All of the procedures described in the present report were performed after approval had been granted by the local Ethical Committee.
The characteristics of the whole cohort of twenty-one patients were reported in the original study16. The patients were referred to us with a diagnosis of chronic Achilles tendon tear (fifteen patients), ankle sprain (three patients), persistent swelling (two patients), or adult acquired flatfoot (one patient). All operations were performed in the period from 1998 to 2001. All patients were tertiary referrals from other health-care professionals. In all instances, the patients had sustained an injury and had consulted a health-care provider who had diagnosed an ankle sprain. When the symptoms did not improve, the patients had consulted another health-care provider who had established the correct diagnosis and had referred the patients to our care. In all cases, a diagnosis of closed rupture of the Achilles tendon was confirmed on clinical grounds by means of ultrasonography17. At the time of the index procedure, the patients (including five women with a mean age [and standard deviation] of 46 ± 5.3 years [range, forty to fifty-two years] and sixteen men with a mean age of 47.3 ± 7.1 years [range, forty to sixty-two years]) underwent surgery for the treatment of a chronic rupture of the Achilles tendon that had occurred at a mean of 4.8 ± 3.3 months (range, sixty-five days to nine months) before the reconstructive procedure. Two of these patients had received one or three peritendinous injections of corticosteroids, with the most recent injection being administered by the primary care physician three to twelve months before the rupture. Both of these patients were male, both played a racquet sport (squash and badminton) as often as twice a week, and both had had chronic Achilles tendinopathy that was resistant to other nonoperative treatment measures. Both had abstained from physical activity involving running, jumping, and hopping for two weeks after each injection.
Long-Term Follow-up
All twenty-one patients who had been enrolled in the original study were contacted by telephone and/or letter by a research assistant who had not been involved in the patient care. Six of the original twenty-one patients were not available for follow-up; three were not traceable, one had had a stroke that had left him hemiplegic on the side of the procedure, one had moved abroad without any reported problems, and one had died from cardiovascular disease. The remaining fifteen patients underwent a final assessment for the purposes of this investigation at an average of 10.9 years (range, eight to twelve years) after the index operation.
The Achilles Tendon Total Rupture Score (ATRS)18 was used to evaluate postoperative symptoms and physical activity. The maximum calf circumference was measured for both the affected and the contralateral leg with use of a non-extensible flexible anthropometry steel measuring-tape (CMS Weighing Equipment, London, United Kingdom). Patients were asked to perform ten single-leg heel lifts on the affected side and were judged as either being able or unable to do so.
The outcome of surgical treatment was rated with use of the 4-point scale described by Boyden et al.19, which had been validated in our setting9,16. A patient with an excellent result had no pain, had no limitation of recreational or daily activities, had no footwear restrictions, and was thoroughly satisfied with the results of the procedure. A patient with a good result had mild occasional pain, had limitation of recreational but not daily activities, had no footwear restrictions, and was satisfied and had only minor reservations. A patient with a fair result had mild to moderate pain, had limitation of recreational and daily activities, had moderate footwear restrictions (an inability to tolerate fashionable shoes, with or without an insert), and was satisfied but had major reservations. A patient with a poor result had moderate to severe pain, had limitation of recreational and daily activities, had severe footwear restrictions (used a brace or modified shoes only), and was dissatisfied or had experienced a tendon rerupture.
The isometric plantar flexion force of the gastrocnemius-soleus complex was determined bilaterally with the ankle in neutral with use of a custom-made apparatus20 consisting of a foot plate, the angle of which could be varied and locked in a given position. An analog-to-digital converter (ADC-10; PICO Technology, Cambridge, United Kingdom) connected a strain gauge on the foot plate to a voltmeter (PicoScope; PICO Technology), which was connected to a computer. The changes in voltage were converted into newtons to measure strength. Calibration was performed by suspending known weights ranging from 2.5 to 37.5 kg from the apparatus, before and after each patient was tested, giving a linear response. Each patient supported the lower limb in a leg rest, with the heel placed firmly at the top of the foot plate and with the plantar aspect of the foot resting at ease. The patient was then asked to apply a maximum plantar flexion force on to the foot plate for three to five seconds. The maximum force was noted. The amplifier was used each time to return the voltmeter to 0. Each patient performed two maximal attempts, and the average was used for further analysis20.
