FOOT AND ANKLE
The management of chronic rupture of the Achilles tendon MINIMALLY INVASIVE PERONEUS BREVIS TENDON TRANSFER N. Maffulli, F. Oliva, V. Costa, A. Del Buono From Centre for Sport and Exercise Medicine, London, United Kingdom
N. Maffulli, PhD, FRCP, FRCS(Orth), Professor of Musculoskeletal Disorders, Consultant Trauma and Orthopaedic Surgeon, Department of Musculoskeletal Surgery University of Salerno, School of Medicine and Surgery, Salerno, Italy. F. Oliva, MD, PhD, Specialist in Orthopaedic and Trauma Surgery, Department of Orthopaedics and Traumatology University of Rome ‘Tor Vergata’ School of Medicine, Viale Oxford 81, Rome, Italy. V. Costa, MD, Resident in Orthopaedic and Trauma Surgery, Department of Orthopaedic and Trauma Surgery Campus Biomedico University , Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy. A. Del Buono, MD, Specialist in Orthopaedic and Trauma Surgery, Department of Orthopaedic and Trauma Surgery Campus Biomedico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy. Correspondence should be sent to Professor N. Maffulli; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B3. 33732 $2.00 Bone Joint J 2015;97-B:353–7. Received 26 December 2013; Accepted 16 October 2014
VOL. 97-B, No. 3, MARCH 2015
We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale. At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities. This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities. Cite this article: Bone Joint J 2015;97-B:353–7.
The management of chronic rupture of the Achilles tendon remains controversial.1,2 The outcome of conservative management may be unsatisfactory, especially in young, physically active patients.3 Many procedures using different materials and tendon grafts can be used for reconstruction, but autogenous tendon grafting is preferable, as it provides excellent clinical and functional results without allograftrelated problems.3,4 Minimally invasive procedures may be advantageous compared with open techniques,5 resulting in less wound breakdown, infections and complications.6 Less extensive soft-tissue exposure and small incisions improve recovery and rehabilitation times.6,7 Plantar strength and the circumference of the calf remain reduced following surgery, but this does not appear to be clinically relevant.8 We report a minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum for chronic rupture of the Achilles tendon. This technique was first proposed for the management of this condition in 1974.9 Since then, it has been used successfully in patients
with large defects of the Achilles tendon.10 The rationale is to supplement the function of the Achilles tendon without restoring its anatomical continuity. We report a minimum two-year follow-up of a two-incision minimally invasive transfer of the peroneus brevis tendon.
Patients and Methods We retrospectively analysed prospectively collected clinical and functional data on 17 consecutive patients (three women, 14 men) who underwent peroneus brevis tendon transfer for the management of chronic rupture of the Achilles tendon at Newham University Hospital (East London, United Kingdom) between 2004 and 2009. At the time of reconstruction, the mean age of the patients was 39 years (31 to 49). At the time of presentation, a mean of 6.3 months (2 to 11) had elapsed since the Achilles tendon had been ruptured. The diagnosis was made clinically in all patients11,12 and confirmed with ultrasound and/or MRI. All patients were tertiary referrals. Each could recall the acute injury and was 353
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Fig. 1
Fig. 2
Photograph showing the peroneus brevis tendon being mobilised and pulled distally after the removal of adhesions and surrounding fibrosis.
Photograph showing the surgeon preparing to pass the peroneus tendon through the hole drilled in the calcaneum.
