SLR - January 2023 - Lahari Madulapally, DPM
Title: Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcomeReference: Maffulli N, Gougoulias N, Christidis P, Maffulli GD, Oliva F. Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcome. Knee Surg Sports Traumatol Arthrosc. 2022 Oct 17. doi: 10.1007/s00167-022-07183-0. Epub ahead of print. PMID: 36251046.
Level of Evidence: Level II
Reviewed By: Lahari Madulapally, DPM
Residency Program: Medstar Health, Washington DC
Podiatric Relevance: Achilles tendon ruptures are common injuries that are treated in the Podiatric surgical profession. There are operative and non-operative treatments based on the type of injury and the patient’s background. For acute injuries that are surgical, there are multiple options. Augmentation of the tendon with the FHL along with primary repair could be beneficial to the patient.
Methods: A level 2 prospective study was performed at University of Salerno, Italy where patients with acute Achilles tendon ruptures were recruited from years of 2015-2019. A total of 30 patients were included in the percutaneous repair under local anesthesia group and 32 patients were included the percutaneous repair with FHL augmentation group under epidural anesthesia. All surgeries were performed by a single surgeon with a 24 month follow up. Objective outcomes were evaluated using the Achilles tendon resting angle (ATRA) and isometric plantarflexion of the gastro-soleus complex. Subjective outcomes were measured using Achilles tendon total rupture score (ATRS), a patient reported score between 0-100 with higher scores indicating lower symptoms.
The percutaneous repair without augmentation was performed under local without a tourniquet using stab incisions and vicryl suture for primary repair. Percutaneous repair with FHL augmentation was performed with epidural and a calf tourniquet. The Achilles tendon stumps were identified and repaired. Then the FHL tendon graft was whip stitched and attached to the Achilles and placed into a bone tunnel in the calcaneus.
Results: At 24 months, the tendon elongation measured by the ATRA was better in the augmented FHL group. The ATRS had significantly better results in the augmented group. Calf circumference of the injured versus the non-injured limb did not differ between the two groups. The plantarflexion strength of the operative leg was weaker than the non-operative leg in both groups. None of the patients in either group experienced a re-rupture or injury to the sural nerve.
Conclusion: Percutaneous repair with FHL augmentation had better functional outcomes and reduced tendon elongation than percutaneous repair alone. However, limitations of this study included lack of randomization as patients were able to pick their group and exclusion of patients with any chronic problems. The patient population in podiatry includes a variety of patients with comorbidities, therefore future studies should include randomization as well as comorbid populations to yield more significant results.