Surgical Technique
Legs, feet, and ankles were prepared bilaterally and were draped to allow direct comparison of the appropriate tension to be used in the repair.
With the patient prone and both feet dangling from the end of the operating table, a single dose of a first-generation cephalosporin was administered at the time of induction of anesthesia. The limb to be operated on was exsanguinated, and a thigh tourniquet was inflated to 250 mm Hg. A 12 to 15-cm longitudinal, slightly curvilinear skin incision was made medial and anterior to the medial border of the Achilles tendon. The paratenon, if not disrupted, was incised longitudinally in the midline throughout the length of the skin incision to expose the Achilles tendon, and gentle continuous traction was then applied to the proximal stump of the ruptured tendon to deliver it into the wound, allowing the least possible residual gap. Scar tissue, involving both the proximal and distal tendon stumps, was excised to reach viable tendon. A gap averaging 6.8 ± 3.7 cm (range, 4.5 to 9 cm) was present with maximum plantar flexion of the ankle and traction applied to both Achilles tendon stumps.
Next, the tendon of the gracilis was harvested through a vertical 2.5-cm longitudinal incision over the ipsilateral pes anserinus. The harvested gracilis tendon was then passed through a small incision in the substance of the distal stump of the Achilles tendon in a medial-to-lateral direction. The tendon graft was then pulled proximally and through a small incision in the substance of the proximal stump of the Achilles tendon in a lateral-to-medial direction. The graft was then sutured to the Achilles tendon at each entry and exit point with use of 3-0 Vicryl sutures (polyglactin 910 braided absorbable suture; Ethicon, Johnson & Johnson, European Logistics Centre, Bruxelles, Belgium) (Fig. 1). Sufficient tension was applied to the repair to reproduce the physiological equinus present in the contralateral resting ankle. When present (four patients), the plantaris tendon was harvested with the tendon stripper, was left attached distally, and was used to reinforce the reconstruction.
Interrupted 4-0 Vicryl reabsorbable sutures were used to close the subcutaneous fat, and the skin was closed with interrupted 4.0 Ethilon (Ethicon, Johnson & Johnson, European Logistics Centre) or with subcuticular 3-0 Vicryl sutures. The tourniquet was deflated, the wound was dressed, and a below-the-knee plaster-of-Paris cast was applied with the patient prone, without changing the physiological equinus position of the ankle.
Postoperative Care
Postoperatively, the injured leg was kept elevated until the patient was discharged on the day after surgery. Thereafter, the patient used crutches as instructed by the physiotherapist17. Thromboprophylaxis was provided with Fragmin (dalteparin sodium; Pharmacia and Upjohn, Milan, Italy) (2500 units, administered subcutaneously once daily) or acetylsalicylic acid (150 mg, administered orally once daily) until removal of the cast. No cast required premature removal or bivalving. The patient was allowed to bear weight as tolerated on the operatively treated leg but was told to keep the leg elevated as much as possible for the first two postoperative weeks.
The cast was removed two weeks after the operation, and an anterior below-the-knee splint made of synthetic cast material was applied, with the foot positioned in gravity equinus. The splint was secured to the leg with three or four removable Velcro straps (Velcro USA, Manchester, New Hampshire) for four weeks. The patient was encouraged to bear weight on the operatively treated limb as soon as he or she felt comfortable and to gradually progress to full weight-bearing. The patient was seen by a trained physiotherapist who taught the patient to perform gentle mobilization exercises for the ankle, isometric contraction of the gastrocnemius-soleus complex, and gentle concentric contraction of the calf muscles. The patient was encouraged to actively plantar flex the involved ankle several times per day after unstrapping the two most distal Velcro straps. Six weeks after the operation, the anterior splint was removed. The patient then mobilized the ankle with physiotherapy guidance, bore weight as tolerated, and performed gradual stretching and strengthening exercises. Cycling and swimming were started eight weeks after surgery if the wound was healed. The patient was prompted to increase the frequency of the self-administered exercise program and was allowed to return to sports activity at five months postoperatively.
Statistical Analysis
Data were entered into a commercially available database, and descriptive statistics were calculated. Comparisons between the operatively treated and normal limbs from the same patient were performed with use of the McNemar test to analyze binary data and the Wilcoxon test for the difference in scores for continuous data. Significance was set at the 0.05 level. The paired-samples t test was used to compare the isometric gastrocnemius-soleus strength of the operatively treated side with that on the contralateral, healthy side.
