Jay Lieberman DPM, FACFAS

Notice pes calcaneus position of foot

This is a 54-year-old male with a one-year history of rupture to the Achilles tendon.  Because of work commitments, the patient was not able to address the problem sooner.  Unfortunately, during the interim, he developed an aberrant and antalgic gait pattern.  For many years before the injury, he suffered with insertional tendinitis.  He had numerous cortisone injections into the heel and has worn a wedged type shoe that incorporated a Polysorb insole.

PAST MEDICAL HISTORY:  Unremarkable and Non-contributory.
MEDICATIONS:  None
ALLERGIES:  NKA

The patient’s neurovascular status was intact.  Peripheral pedal pulses were graded +2/+4 bilateral.  Capillary refill was less than five seconds bilaterally.  Digital hair was present.  There was no rubor on dependency or pallor on elevation.  Proprioceptive sensoriums were intact.  The skin was supple and well hydrated.  The nails were normal.

Clinically one noted a combination of both forefoot and rear foot equinas globally.  There was a dell in the posterior aspect of the heel with the distance between ruptured segments measuring in the range of 4cm to 6cm. 

Upon review of the MRI that the patient brought with him during the initial visit, it was apparent that the rupture occurred in the lower end of the watershed area.  A small tag remained on the heel.  The muscle belly of the gastrocnemius was atrophied.

PLAN

We discussed augmenting the repair with fresh, frozen allograft tendon, possibly, with attached bone.  This was to be used along with a synthetic tendon jacket wrap to reinforce the repair and act as a lattice for in growth of new tendon.  The patient understood that following the procedure, he would require cast immobilization for six to eight weeks.

There was no question as to the diagnosis.  The gastrocnemius muscle belly was severely atrophied and a large dell was readily apparent in the Achilles tendon.  These findings are considered pathognomonic for an Achilles tendon rupture.  In an acute situation, we would have relied on a positive Thompson test or magnetic resonance imaging. 

Rehydration of Allograft

In planning for the repair, our main concern was being able to span a gap that may well turn out to be more than 6cm.  We presumed that once the devitalized component of the tendon was removed, the real gap between the remaining components of the tendon might be up to 8cm.  By performing a gastrocnemius recession, we felt that we could lessen the span by 2cm - 4cm.  Gastrocnemius recessions ordinarily heal well owing to the underlying blood rich muscle belly.  Another consideration was an advancement flap, but we were unsure as to whether enough length could be achieved.  This approach often leaves the surgeon with a bulky component of the tendon after the procedure is performed.  Ultimately, we decided on a fresh, frozen Allographic Achilles tendon graft with an attached portion of the calcaneal insertion.  Tendon Allografts have proven to be as good, if not better, than autografts without the need for a separate incision (Nellas 1996, Yuen 2000, Lepow, et al, 2006). 

	Tissue Mend

The negative aspects of using an allograft versus an autograft are a longer period of incorporation and a small risk of disease transmission.  However, the most recently published report of The American Association of Tissue Banks states that more than two million musculoskeletal Allografts have been distributed during the past five years with NO documented incident of a viral disease transmission caused by an Allograft.  Lastly, the allograft tissue needs thirty minutes of re-hydration before use.

To augment the repair, we used Tissue Mend soft tissue repair matrix (Stryker).  This is acellular collagen membrane served as a scaffold for cellular ingrowth.  The acellular collagen fibers are Type I and Type II.  The source of the material is fetal bovine dermis. 

The Allograft and Tissue Mend were fixed in place with fiber wire.  The repair was placed under physiologic tension.

Please Click on Images Below To Enlarge
Irregular Paratenon with Soft Tissue ossification	Retracted Proximal Segment

Gastroc Recession	Debridement of Proximal Segment

Resection of Hyperostosis	Cancellous Bone Exposed

Distal Segment AT	Krakow Stitch Proximal Segment

Expansion of Gastro Recession	Krakow Stitch in Allograft

Allograft tied to proximal segment	Bone Anchor

Repair, Completed with adherence to exposed bone	Tissue Mend

Paratenon Repair	Final

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