unable to stand on tiptoe and or ascend stairs leading with the affected foot. Each had a palpable defect of the Achilles tendon and atrophy of the calf. The senior author (NM) was clinically responsible for all the patients and performed the investigations at presentation, which included the measurement of the maximum circumference of the calf and the strength of isometric plantar flexion,4 as well as completing the Achilles Tendon Total Rupture Score (ATRS); a patientreported instrument with high reliability, validity, and sensitivity to measure outcome after treatment in patients with a total rupture of the Achilles tendon.13 He also performed all the operations. At the final review a research fellow (ADB) who had not been involved in the original management examined the patients and administered all the tests. He had a specialist degree in trauma and orthopaedic surgery. The study had retrospective ethical approval. Surgical technique. Pre-operatively, once the tendon defect had been palpated, the insertion of the Achilles tendon on the calcaneum, and the insertion of the peroneus brevis tendon over the base of the fifth metatarsal were identified as landmarks. Under general anaesthesia and with the patient prone, a thigh tourniquet was applied, the limb exsanguinated and the tourniquet inflated to 300 mmHg. Intravenous antibiotic prophylaxis was administered through a dorsal vein of the ipsilateral foot. A 3 cm longitudinal incision lateral to the midline was used to expose the insertion of the Achilles tendon into the posterolateral corner of the calcaneum, taking care to prevent damage to the sural nerve.14 An osteotomy of the posterosuperior corner of the calcaneum was then performed using an oscillating saw, without detaching the insertion of the Achilles tendon, which remained below the lower margin of the osteotomy. This osteotomy prevents impingement of the posterosuperior corner against the Achilles tendon and allows placement of the peroneus brevis tendon closer to the
insertion of the Achilles tendon. A 2.5 cm transverse incision over the base of the fifth metatarsal was then used and the tendon of peroneus brevis was detached from its insertion into the base of the fifth metatarsal. The distal 3 cm of the peroneus brevis tendon were tubularised with # 1 Vicryl (Ethicon, Edinburgh, United Kingdom) sutures and passed through the proximal incision, beneath the intact bridge of skin (Fig. 1). The proximal portion of the tendon was released from the surrounding tissues, mobilised, and the distal edge gently pulled down. The calcaneum was drilled from dorsal to plantar with a Beath pin (Arthrex Inc., Naples, Florida) at an angle of about 45° to the plantar surface of the heel. A 7 mm cannulated headed reamer was used to drill a tunnel, through which the perouneus brevis tendon was passed (Fig. 2). The transfer was tensioned with the ankle held in maximum equinus. A guide wire was then introduced to place a 7 mm × 20 mm or a 7 mm × 25 mm metallic or bioabsorbable interference screw to secure the tendon of the peroneus brevis to the calcaneum. The tendon of peroneus brevis was then tenodesed to the distal stump of the Achilles tendon with 2.0 Vicryl sutures (Ethicon). After irrigation with normal saline, the incisions were closed and Steri-strips (3 M Health Care, St Paul, Minnesota) were applied. A below-knee weight-bearing synthetic cast was applied with the ankle in maximal plantar flexion, leaving the metatarsal heads free. Post-operative management. Patients were discharged within 24 hours of operation, with the advice to bear weight on the metatarsal heads of the operated foot as tolerated, using elbow crutches. The cast was removed two weeks postoperatively and instructions were given to wear a commercially available removable boot. Rehabilitation was then supervised by a physiotherapist. Proprioceptive, inversion and eversion exercises and active plantar flexion were recommended, but dorsiflexion was THE BONE & JOINT JOURNAL
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avoided. Patients were permitted to progress gradually to full weight-bearing, generally by the end of the third week. After six weeks, isometric and concentric contractions of the gastrocnemius–soleus complex were allowed.15,16 The boot was removed eight weeks post-operatively and patients were allowed to bear full weight without aids. The patients were reviewed at three and six months postoperatively and, if necessary, were recommended to undertake more vigorous exercises. They were then further reviewed every three months and discharged after two years, once they were able to perform at least ten heel lifts unaided on the operated limb. At the last appointment, the ATRS13 was repeated, the maximum circumference of both calves was measured, and the task of performing ten singleleg heel lifts on the affected limb was tested. The isometric strength of plantar flexion and of eversion of the ankle were measured bilaterally and compared, using a custom-made apparatus, which consists of a foot plate, the angle of which could be varied and locked into a given position. An analogue to digital converter (ADC-10; PICO Technology, Cambridge, UK) connected the strain gauge on the foot plate to a voltmeter (Picoscope; PICO Technology). In its turn, the voltmeter was connected to a computer. Voltage changes were then converted into Newtons to measure strength. The ankle was placed in a neutral position (0°) as described elsewhere.17 Functional outcomes were classified according to the four-point Boyden scale.18 Statistical analysis. Data were tested for normal distribution by the Kolmogorov–Smirnov test. The Mann– Whitney U test was used to compare the isometric strength of gastrocsoleus and the circumference in both calves, and Wilcoxon’s signed-ranks test was used to compare pre- and post-operative strength and circumference, measured using our bespoke apparatus. 95% confidence intervals (CI) were measured, with the threshold for good and excellent set at 0.75. A p-value < 0.05 was considered statistically significant.
