Endoscopically assisted reconstruction of chronic Achilles tendon ruptures and re-ruptures using a semitendinosus autograft is a viable alternative to pre-existing techniques

Abstract

Purpose: Achilles tendon ruptures are termed chronic after a delay in treatment for more than 4 weeks. The literature advocates surgical treatment with reconstruction to regain ankle push-off strength. The preferred technique is, however, still unknown and is often individualized. This study aims to present the technique and clinical outcome of an endoscopically assisted free semitendinosus reconstruction of chronic Achilles tendon rupture and Achilles tendon re-ruptures with delayed representation. It is hypothesized that the presented technique is a viable and safe alternative for distal Achilles tendon ruptures and ruptures with large tendon gaps.

Method: Twenty-two patients (13 males and 9 females) with a median (range) age of 64 (34-73) treated surgically with endoscopically assisted Achilles tendon reconstruction using a semitendinosus autograft were included. The patients were evaluated at 12 months post-operatively for Achilles tendon Total Rupture Score (ATRS), calf circumference, Achilles Tendon Resting Angle (ATRA), heel-rise height and repetitions together with tendon length determined by ultrasonography, concentric heel-rise power and heel-rise work.

Results: The patients reported a median (range) ATRS of 76 (45-99) out of 100. The median (range) ATRA on the injured side was 60° (49°-75°) compared with 49.5° (40-61°), p < 0.001, on the non-injured side. Eighteen out of 22 patients were able to perform a single-leg heel-rise on the non-injured side. Sixteen patients out of those 18 (89%) were also able to perform a single heel-rise on the injured side. They did, however, perform significantly lower number of repetitions compared with the non-injured side with a median (range) heel-rise repetitions of 11 (2-22) compared with 26 (2-27), (p < 0.001), and a median (range) heel-rise height of 5.5 cm (1.0-11.0 cm) compared with 9.0 cm (5.0-11.5 cm), (p < 0.001). The median calf circumference was 1.5 cm smaller on the injured side, 37.5 cm compared with 39 cm, when medians were compared. The median (range) tendon length of the injured side was 24.8 cm (20-28.2 cm) compared with 22 cm (18.4-24.2 cm), (p < 0.001), on the non-injured side.

Conclusion: The study shows that endoscopically assisted reconstruction using a semitendinosus graft to treat chronic Achilles tendon ruptures and re-ruptures with delayed representation produces a satisfactory outcome. The technique can restore heel-rise height in patients with more distal ruptures or large tendon defects and is therefore a viable technique for Achilles tendon reconstruction.

Level of evidence: IV.

Keywords: ATRS; Achilles tendon re-rupture; Chronic Achilles tendon rupture; Endoscopically assisted technique; Semitendinosus graft; Surgical repair.

Fig. 1

An endoscopic calcaneoplasty using standard posteromedial, posterolateral and accessory posterolateral portals was performed using a bone shaving burr at the level of the Achilles tendon insertion. A guide-wire was positioned and passed through the calcaneum bone under endoscopic visualization

Fig. 2

The proximal tendon end was exposed using a 4–5 cm longitudinal incision. The standardized semitendinosus graft was passed through a coronal tenotomy to produce equal lengths on the lateral and medial side. The proximal tendon end was reinforced using running locking sutures

Fig. 3

The semitendinosus graft was threaded down towards the distal tendon end and then through the calcaneal tunnel. The semitendinosus graft was held in maximal tension and then secured using a 7–8 mm interference screw from the posteromedial incision

Fig. 4

Post-operative anatomical pictures describing the graft positioning and channelling as well as the location of the fixation screw in the calcaneum