A Handy Way to Reconstruct Chronic Achilles Ruptures

What’s the Claim?

In a small but important case series, the large majority of patients treated with dual semitendinosus allografts to reconstruct chronic Achilles tendon ruptures did well at a median of more than 5 years after surgery. Graft rupture occurred in only one of nine patients, and one other was doing poorly but had an intact graft; seven of nine had good or excellent scores on the Achilles Tendon Rupture Score scale, which is considered by some the best tool for evaluating patients with this problem. No patients required assistive devices or walking boots for ambulation.

How’s It Stack Up?

CORRelations’ Foot and Ankle advisor describes this as, “A new and very effective alternative to local soft tissue rearrangement procedures for severe Achilles tendinopathy.” This is a challenging problem to treat, and the authors of this case series used this approach for the toughest of the tough reconstructions — those with a tendon gap too large for end-to-end reconstruction or V-Y advancement. Flexor hallucis longus tendon transfer is an option that can be used in conjuction with this procedure, but used by itself, FHL transfer does not connect the gastrosoleus back to the calcaneus, and it also is associated with real donor site morbidity and other complications. Gracilis and single semitendinosus allografts have been reported; a dual-semitendinosus approach seems likely to be stronger, though obviously there are no comparative trials on this.

What’s Our Take?

Case series tend to overestimate treatment benefits, which may be the situation here. Three patients treated with this approach during the study were lost to follow-up; if all of them did poorly, that could change perceptions of the findings, perhaps substantially. On the other hand, it's somewhat reassuring that all but one of the patients had a follow-up of more than 50 months (so the grafts seem to be holding up), and the two patients who had problems had a follow-up of 27 months and 121 months (so no obvious learning curve effects here).

Notwithstanding the shortcomings of case series, we’re highlighting this one because it's practical. These chronic ruptures are common enough, and surgeons faced with them don’t have many good treatment choices available, so it’s nice to have one more. The authors provide good descriptions and images, so we believe it would be possible for a capable surgeon to study this article and be comfortable trying this reconstructive approach. It seems worth having this one in the toolkit.

Source

McCormick BP, Trent S. Haislup BD, et al. Dual Semitendinosus Allograft Reconstruction of Chronic Achilles Tendon Ruptures: Operative Technique and Outcomes. Foot Ankle Int. 2023;44:48-53.