Results The mean follow-up was 4.6 years (two to seven). No patient was lost to follow-up. At the most recent review the mean maximum circumference of the calf of the operated limb was 41.4 cm (SD 6.5): this was not significantly different from the pre-operative mean of 40.6 cm (SD 5.3) (p = 0.45), and not significantly less than the mean circumference of the contralateral calf (43.1 cm (SD 7.1) (p = 0.16). The intra-observer (ADB) reliability for assessment of the isometric strength of gastrocsoleus was 0.88 (95% CI 0.82 to 0.95). The mean peak force at the last review of the operated limb was significantly lower than that of the contralateral limb (244.6 N; SD 119.8 vs 289.7 N; SD 124.3; Mann– Whitney test, p < 0.0001). The mean strength of eversion of the operated ankle was also significantly lower than that of the contralateral ankle (149.1 N; SD 82.3 vs 175.2 N SD 00.2; Mann–Whitney test, p < 0.0001). At the final review all patients were able to walk on tiptoe, without VOL. 97-B, No. 3, MARCH 2015
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using a heel lift or limping, and all were able to perform at least ten single leg heel lifts on the affected limb. At the final review, the mean ATRS had improved from 58 points (35 to 68) pre-operatively to 91 points (75 to 97; 95% CI 85.3 to 93.2; p = 0.0001). According to the Boyden classification system, six patients had an excellent result, ten a good result and one a fair result. None had a poor result. Return to sport and daily activity. All patients returned to their pre-injury occupation at a mean of nine weeks (5 to 16) following surgery. Before injury, 13 patients had practised high-impact recreational activities two to three times per week, and four were sedentary. All 13 patients returned to their recreational activities at a mean of 6.8 months (six to nine) after surgery. At the final review, ten of 13 patients still undertook recreational activities (football, tennis, skiing), and three had changed from weight-bearing to non-weight-bearing activities (cycling and swimming). The remaining four patients did not practice any sport, and did not experience problems in their daily activities. Complications. No patient complained of symptoms related to the harvesting of the tendon. At the final review, none had developed a wound infection, scar adhesions or deformity of the hindfoot. No patient had detachment of the Achilles tendon, wound breakdown, complex regional pain syndrome or sural nerve injury. One patient complained of hypersensitivity around the lateral aspect of the mid-foot in the early post-operative period, but these symptoms subsided spontaneously by six months after surgery.
Discussion This study shows that transfer of the peroneus brevis tendon offers encouraging results in patients with chronic rupture of the Achilles tendon, at a mean follow-up of 4.6 years (two to seven) after reconstruction. We have already reported using the peroneus brevis tendon to reconstruct chronic ruptures of the Achilles tendon with a gap between the stumps < 6 cm, at a mean of almost 16 years post-operatively, when, in a series of 16 patients, > 80% had a good or excellent outcome.7 Miskulin et al19 used combined peroneus brevis transfer with augmentation of the plantaris tendon for the management of chronic ruptures of the Achilles tendon to supplement function of the Achilles tendon without restoring its anatomy and continuity, but reproducing its dynamic function. Transfers of the flexor hallucis longus (FHL) tendon have been used in ruptures of the Achilles tendon and tendinopathy, with satisfactory clinical and functional outcomes.20,21 However, as active range of movement of the interphalangeal joint of the hallux and the peak torque of plantar flexion are significantly decreased compared with the contralateral side following this procedure, impaired strength of push-off may be troublesome for athletes and young patients.22,23 It has been reported that, in two series of 1924 and 4421 patients respectively, between 50% and 86% of patients were able to perform a single-heel rise test on the operated side after transfer of the FHL, with poorer
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results in patients with chronic ruptures.24 A reasonable explanation for the loss of strength is that the length– tension relationship of the fibres of the gastrocsoleus complex could change over time, especially in chronic ruptures. On the other hand, the peroneal muscles provide only 4% of the total work capacity in plantar flexion25 and, specifically, the action of the peroneus brevis may be in part supplemented by the peroneus longus and tertius muscles. In our study, all patients were able to perform single-heel toe raises and walk on tiptoe, without any obvious muscle imbalance or gait abnormality. We excise the adhesions around the distal stump of the Achilles tendon, taking care to preserve the distal stump for side-to-side tenodesis with the proximal portion of peroneus brevis. Our aim is to reinforce the peroneus brevis transfer, improve its integration with the Achilles tendon and prevent pullout.3 As observed following transfer of the tendon of FHL, the peroneus brevis tendon will hypertrophy over time, and its functional incorporation to the Achilles tendon will increase the strength of plantar flexion.26 This provides a dynamic system which supplies the action of the Achilles tendon and gastrocnemius complex, and provides similar contractile forces and normal muscle balance of the ankle. According to Turco and Spinella,27 the tendon of peroneus brevis can be passed through the distal stump of the Achilles tendon. This is what we undertook in a traditional open fashion14 and in a minimally invasive way.17 However, the technique described here is, in our hands, less technically demanding, allows less exposure of the ends of the Achilles tendon, and the use of interference screw fixation of the tendon in the calcaneum allows secure fixation. The osteotomy of the posterolateral calcaneal tuberosity prevents impingement of the posterosuperior corner of the calcaneum against the transferred tendon28,29 and allows transfer the tendon of peroneus brevis more posteriorly, closer to the native insertion of the Achilles