Managing Complications With A Failed Tendo-Achilles Allograft

These authors discuss the use of tendon transfers and Achilles tendon resection for a 56-year-old patient who presented with drainage and dermatitis after receiving an allograft for an injury to the Achilles tendon.

While Achilles tendon injuries are the most common tendon injuries in the lower extremity, clinicians misdiagnose these injuries between 20 to 25 percent of the time.^1,2 These injuries often occur in young athletic males due to indirect trauma or a sudden forceful contraction. For acute Achilles tendon injuries, conservative treatment versus surgical treatment is often debated, and well documented throughout the literature. However, after 4 to 6 weeks, Achilles tendon ruptures are considered chronic and surgical repair is recommended.

Multiple authors have described classification and recommendations for surgical management of Achilles tendon ruptures. Myerson and colleagues advocate end- to-end repair for deficits less than 2 cm; fascial advancement (such as a gastroc recession or V-Y fascial myotendinous lengthening) in defects up to between 2 to 5 cm; and a tendon transfer along or in conjunction with a V-Y fascial myotendinous advancement.³ In these larger defects, surgeons have utilized allograft substitutes to assist in strengthening the repair either through direct incorporation such as weaving the allograft throughout the ruptured tendon or indirectly through overlaying augmentation of the allograft to increase suture pullout strength.^4,5 Overall, Achilles tendon allografts are considered allogenic and rejection is reportedly rare.

With this in mind, let us take a closer look at a recent case involving revision of a chronic Achilles tendon rupture with allograft Achilles repair.

A 56-year-old Caucasian female with a significant past medical history of hypertension and MRSA states her initial injury occurred while missing a step and rupturing her Achilles tendon. The patient subsequently had an open repair in September 2012. A previous physician told the patient that the tendon was “so bad” that he used an allograft for the repair. The patient stated she did reasonably well but at six months post-op, she developed drainage and severe reactive dermatitis. After treatment consisting of local wound care, topical and oral steroids, and antibiotics for a period of four months, the posterior wound and sinus tract improved but the dermatitis persisted.

The patient was referred to us for evaluation and further treatment in May 2014. At this point, she had been taking doxycycline for six months with a lack of wound improvement. The physical exam revealed an unremarkable neurovascular status. The musculoskeletal exam demonstrated a decreased strength +3/5 of the gastroc-soleus complex with some calf atrophy and the patient was unable to rise on her toes. We also noted a small persistent ulceration to the posterior Achilles tendon.

Step-By-Step Surgical Pearls

With the patient in the prone position, there was a linear incision posteriorly and slightly lateral through the previous surgical incision. Upon inspection of the Achilles tendon, it was apparent that the previous repair was degenerative with inflammation at the level of the Achilles insertion distally to approximately 10 cm proximally. We determined that excision was necessary due to the host rejection of the incorporated Achilles allograft.

We identified and transected the peroneus brevis tendon at the insertion of the fifth metatarsal. After identifying the peroneus brevis tendon through the Achilles tendon incision laterally and drawing it into the wound through its sheath, we transferred the tendon to the superior calcaneus through a 4.5 mm drill hole from lateral to medial, and sutured the redundant tendon to the proximal portion of the peroneus brevis tendon under maximum tension. Subsequently, we identified the flexor hallucis longus tendon proximal and medial at the ankle joint level, and “short harvested” the tendon. We then transferred the flexor hallucis longus tendon under maximum tension from medial to lateral and secured it with a 6 mm interference screw.

Following peroneus brevis and flexor hallucis longus tendon transfers with resection of the degenerative Achilles tendon, we were able to resolve the patient’s dermatitis. At six weeks, the patient began partial weightbearing exercises. At twelve weeks, the patient was ambulating in a tennis shoe with the ability to perform a double heel rise without difficulty. At the last follow-up visit, the patient was pain-free with resolution of her wound healing complications.

Current Concepts With Tendon Transfers And Achilles Tendon Injuries

Chronic injuries of the Achilles tendon have been well documented in the literature and authors have discussed techniques utilizing Achilles tendon allograft material to assist in surgical repair. In 2011, Branch described the use of a Pulvertaft weave technique for Achilles tendon repair.⁴ in a three-person case series, and reported no complications. In a similar study in 2008, Lee treated 11 acute Achilles tendon ruptures with Achilles allograft and found that all patients could perform a single heel rise with no complications at six months.⁵

When performing a revision in a chronic Achilles tendon rupture, transfer of the peroneus brevis or flexor hallucis longus tendon may be required. In the current case study, an adverse reaction to the Achilles allograft precipitated a dermatitis reaction. This created a chronic sinus tract and draining wound, which led to a pathologic tear and dysfunction of the Achilles tendon. Therefore, resection of the Achilles tendon allograft was required and a peroneus brevis and flexor hallucis longus tendon transfer was warranted.

Multiple studies have demonstrated the efficacy of using a peroneus brevis or flexor hallucis longus tendon transfer. In a 2007 cadaveric study, Sebastian and colleagues found that peroneus brevis tendon transfers individually had a significantly increased failure load in comparison to flexor hallucis longus transfers.⁶ In 2005, Miskulin and coworkers performed a peroneus brevis tendon transfer with a plantaris tendon transfer in five patients, demonstrating improvement among plantar flexion mean peak torque.⁷

In the present case, we performed peroneus brevis and flexor hallucis longus tendon transfers, and saw noted improvement with plantarflexion and heel rise. Biomechanical studies show the peroneus longus tendon is able to neutralize any overpull of the tibialis posterior tendon. Although the flexor hallucis longus tendon transfer may lead to decreased hallux flexion strength, there have been no significant biomechanical effects due to the harvesting of the tendon at the master knot.

Achilles tendon rupture augmentation with Achilles allograft may precipitate wound healing complications secondary to dermal rejection. In such instances, the affected Achilles tendon may not be salvageable due to the chronic inflammatory and degenerative state. As we have demonstrated above, utilizing peroneus brevis and flexor hallucis longus tendon transfers can be helpful in revising an Achilles tendon rupture with wound healing complications secondary to reactive dermatitis.

Dr. Visser is the Director of the SSM Health DePaul Hospital Foot and Ankle Surgery Residency. He is a Fellow of the American College of Foot and Ankle Surgeons.

Drs. Wolfe, Schergen, Maestas and Ermitano are second-year residents with the SSM Health DePaul Hospital Foot and Ankle Surgery Residency.

References

1. Bevilacqua N. Treatment of the neglected Achilles tendon rupture. Clin Podiatr Med Surg. 2012; 29(2):291-299.
2. Scheller AD, Kasser Jr, Quigley TB. Tendon injuries about the ankle. Orthop Clin North Am. 1980; 11(4):801-11.
3. Myerson MS. Achilles tendon ruptures. Instr Course Lect. 1999; 48:219–230.
4. Branch JP. A tendon graft weave using an acellular dermal matrix for repair of the achilles tendon and other foot and ankle tendons. J Foot Ankle Surg. 2011; 50(2):257-265.
5. Lee DK. Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures. J Foot Ankle Surg. 2007; 45(6):451-455.
6. Sebastian H, Datta B, Maffulli N, et al. Mechanical properties of reconstructed achilles tendon with transfer of peroneus brevis or flexor hallucis longus tendon. J Foot Ankle Surg. 2007; 46(6):424-428.
7. 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(1):49-56.