles tendon; this will leave a 3- to 4-mm-thick posterior wall for the tunnel, as shown on the sagittal computed tomography scan cut.
tendon, and the graft was passed from medial to lateral through the substance of the proximal Achilles tendon stump (Fig 4A). Next, the graft ends were retrieved from the corresponding inferior portals by means of a small vascular clamp passing from the inferior portal to the corresponding superior portal (Fig 4B). Finally, the graft ends were retrieved from the calcaneal tunnel under endoscopic control. A Prolene loop was inserted from the calcaneal tunnel to the retrocalcaneal space. Under endoscopic control, the loop was grasped and delivered from the medial-inferior portal. The medial Ethibond suture of the graft was tied through the loop, and the loop was pulled out of the tunnel so that the Ethibond suture and the medial graft end would exit from the tunnel. The same steps were repeated on the other side so that we could obtain both graft ends exiting from the tunnel. By this step, the graft loop was passing through the substance of the proximal stump of the Achilles tendon and through the calcaneal tunnel distally (Fig 4C). Fixation of Graft. The graft loop was fixed first to the proximal stump by means of percutaneous locking stitches. The needle of a No. 2-0 braided absorbable suture was inserted through the superior portal deep to the tendon to exit from the skin at the midline of the Achilles tendon. Then, the needle was turned subcutaneously to exit from the superior portal again. The stitch was tied subcutaneously; thus the graft loop became locked to the tendon at this point. Another locking stitch was taken on the other side through the other superior portal. Next, the graft was fixed to the calcaneal tunnel by a biodegradable interference screw according to the size of
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Fig 4. Left foot, posterior view. (A) The graft is passed through the proximal stump through superior portals. (B) The graft ends are retrieved from the inferior portal. (C) Under endoscopic control, the graft ends are retrieved through the calcaneal tunnel.
the tunnel. The surgeon achieved fixation while applying manual tension on the graft and the ankle was placed in a neutral position. Additional fixation was achieved by applying multiple locking sutures to the distal stump using the same technique described for the proximal locking sutures. Finally, closure of the portals was performed (Fig 5; Video 1, available at www.arthroscopyjournal. org). Postoperatively, a bulky dressing was applied and the ankle was immobilized by a posterior splint in 30 of plantar flexion for 2 weeks. At 2 weeks postoperatively, the skin stitches were removed and the ankle was then immobilized with a hinged foot and ankle orthosis fixed in 30 of plantar flexion for 1 month. At 6 weeks, the brace was fixed in the neutral position and the patient was allowed full weight bearing. Isotonic Achilles exercises and proprioceptive training were started at 8 weeks. Loading exercises and stretching Achilles exercises were started at 12 weeks. Running and sportsrelated exercises were allowed after 16 weeks. We performed functional evaluation at 24 months using the AOFAS score for the hindfoot. In addition, we performed objective evaluation of tendon function using isokinetic strength testing. Postoperative isokinetic muscle strength assessment was performed for the ankle dorsiflexors and plantar flexors in all patients at 2 years’ follow-up by use of a standard protocol on the isokinetic Biodex System 3 (Biodex Medical Systems, Shirley, NY).18 Data for the normal side were obtained as control
Fig 5. (A) The graft is fixed distally to the calcaneal tunnel by a bioabsorbable screw. The inset shows an endoscopic view of the doublebundle graft after fixation in the calcaneal tunnel. (B) Closure of portals after reconstruction of tendon.