tendon. Harvesting the tendon of peroneus brevis is safe. The tendon of peroneus tertius is commonly found in the same region and care should be taken not to damage or harvest this tendon. No skin or wound healing complications were reported. Even though the strength of eversion of the ankle was significantly different from that of the contralateral side, the peroneus longus and tertius may effectively supply the action of this tendon.14 Peroneus brevis is an important stabiliser of the ankle and its transfer reduces the strength of eversion of the ankle by about 9%,30 but we doubt whether this loss of strength, albeit statistically significant (p = 0.04), has any clinical relevance. In fact, appropriate rehabilitation results in recovery of strength.7,31 Most of our active patients had returned to their preinjury level of physical activity and all had returned to preinjury daily activities without any disturbance of balance, and with good to excellent outcomes in most cases. At the final review, the mean ATRS of 91 (75 to 97; p = 0.0001) was significantly improved compared with the mean pre-
operative score of 58 (35 to 68), the tendon was functional in all patients, and none of the patients had developed instability of the ankle. The main limitation of this study is its retrospective nature, even though we were able to review all the patients. Because all studies available in the literature report findings of different procedures, a comparison with them is not possible. A limitation of our study is that the ATRS questionnaire13 was developed only after we started the present study. Therefore, we administered the questionnaire retrospectively, asking patients about their condition at the time before the operation. The strengths of this study include the fact that all operations were undertaken by a single surgeon using a constant technique, the rehabilitation protocol was uniform throughout the study and the assessment of the function of the ankle and hindfoot was performed using an accepted instrument (ATRS). We have used the transfer of the peroneus brevis tendon for the management of chronic ruptures of the Achilles tendon regardless of the size of the gap. Indeed, in this technique the gap in the Achilles tendon is not exposed, and the rationale of the transfer is not to fill a gap but to provide a ‘motor’ which re-tensions, supplies and augments the function of the gastrocsoleus–Achilles tendon complex.31,32 In conclusion, this study shows that peroneus brevis transfer to the Achilles tendon may be securely performed, is minimally invasive, has low morbidity and allows most patients to return to pre-injury sporting and daily activities. Author contributions N. Maffulli: Designed and implemented the study, Described the original techniques, Revised drafts of the manuscript, Approved final manuscript. E. Oliva: Contributed to the study design, Study implementation, Refinement of the study protocol, Data analysis, Drafted manuscript, Approved final manuscript. V. Costa: Contributed to the study design, Study implementation, Refinement of the study protocol, Data analysis, Drafted manuscript, Approved final manuscript. A. Del Buono: Contributed to the study design, Study implementation, Refinement of the study protocol, Data analysis, Drafted manuscript, Approved final manuscript. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by G. Scott and first proof edited by J. Scott.
References 1. Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc 2009;17:112–126. 2. Flint JH, Wade AM, Giuliani J, Rue JP. Defining the terms acute and chronic in orthopaedic sports injuries: a systematic review. Am J Sports Med 2014;42:235–241. 3. Maffulli N, Ajis A, Longo UG, Denaro V. Chronic rupture of tendo Achillis. Foot Ankle Clin 2007;12:583–596. 4. Guillo S, Del Buono A, Dias M, Denaro V, Maffulli N. Percutaneous repair of acute ruptures of the tendo Achillis. Surgeon 2013;11:14–19. 5. Maffulli N, Del Buono A, Spiezia F, et al. Less-invasive semitendinosus tendon graft augmentation for the reconstruction of chronic tears of the Achilles tendon. Am J Sports Med 2013;41:865–871. 6. Maffulli N, Longo UG, Gougoulias N, et al. Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon . BMC Musculoskelet Disord 2008;9:100. 7. Maffulli N, Spiezia F, Pintore E, et al. Peroneus brevis tendon transfer for reconstruction of chronic tears of the Achilles tendon: a long-term follow-up study. J Bone Joint Surg [Am] 2012;94-A:901–905. THE BONE & JOINT JOURNAL
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8. Maffulli N, Del Buono A. Release of the medial head of the gastrocnemius for Achilles tendinopathy in sedentary patients: a retrospective study. Int Orthop 2014 (Epub ahead of print). 9. Perez Teuffer A. Traumatic rupture of the Achilles Tendon: reconstruction by transplant and graft using the lateral peroneus brevis. Orthop Clin North Am 1974;5: 89-93. 10. Hepp WR, Blauth W. Repair of defects in the Achilles tendon with the peroneus brevis muscle (In German). Arch Orthop Trauma Surg 1978;91:195–200. 11. Simmonds FA. The diagnosis of the ruptured Achilles tendon. Practitioner 1957;179:56–58. 12. Matles AL. Rupture of the tendo achilles: another diagnostic sign. Bull Hosp Joint Dis 1975;36:48–51. 13. Nilsson-Helander K, Thomeé R, Silbernagel KG, et al. The Achilles tendon. Total Rupture Score (ATRS): development and validation. Am J Sports Med 2007;35:421–426. 14. 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. 15. Maffulli N, Tallon C, Wong J, et al. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med 2003;31:692–700. 16. Maffulli N, Tallon C, Wong Jet, et al. No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon. J Sports Med Phys Fitness 2003;43:367–379. 17. Bleakney RR, Tallon C, Wong JK, et al. Long-term ultrasonographic features of the Achilles tendon after rupture. Clin J Sport Med 2002;12:273–278. 18. Boyden EM, Kitaoka HB, Cahalan TD, An KN. Late versus early repair of Achilles tendon rupture: clinical and biomechanical evaluation. Clin Orthop Relat Res 1995;317:150–158. 19. Miskulin M, Miskulin A, Klobucar H, et al. 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. 20. Den Hartog BD. Flexor hallucis longus transfer for chronic Achilles tendonosis. Foot Ankle Int 2003;24:233–237.