Source of Funding
No external funding source played a role in the investigation.
At the time of long-term follow-up, two patients had developed tendinopathy of the contralateral Achilles tendon, one had developed tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon eight years after the index tear. Most patients remained satisfied with the procedure. There were two excellent, eleven good, and two fair results (Table I).
The maximum calf circumference was significantly decreased in the operatively treated leg than in the contralateral leg both at the time of presentation (mean, 38.1 ± 5.3 compared with 41.0 ± 5.9 cm; p = 0.05) and at the time of the latest follow-up (mean, 35.2 ± 3.1 cm compared with 40.6 ± 3.2 cm; p = 0.04) (Table II).
When last evaluated, all patients were able to perform at least ten single-leg heel lifts on the affected side and eight patients were able to perform at least sixty single leg heel lifts on the affected side. All fifteen patients had returned to their preinjury occupations. Details on the leisure activities in which the patients participated at the time of the latest follow-up are reported in Table II. The mean ATRS score at the time of the latest follow-up was 90.1 ± 5.8.
In the evaluation of gastrocnemius-soleus strength, the duplicate measurements showed a high intraobserver reliability (r = 0.91; p = 0.01). The operatively treated limb showed a lower mean peak torque than the contralateral limb (223.4 ± 66.2 N compared with 296.5 ± 64.5 N; p = 0.032). However, none of the patients perceived this decrease in strength as hampering their daily or leisure activities. With the small number of patients in the study, we were not able to identify an association between age at the time of the injury, or time between the injury and surgery, and isometric muscle strength and calf circumference.
Complications
No patient experienced any wound problems at the gracilis tendon harvest site. Three patients had a superficial infection of the Achilles tendon surgical wound. All three were managed conservatively with oral antibiotics and limitation of activity, and the wounds healed by the eighteenth postoperative week. At six months postoperatively, two patients complained of hypersensitivity of the surgical wounds, but both were asymptomatic by the time of the next visit. One patient developed a hypertrophic scar in the area of the Achilles tendon surgical wound, and she was not pleased with the appearance of the operative scar. No patient developed a clinically detected deep-vein thrombosis or sustained a re-rupture of the reconstructed tendon. All patients were able to walk on the tiptoes, and no patient used a heel lift or walked with a visible limp.
Free gracilis tendon graft can be used to reconstruct the continuity of the Achilles tendon in patients with a chronic rupture and a wide gap between the stumps. Patients with a chronic rupture of the Achilles tendon have been found to have worse functional and anthropometric results than patients with an acute rupture and to have a greater tendency to experience complications9. The surgical incision impairs the local vascular supply21,22 and can compromise wound-healing. The free gracilis tendon graft, which is relatively easy to harvest, acts as an autologous biological scaffold for the Achilles tendon defect, as was shown in our previous study16. Furthermore, gracilis reconstruction has the advantage of not depriving the foot of motor strength and power, and, given the length of the tendon graft available, can be also used to bridge large gaps in the Achilles tendon.
In the present study, the calf circumference was measured on both the affected and contralateral sides with use of a commercially available steel tape measure. As we measured the maximum calf circumference, no actual anatomical landmarks were used and we simply selected the greatest measurement. Our data showed that the maximum calf circumference was decreased on the affected side, and this finding was in accordance with those of other studies that have demonstrated permanent calf muscle atrophy following Achilles tendon repair23-25. Although a chronic Achilles tendon rupture is a serious injury, the strength deficit of the gastrocnemius-soleus complex in our patients was relatively small following reconstruction, and patients reported no subjective loss of strength. This result was in accordance with those of most previous studies, which have demonstrated permanent deficit in isometric plantar flexion strength following Achilles tendon ruptures, even after repair25-32.
In conclusion, this technique allows reconstruction of a chronic tear of the Achilles tendon with use of a free gracilis tendon graft, even in the presence of a gap as large as 6 cm. The patients should be warned about postoperative complications, that the muscle atrophy of the calf is not likely to resolve fully, and that the ankle plantar flexion strength can remain reduced. Nevertheless, the levels of satisfaction and function in these patients should be high.