SLR - February 2015 - Stephanie Eldridge

Repair of Achilles Tendon Ruptures with Peroneus Brevis Tendon Augmentation

Reference: Singh A, Nag E, Roy SP, Gupta RC, Gulati V, Agrawal N. Repair of Achilles Tendon Ruptures with Peroneus Brevis Tendon Augmentation. J Othop Surg (Hong Kong). 2014 Apr; 22(1): 52-5.

Scientific Literature Review

Reviewed by: Stephanie Eldridge, DPM
Residency Program: Phoenixville Hospital

Podiatric Relevance:
Complex Achilles tendon ruptures can be challenging to restore to normal function with end-to-end repair alone. Prior studies have demonstrated an increased risk for infection, dehiscence, and other complications. Augmented Achilles tendon repairs with tendon transfers can also help restore length. They have previously been described using flexor hallucis longus (FHL), peroneus brevis (PB), or plantaris. Plantaris may not be present or sufficient in structure to be utilized for augmentation, while harvest of FHL may weaken the push-off phase of ambulation. In this article, the authors examine outcomes of tendon augmentation utilizing peroneus brevis.

Methods: The authors conducted a retrospective review of their records from 2008 to 2010 including patients who sustained a compound Achilles tendon rupture and underwent repair with peroneus brevis tendon augmentation. Exclusion criteria included diabetics, history of steroid injections, and age >60 years. Injuries were secondary to lacerations or industrial accidents. 22 patients were included and consisted of 6 women and 19 men ranging from 21 to 42 years of age.

A posterolateral longitudinal incision was employed and modifications were made if necessary based on the rupture location. The ruptured tendon was trimmed and repaired. A separate incision was made at the base of the fifth metatarsal to identify and free the peroneus brevis tendon for transfer. The PB tendon was transferred through the aponeurotic septum from the lateral to the posterior compartment and out of the posterior incision. PB was further mobilized by freeing up the proximal muscle belly. The tendon was then passed through a mid-coronal slit in the distal stump and redirected proximally. The transfer was secured with No. 1 Vicryl both proximally and distally. The injured extremity was compared to the contralateral extremity to match the degree of resting equinus. In situations where the distal Achilles tendon stump was inadequate, PB was instead passed through a drill hole in the calcaneus. Postoperatively, an above-knee posterior splint was applied in a gravity ankle equinus position with 45 degrees of knee flexion. At week 4, patients began ankle movement exercises and toe-touch weight bearing was allowed. Upon achieving full ankle ROM at week 8, the patients were allowed full weight bearing status. The patients had follow up evaluations bimonthly for two months, monthly for three months, at nine months and one year utilizing the Foot and Ankle Outcome Score (FAOS).

Results: There were no observed re-ruptures. Three patients had superficial skin complications and two separate patients developed wounds requiring debridement. Mean FAOS improved most significantly between months three through twelve. At final follow-up all patients achieved satisfactory outcome using FAOS.

Conclusion: This repair should be considered in younger individuals, runners, and in those who particularly need to maintain strong hallux plantarflexory force for push-off. Ankle plantarflexion strength will be largely maintained, with a possible decrease in ankle eversion strength. Peroneus brevis tendon augmentation is a viable option for repair of Achilles ruptures in which end-to-end repair is not sufficient to restore adequate length.

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