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21. Martin RL, Manning CM, Carcia CR, et al. An outcome study of chronic Achilles tendinosis after excision of the Achilles tendon and flexor hallucis longus tendon transfer. Foot Ankle Int 2005;26:691–697. 22. Ferris L, Sharkey NA, Smith TS, et al. Influence of extrinsic plantar flexors on forefoot loading during heel rise. Foot Ankle Int 1995;16:464–473. 23. Jacob HA. Forces acting in the forefoot during normal gait--an estimate. Clin Biomech (Bristol, Avon) 2001;16:783–792. 24. Will R, Galey SM. Outcome of single incision flexor hallucis longus transfer for chronic achilles tendinopathy. Foot Ankle Int 2009;30:315–317. 25. Maffulli N, Longo UG, Gougoulias N, et al. Sport injuries: a review of outcomes. Br Med Bull 2011;97:47–80. 26. Hahn F, Meyer P, Maiwald C, et al. Treatment of chronic achilles tendinopathy and ruptures with flexor hallucis tendon transfer: clinical outcome and MRI findings. Foot Ankle Int 2008;29:794–802. 27. Turco VJ, Spinella AJ. Achilles tendon ruptures--peroneus brevis transfer. Foot Ankle 1987;7:253–259. 28. Loppini M, Maffulli N. Conservative management of tendinopathy: an evidencebased approach. Muscles Ligaments Tendons J 2012;1:134–137. 29. Maffulli N, Del Buono A, Testa V, et al. Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision. J Bone Joint Surg [Br] 2011;93-B:1503–1507. 30. Karlsson J, Bergsten T, Lansinger O, et al. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg [Am] 1988;70A:581–588. 31. Maffulli N, Spiezia F, Longo UG, et al. Less-invasive reconstruction of chronic achilles tendon ruptures using a peroneus brevis tendon transfer. Am J Sports Med 2010;38:2304–2312. 32. Hadi M, Young J, Cooper L, et al. Surgical management of chronic ruptures of the Achilles tendon remains unclear: a systematic review of the management options. Br Med Bull 2013;108:95–114.
The management of chronic rupture of the Achilles tendon MINIMALLY INVASIVE PERONEUS BREVIS TENDON TRANSFER N. Maffulli, F. Oliva, V. Costa, A. Del Buono From Centre for Sport and Exercise Medicine, London, United Kingdom
N. Maffulli, PhD, FRCP, FRCS(Orth), Professor of Musculoskeletal Disorders, Consultant Trauma and Orthopaedic Surgeon, Department of Musculoskeletal Surgery University of Salerno, School of Medicine and Surgery, Salerno, Italy. F. Oliva, MD, PhD, Specialist in Orthopaedic and Trauma Surgery, Department of Orthopaedics and Traumatology University of Rome ‘Tor Vergata’ School of Medicine, Viale Oxford 81, Rome, Italy. V. Costa, MD, Resident in Orthopaedic and Trauma Surgery, Department of Orthopaedic and Trauma Surgery Campus Biomedico University , Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy. A. Del Buono, MD, Specialist in Orthopaedic and Trauma Surgery, Department of Orthopaedic and Trauma Surgery Campus Biomedico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy. Correspondence should be sent to Professor N. Maffulli; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B3. 33732 $2.00 Bone Joint J 2015;97-B:353–7. Received 26 December 2013; Accepted 16 October 2014
VOL. 97-B, No. 3, MARCH 2015
We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale. At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities. This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities. Cite this article: Bone Joint J 2015;97-B:353–7.
The management of chronic rupture of the Achilles tendon remains controversial.1,2 The outcome of conservative management may be unsatisfactory, especially in young, physically active patients.3 Many procedures using different materials and tendon grafts can be used for reconstruction, but autogenous tendon grafting is preferable, as it provides excellent clinical and functional results without allograftrelated problems.3,4 Minimally invasive procedures may be advantageous compared with open techniques,5 resulting in less wound breakdown, infections and complications.6 Less extensive soft-tissue exposure and small incisions improve recovery and rehabilitation times.6,7 Plantar strength and the circumference of the calf remain reduced following surgery, but this does not appear to be clinically relevant.8 We report a minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum for chronic rupture of the Achilles tendon. This technique was first proposed for the management of this condition in 1974.9 Since then, it has been used successfully in patients
with large defects of the Achilles tendon.10 The rationale is to supplement the function of the Achilles tendon without restoring its anatomical continuity. We report a minimum two-year follow-up of a two-incision minimally invasive transfer of the peroneus brevis tendon.
