Jorge I. Acevedo
SURGICAL MANAGEMENT
Indications include neglected ruptures requiring secondary repair or revision surgery.
Soft tissue expansion over the Achilles tendon and subsequent repair of the tendon are performed as a staged, two-part procedure about 3 to 4 weeks apart.
This can be particularly effective when performing augmented procedures that increase the girth at the distal tendon or when the local skin is contracted.
Preoperative Planning
MRI studies are reviewed to determine the ideal placement of the expander and to plan second-stage repair.
The patient is instructed on the rationale for the staged procedure and the importance of weekly follow-up visits between each stage.
Positioning
The prone position allows the best access when approaching the Achilles tendon.
A well-padded pillow is placed underneath the knees and anterior tibia–ankle.
This allows for free plantarflexion and dorsiflexion of the ankle.
Approach
The preferred approach is a posteromedial incision adjacent to the Achilles tendon. This allows the surgeon to avoid injury to the short saphenous vein and sural nerve.
Simple extension of the incision is performed for the secondstage definitive repair.
The posteromedial incision may be extended into a lazy-S, L shape, or a direct medial approach.
TECHNIQUES
IMPLANTATION OF EXPANDER
The initial stage of treatment involves subcutaneous placement of a 70-mL, rectangular soft tissue expander (McGhan, Santa Barbara, CA) between the Achilles tendon and the skin (TECH FIG 1).
After sterile preparation, make a longitudinal incision along the medial aspect of the ankle, adjacent to the course of the Achilles tendon.
Perform superficial subcutaneous elevation until a pocket about 6 × 4 cm is created.
Insert a McGhan tissue expander into this cavity and place the injection catheter away from the implant.
Subcuticular closure is followed by reapproximation of the skin.
10 mL of normal saline is initially injected into the implant via the injection port.
The patient is seen 1 week postoperatively for further inflation of the implant.
Ten mL of normal saline is added to the expander weekly.
TECH FIG 1 • McGhan 70-mL soft tissue expander.
REMOVAL OF EXPANDER AND TENDON REPAIR
The expander is removed 3 to 4 weeks postoperatively (TECH FIG 2). At that time, removal of the tissue expander and Achilles repair are performed.
The previously created incision is accessed and extended as necessary. The expansion balloon is then easily removed from its subcutaneous pocket.
Surgical repair of the injured tendon is carried out in the surgeon’s preferred fashion.
TECH FIG 2 • Inflated soft tissue expander in place subcutaneously.
Careful repair of the paratenon overlying the Achilles tendon is essential at this stage to re-establish the fragile blood supply to this area.
Upon completion of the repair, subcutaneous closure is achieved and reapproximation of the wound is then afforded by the lack of tension at the expanded skin margins (TECH FIG 3).
TECH FIG 3 • Tension-free skin closure after Achilles tendon repair.
POSTOPERATIVE CARE
After the initial stage of insertion, the patient is followed weekly for subsequent expander inflation. The inflation rate is 10 mL per week for 3 to 4 weeks.
After expander removal and second-stage reconstruction the operative limb is placed into a short-leg splint in 10 to 15 degrees of plantarflexion.
Non–weight-bearing with immobilization in a short-leg cast is maintained for 3 weeks. Range-of-motion exercises are initiated at 3 to 4 weeks postoperatively. Finally, weight bearing is allowed at 6 weeks after surgical repair (FIG 1).
OUTCOMES
This technique has been used successfully in our practice with no complications related directly to soft tissue expansion.
FIG 1 • Outcome 8 weeks after second-stage surgery.
COMPLICATIONS
Infection
Seroma
Sural nerve injury
Fibrotic reaction
REFERENCES
1. Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon. J Bone Joint Surg Am 1975;57:253–255.
2. Acevedo JI, Weber KS, Eidelman DI. Avoiding wound complications after neglected Achilles tendon repair: tissue expansion technique. Foot Ankle Int 2007;28:393–395.
3. Ademoglu Y, Ozerkan F, Ada S, et al. Reconstruction of skin and tendon defects from wound complications after Achilles tendon rupture. J Foot Ankle Surg 2001;40:158–165.
4. Dalton G, Wapner K, Hecht P. Complications of Achilles and posterior tibial tendon surgeries. Clin Orthop Relat Res 2001;391: 133–139.
5. Kumta SM, Maffulli N. Local flap coverage for soft tissue defects following open repair of Achilles tendon rupture. Acta Orthop Belg 2003;69:59–66.
6. Leppilahti J, Kaarela O, Teerikangas H, et al. Free tissue coverage of wound complications following Achilles tendon rupture surgery. Clin Orthop Relat Res 1996;328:171–176.
7. Ozaki J, Fujiki J, Sugimoto K, et al. Reconstruction of neglected Achilles tendon rupture with Marlex mesh. Clin Orthop Relat Res 1989;238:204–208.
8. Paavola M, Orava S, Leppilahti J, et al. Chronic Achilles tendon overuse injury: complications after surgical treatment. Am J Sports Med 2000;28:77–82.
9. Parker R, Repinecz M. Neglected rupture of the Achilles tendon: treatment by modified Strayer gastrocnemius recession. J Am Podiatry Assoc 1979;69:548–555.