data. The test protocol chosen comprised concentricconcentric contractions with test speeds of 60 /s and 120 /s with 5 test repetitions. The test protocol was explained to the patient, and there was a 5-minute warmup period before starting the test. Visual feedback was provided. The following data were obtained from the test: peak torque (in newton meters), peak torque/body weight (as a percent), maximum repetition total work (in joules), and average power (in watts). The deficit between the normal and operative sides was detected for all these parameters. According to the Biodex System 3 scale, deficits of 1% to 10% are considered nonsignificant whereas deficits of 11% to 25% are considered significant and require rehabilitation and deficits greater than 25% are considered functional impairment and require revision.18 Postoperative MRI was obtained in the immediate postoperative period and at 1 year of follow-up. We used a 1.5-T MRI system (Signa Horizon; GE Medical Systems, Milwaukee, WI) with a commercially available quadrature cervical spinal coil or knee coil. Statistical Analysis The collected data were revised, coded, tabulated, and introduced onto a personal computer using SPSS software (SPSS for Windows, version 15.0.1; SPSS, Chicago, IL). Data were presented and a suitable analysis was performed according to the type of data obtained for each parameter. Analytic statistical analysis for isokinetic test
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Fig 6. MRI study. (A) Preoperative sagittal MRI cut showing chronic rupture of Achilles tendon with 5-cm gap. (B) Immediate postoperative MRI cut showing semitendinosus graft (arrow heads) bridging defect, passing through proximal stump, and fixed to calcaneal tunnel. (C) MRI cut at 2 years’ follow-up showing incorporation of graft into old stumps with absence of gap and presence of homogenous signal intensity, as well as no discontinuity of fibers.
readings was performed with the Student t test to assess the statistical significance of the difference between the involved and uninvolved limbs. The analysis-of-variance test was used to assess the statistical significance of the difference between preoperative and postoperative AOFAS scores. The post hoc test was used for comparisons of all possible pairs of group means. The level of significance (P value) was ranked as follows: P > .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 (<10%) between the involved and uninvolved plantar flexors and dorsiflexors at 120 /s and 60 /s in peak torque, average power, and total work (Table 1). With regard to complications, paresthesia developed at the distribution of the sural nerve in 1 case and resolved spontaneously after 6 months. There were no cases of infection or deep venous thrombosis.
Discussion Treatment of a neglected rupture of the Achilles tendon is a challenging problem for both the orthopaedic surgeon and the patient. For the surgeon, there are many technical difficulties that are usually encountered, including the presence of a tendon gap, tendon fraying, tendon retraction, and disruption of the blood supply of the tendon
*Deficit is determined as follows: (Uninvolved side e Involved side)/Uninvolved side.
Uninvolved Involved Deficit* (%) Uninvolved Involved Deficit* (%) Uninvolved Involved Deficit* (%) Uninvolved Involved Deficit* (%) 28.4 27.6 2.8 32.4 31.8 1.8 20.8 20.5 1.4 23.2 23 0.8 27.2 26.1 31.2 30.9 20 19.4 3 22.3 21.9 1.7 10.5 9.8 6.6 15.4 15.2 1.2 8.6 8.4 2.3 13.3 13 2.2 13.0 12.7 2.3 18.3 17.9 2.1 12.9 12.6 2.3 21.8 21.5 1.3 36.3 35.7 1.6 66.1 65.6 0.7 61.3 61 0.4 110.4 109.8 0.5 Peak torque (N-m) Peak torque/body weight (%) Maximum repetition total work (J) Average power (W) Total work (J)
Table 1. Isokinetic Testing Results
Mean Plantar Flexion at 60 /s
Mean Dorsiflexion at 60 /s
Mean Plantar Flexion at 120 /s
Mean Dorsiflexion at 120 /s
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during surgery. For the patient, there is a relatively high risk of postoperative wound complications, in addition to tendon adhesion and stiffness.13-15 When the defect is larger than 2.5 cm, reconstruction of the defect is needed by graft augmentation.9 Maffulli and Leadbetter10 treated 21 patients with a neglected rupture of the Achilles tendon by open reconstruction using free gracilis tendon graft. They concluded that the technique is safe but technically demanding and carries a risk of complications. They reported superficial wound infections in 5 patients (23.8%) and a significant decrease in the calf muscle circumference and strength at the end of follow-up. In 2012 Maffulli et al.19 reported the long-term results of their technique; on the basis of the results of treatment of chronic tears of the Achilles tendon with free gracilis tendon grafting, they concluded that patients retained good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference. In a study performed by Sarzaeem et al.,20 11 patients with chronic rupture of the Achilles tendon with a large gap (>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.
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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.