Patients and Methods We retrospectively analysed prospectively collected clinical and functional data on 17 consecutive patients (three women, 14 men) who underwent peroneus brevis tendon transfer for the management of chronic rupture of the Achilles tendon at Newham University Hospital (East London, United Kingdom) between 2004 and 2009. At the time of reconstruction, the mean age of the patients was 39 years (31 to 49). At the time of presentation, a mean of 6.3 months (2 to 11) had elapsed since the Achilles tendon had been ruptured. The diagnosis was made clinically in all patients11,12 and confirmed with ultrasound and/or MRI. All patients were tertiary referrals. Each could recall the acute injury and was 353
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N. MAFFULLI, F. OLIVA, V. COSTA, A. DEL BUONO
Fig. 1
Fig. 2
Photograph showing the peroneus brevis tendon being mobilised and pulled distally after the removal of adhesions and surrounding fibrosis.
Photograph showing the surgeon preparing to pass the peroneus tendon through the hole drilled in the calcaneum.
unable to stand on tiptoe and or ascend stairs leading with the affected foot. Each had a palpable defect of the Achilles tendon and atrophy of the calf. The senior author (NM) was clinically responsible for all the patients and performed the investigations at presentation, which included the measurement of the maximum circumference of the calf and the strength of isometric plantar flexion,4 as well as completing the Achilles Tendon Total Rupture Score (ATRS); a patientreported instrument with high reliability, validity, and sensitivity to measure outcome after treatment in patients with a total rupture of the Achilles tendon.13 He also performed all the operations. At the final review a research fellow (ADB) who had not been involved in the original management examined the patients and administered all the tests. He had a specialist degree in trauma and orthopaedic surgery. The study had retrospective ethical approval. Surgical technique. Pre-operatively, once the tendon defect had been palpated, the insertion of the Achilles tendon on the calcaneum, and the insertion of the peroneus brevis tendon over the base of the fifth metatarsal were identified as landmarks. Under general anaesthesia and with the patient prone, a thigh tourniquet was applied, the limb exsanguinated and the tourniquet inflated to 300 mmHg. Intravenous antibiotic prophylaxis was administered through a dorsal vein of the ipsilateral foot. A 3 cm longitudinal incision lateral to the midline was used to expose the insertion of the Achilles tendon into the posterolateral corner of the calcaneum, taking care to prevent damage to the sural nerve.14 An osteotomy of the posterosuperior corner of the calcaneum was then performed using an oscillating saw, without detaching the insertion of the Achilles tendon, which remained below the lower margin of the osteotomy. This osteotomy prevents impingement of the posterosuperior corner against the Achilles tendon and allows placement of the peroneus brevis tendon closer to the
insertion of the Achilles tendon. A 2.5 cm transverse incision over the base of the fifth metatarsal was then used and the tendon of peroneus brevis was detached from its insertion into the base of the fifth metatarsal. The distal 3 cm of the peroneus brevis tendon were tubularised with # 1 Vicryl (Ethicon, Edinburgh, United Kingdom) sutures and passed through the proximal incision, beneath the intact bridge of skin (Fig. 1). The proximal portion of the tendon was released from the surrounding tissues, mobilised, and the distal edge gently pulled down. The calcaneum was drilled from dorsal to plantar with a Beath pin (Arthrex Inc., Naples, Florida) at an angle of about 45° to the plantar surface of the heel. A 7 mm cannulated headed reamer was used to drill a tunnel, through which the perouneus brevis tendon was passed (Fig. 2). The transfer was tensioned with the ankle held in maximum equinus. A guide wire was then introduced to place a 7 mm × 20 mm or a 7 mm × 25 mm metallic or bioabsorbable interference screw to secure the tendon of the peroneus brevis to the calcaneum. The tendon of peroneus brevis was then tenodesed to the distal stump of the Achilles tendon with 2.0 Vicryl sutures (Ethicon). After irrigation with normal saline, the incisions were closed and Steri-strips (3 M Health Care, St Paul, Minnesota) were applied. A below-knee weight-bearing synthetic cast was applied with the ankle in maximal plantar flexion, leaving the metatarsal heads free. Post-operative management. Patients were discharged within 24 hours of operation, with the advice to bear weight on the metatarsal heads of the operated foot as tolerated, using elbow crutches. The cast was removed two weeks postoperatively and instructions were given to wear a commercially available removable boot. Rehabilitation was then supervised by a physiotherapist. Proprioceptive, inversion and eversion exercises and active plantar flexion were recommended, but dorsiflexion was THE BONE & JOINT JOURNAL
