Arthroscopic Flexor Halluces Longus Transfer and Percutaneous Achilles Tendon Repair for Distal Traumatic Ruptures

ABSTRACT: The Achilles tendon is the largest and strongest tendon in the human body. It is the tendon that most often suffers injury and accounts for 20% of all tendon ruptures. These types of ruptures often occur 2 to 6 cm proximal to the stumps in an area of reduced vascularity. One such injury, the distal acute Achilles tendon rupture, is quite uncommon. For distal repairs, there have been studies that used a pullout technique, a button technique, and the use of local tendons for open-fashion augmentation. Although percutaneous repair and endoscopic flexor hallucis longus (FHL) tendon transfer techniques have been described for both acute midportion and chronic Achilles tendon rupture repair, there are no studies that describe the use of percutaneous sutures and biological augmentation with FHL transfer as a treatment option for acute distal injuries. The purpose of this Technical Note is to describe a novel approach to repair. It combines arthroscopic FHL tendon transfer with a percutaneous Achilles tendon repair technique for traumatic distal ruptures. Technique Video Video 1 The patient is positioned prone with the ankle draped and hanging freely over the edge of the table. Conventional posterolateral and posteromedial endoscopic portals as originally described by van Dijk are used. The posterolateral portal is the viewing portal and posteromedial the working portal. A 4.0-mm 30° arthroscopic camera is used for this procedure. The Rouviere and Canela fascia is opened and posterior soft tissues are removed until the subtalar joint can be visualized. The FHL is localized medially using passive plantar flexion of the hallux to identify it. A braid suture (VICRYL) is passed around the FHL to traction it if it is necessary. It is important to pull on the suture that was passed around the tendon and perform ankle plantar flexion and hallux plantar flexion to allow maximal harvesting length of the FHL tendon. FHL sectioning can be performed in FHL zone 2 or 1. (1) For zone 2, the FHL is sectioned percutaneously under direct arthroscopic visualization with a percutaneous retrograde knife. (2) For zone 1, the FHL is sectioned at the entrance of its fibro-osseous tunnel with a #11 knife or arthroscopic scissors. The FHL harvest is recovered through the posteromedial portal and a high resistance suture loop is put in place. The calcaneal bone tunnel entrance is created through the posteromedial portal, from dorsal-medial to plantar-lateral with a K-wire with eyelets. The posterior-superior site of the os calcis is the optimal zone of insertion. Then, the calcaneal bone is drilled. The tunnel should be 10 to 15 mm longer than optimal length of the harvest. A 25- to 30-mm long tunnel should be enough. The sutures of the FHL harvest are passed through the eyelet of the K-wire and K-wire is progressed to the sole of foot and then collected. The sutures are carefully pulled through to the sole of foot, which makes for the introduction of the FHL harvest into the calcaneal tunnel. It is fixed with an interference screw with the ankle in mild plantar flexion. The percutaneous Achilles tendon suture rupture zone is identified and marked. At the site of each needle perforation, a small longitudinal incision is made with a #11 blade so that the needle can pass without entrapping subcutaneous tissue. The tendon is then repaired with the modified Bunnel configuration by suturing with VICRYL (polyglactin) No. 1 (ETHICON, Inc). The ends of the sutures are collected and tied medially and laterally at the height of the rupture while keeping the ankle in 20° of plantar flexion A clamp is used to make sure that subcutaneous tissue is not entrapped with the suture. (FHL, flexor hallucis longus.)

SUBMITTER: Campillo-Recio D 

PROVIDER: S-EPMC8626620 | biostudies-literature |

REPOSITORIES: biostudies-literature