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Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcome

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus—Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation.

Methods

Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3 cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24 months.

Results

The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6 years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2 min, p < 0.001). At 24 months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (−0.5 ± 1.7 vs −4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24 months (435 ± 37.9 vs 436 ± 39.7 N, n.s.).

Conclusion

Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome.

Level of evidence

Level II.

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Authors and Affiliations

  1. Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy

    Nicola Maffulli & Francesco Oliva

  2. School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK

    Nicola Maffulli

  3. Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England, UK

    Nicola Maffulli

  4. Department of Orthopedic Surgery, General Hospital of Katerini, Katerini, Greece

    Nikolaos Gougoulias & Panagiotis Christidis

  5. Wholelife Clinics, London, UK

    Gayle D. Maffulli

Authors
  1. Nicola Maffulli
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  2. Nikolaos Gougoulias
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  3. Panagiotis Christidis
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  4. Gayle D. Maffulli
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  5. Francesco Oliva
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Contributions

All authors contributed to the preparation of the manuscript and approved its content. NM: Performed the surgical procedures, and supervised the patient’s post-operative rehabilitation; FO: Did the follow-up assessment; PC: Analyzed the data; NG and PC: Prepared the initial manuscript; NM and NG: As senior authors, edited the final form of the manuscript.

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Correspondence to Nicola Maffulli.

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The present investigation was approved by our local ethics committee.

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Maffulli, N., Gougoulias, N., Christidis, P. et al. Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcome. Knee Surg Sports Traumatol Arthrosc 31, 94–101 (2023). https://doi.org/10.1007/s00167-022-07183-0

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