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avoided. Patients were permitted to progress gradually to full weight-bearing, generally by the end of the third week. After six weeks, isometric and concentric contractions of the gastrocnemius–soleus complex were allowed.15,16 The boot was removed eight weeks post-operatively and patients were allowed to bear full weight without aids. The patients were reviewed at three and six months postoperatively and, if necessary, were recommended to undertake more vigorous exercises. They were then further reviewed every three months and discharged after two years, once they were able to perform at least ten heel lifts unaided on the operated limb. At the last appointment, the ATRS13 was repeated, the maximum circumference of both calves was measured, and the task of performing ten singleleg heel lifts on the affected limb was tested. The isometric strength of plantar flexion and of eversion of the ankle were measured bilaterally and compared, using a custom-made apparatus, which consists of a foot plate, the angle of which could be varied and locked into a given position. An analogue to digital converter (ADC-10; PICO Technology, Cambridge, UK) connected the strain gauge on the foot plate to a voltmeter (Picoscope; PICO Technology). In its turn, the voltmeter was connected to a computer. Voltage changes were then converted into Newtons to measure strength. The ankle was placed in a neutral position (0°) as described elsewhere.17 Functional outcomes were classified according to the four-point Boyden scale.18 Statistical analysis. Data were tested for normal distribution by the Kolmogorov–Smirnov test. The Mann– Whitney U test was used to compare the isometric strength of gastrocsoleus and the circumference in both calves, and Wilcoxon’s signed-ranks test was used to compare pre- and post-operative strength and circumference, measured using our bespoke apparatus. 95% confidence intervals (CI) were measured, with the threshold for good and excellent set at 0.75. A p-value < 0.05 was considered statistically significant.
Results The mean follow-up was 4.6 years (two to seven). No patient was lost to follow-up. At the most recent review the mean maximum circumference of the calf of the operated limb was 41.4 cm (SD 6.5): this was not significantly different from the pre-operative mean of 40.6 cm (SD 5.3) (p = 0.45), and not significantly less than the mean circumference of the contralateral calf (43.1 cm (SD 7.1) (p = 0.16). The intra-observer (ADB) reliability for assessment of the isometric strength of gastrocsoleus was 0.88 (95% CI 0.82 to 0.95). The mean peak force at the last review of the operated limb was significantly lower than that of the contralateral limb (244.6 N; SD 119.8 vs 289.7 N; SD 124.3; Mann– Whitney test, p < 0.0001). The mean strength of eversion of the operated ankle was also significantly lower than that of the contralateral ankle (149.1 N; SD 82.3 vs 175.2 N SD 00.2; Mann–Whitney test, p < 0.0001). At the final review all patients were able to walk on tiptoe, without VOL. 97-B, No. 3, MARCH 2015
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using a heel lift or limping, and all were able to perform at least ten single leg heel lifts on the affected limb. At the final review, the mean ATRS had improved from 58 points (35 to 68) pre-operatively to 91 points (75 to 97; 95% CI 85.3 to 93.2; p = 0.0001). According to the Boyden classification system, six patients had an excellent result, ten a good result and one a fair result. None had a poor result. Return to sport and daily activity. All patients returned to their pre-injury occupation at a mean of nine weeks (5 to 16) following surgery. Before injury, 13 patients had practised high-impact recreational activities two to three times per week, and four were sedentary. All 13 patients returned to their recreational activities at a mean of 6.8 months (six to nine) after surgery. At the final review, ten of 13 patients still undertook recreational activities (football, tennis, skiing), and three had changed from weight-bearing to non-weight-bearing activities (cycling and swimming). The remaining four patients did not practice any sport, and did not experience problems in their daily activities. Complications. No patient complained of symptoms related to the harvesting of the tendon. At the final review, none had developed a wound infection, scar adhesions or deformity of the hindfoot. No patient had detachment of the Achilles tendon, wound breakdown, complex regional pain syndrome or sural nerve injury. One patient complained of hypersensitivity around the lateral aspect of the mid-foot in the early post-operative period, but these symptoms subsided spontaneously by six months after surgery.
Discussion This study shows that transfer of the peroneus brevis tendon offers encouraging results in patients with chronic rupture of the Achilles tendon, at a mean follow-up of 4.6 years (two to seven) after reconstruction. We have already reported using the peroneus brevis tendon to reconstruct chronic ruptures of the Achilles tendon with a gap between the stumps < 6 cm, at a mean of almost 16 years post-operatively, when, in a series of 16 patients, > 80% had a good or excellent outcome.7 Miskulin et al19 used combined peroneus brevis transfer with augmentation of the plantaris tendon for the management of chronic ruptures of the Achilles tendon to supplement function of the Achilles tendon without restoring its anatomy and continuity, but reproducing its dynamic function. Transfers of the flexor hallucis longus (FHL) tendon have been used in ruptures of the Achilles tendon and tendinopathy, with satisfactory clinical and functional outcomes.20,21 However, as active range of movement of the interphalangeal joint of the hallux and the peak torque of plantar flexion are significantly decreased compared with the contralateral side following this procedure, impaired strength of push-off may be troublesome for athletes and young patients.22,23 It has been reported that, in two series of 1924 and 4421 patients respectively, between 50% and 86% of patients were able to perform a single-heel rise test on the operated side after transfer of the FHL, with poorer
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results in patients with chronic ruptures.24 A reasonable explanation for the loss of strength is that the length– tension relationship of the fibres of the gastrocsoleus complex could change over time, especially in chronic ruptures. On the other hand, the peroneal muscles provide only 4% of the total work capacity in plantar flexion25 and, specifically, the action of the peroneus brevis may be in part supplemented by the peroneus longus and tertius muscles. In our study, all patients were able to perform single-heel toe raises and walk on tiptoe, without any obvious muscle imbalance or gait abnormality. We excise the adhesions around the distal stump of the Achilles tendon, taking care to preserve the distal stump for side-to-side tenodesis with the proximal portion of peroneus brevis. Our aim is to reinforce the peroneus brevis transfer, improve its integration with the Achilles tendon and prevent pullout.3 As observed following transfer of the tendon of FHL, the peroneus brevis tendon will hypertrophy over time, and its functional incorporation to the Achilles tendon will increase the strength of plantar flexion.26 This provides a dynamic system which supplies the action of the Achilles tendon and gastrocnemius complex, and provides similar contractile forces and normal muscle balance of the ankle. According to Turco and Spinella,27 the tendon of peroneus brevis can be passed through the distal stump of the Achilles tendon. This is what we undertook in a traditional open fashion14 and in a minimally invasive way.17 However, the technique described here is, in our hands, less technically demanding, allows less exposure of the ends of the Achilles tendon, and the use of interference screw fixation of the tendon in the calcaneum allows secure fixation. The osteotomy of the posterolateral calcaneal tuberosity prevents impingement of the posterosuperior corner of the calcaneum against the transferred tendon28,29 and allows transfer the tendon of peroneus brevis more posteriorly, closer to the native insertion of the Achilles tendon. Harvesting the tendon of peroneus brevis is safe. The tendon of peroneus tertius is commonly found in the same region and care should be taken not to damage or harvest this tendon. No skin or wound healing complications were reported. Even though the strength of eversion of the ankle was significantly different from that of the contralateral side, the peroneus longus and tertius may effectively supply the action of this tendon.14 Peroneus brevis is an important stabiliser of the ankle and its transfer reduces the strength of eversion of the ankle by about 9%,30 but we doubt whether this loss of strength, albeit statistically significant (p = 0.04), has any clinical relevance. In fact, appropriate rehabilitation results in recovery of strength.7,31 Most of our active patients had returned to their preinjury level of physical activity and all had returned to preinjury daily activities without any disturbance of balance, and with good to excellent outcomes in most cases. At the final review, the mean ATRS of 91 (75 to 97; p = 0.0001) was significantly improved compared with the mean pre-
operative score of 58 (35 to 68), the tendon was functional in all patients, and none of the patients had developed instability of the ankle. The main limitation of this study is its retrospective nature, even though we were able to review all the patients. Because all studies available in the literature report findings of different procedures, a comparison with them is not possible. A limitation of our study is that the ATRS questionnaire13 was developed only after we started the present study. Therefore, we administered the questionnaire retrospectively, asking patients about their condition at the time before the operation. The strengths of this study include the fact that all operations were undertaken by a single surgeon using a constant technique, the rehabilitation protocol was uniform throughout the study and the assessment of the function of the ankle and hindfoot was performed using an accepted instrument (ATRS). We have used the transfer of the peroneus brevis tendon for the management of chronic ruptures of the Achilles tendon regardless of the size of the gap. Indeed, in this technique the gap in the Achilles tendon is not exposed, and the rationale of the transfer is not to fill a gap but to provide a ‘motor’ which re-tensions, supplies and augments the function of the gastrocsoleus–Achilles tendon complex.31,32 In conclusion, this study shows that peroneus brevis transfer to the Achilles tendon may be securely performed, is minimally invasive, has low morbidity and allows most patients to return to pre-injury sporting and daily activities. Author contributions N. Maffulli: Designed and implemented the study, Described the original techniques, Revised drafts of the manuscript, Approved final manuscript. E. Oliva: Contributed to the study design, Study implementation, Refinement of the study protocol, Data analysis, Drafted manuscript, Approved final manuscript. V. Costa: Contributed to the study design, Study implementation, Refinement of the study protocol, Data analysis, Drafted manuscript, Approved final manuscript. A. Del Buono: Contributed to the study design, Study implementation, Refinement of the study protocol, Data analysis, Drafted manuscript, Approved final manuscript. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by G. Scott and first proof edited by J. Scott.
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