Percutaneous Hemisection Achilles Tendon

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Figure 24.3. (A) Stretching with the knee straight creates tension on the gastrocnemius. (B) Stretching with the knee bent creates tension on the soleus and deep posterior muscle compartment.

as well. Commonly prescribed stretching regimens designed long term to "eliminate contracture" are probably more effective at preventing further contracture than at decreasing the tightness already present.

Eccentric strengthening for up to one year is beneficial in reducing pain and allows for increased function in patients with Achilles tendinopathy.33 Strengthening of the anterior leg muscles may also improve ankle dorsiflexion.

Elongation of the Achilles tendon produces disruption at 3% and complete loss of integrity at 8%.22 Stretch likely occurs mostly in the muscle, and only a small amount in the tendon.22,23 Other modalities of nonsurgical lengthening have been casting and immobilization, though this has been predominantly studied in diabetic populations.12

Recently, injections with botulinum toxin A have become popular for cerebral palsy patients. A large multicenter clinical trial showed improvement in gait after botulinum injections, but the gains in ankle dorsiflexion were not reported. To date, none of the studies using botulinum injections have included athletic individuals or neuro-logically normal patients.34

Surgical lengthening of the Achilles tendon complex was first reported by Delpech in 1816.35 William Little, a physician with infantile paralysis and equinovarus deformity, had an Achilles tenotomy performed by Stromeyer and became a proponent of this procedure for Achilles tendon contracture.5,36 Throughout the twentieth century, other lengthening procedures were described. Variations of Achilles tenotomies were described by Hatt and Lampier, and Hoke and Sgarlato.4,18,37 Hatt and Lampier described a triple hemisection of the Achilles tendon, attributed to Hoke. Two medial and one lateral evenly interspaced hemi-tenotomies were performed (Fig. 24.4).4 Sgarlato described an open Z-plasty, distally severing the anterior two-thirds of the lateral tendon and proximally severing the posterior two-thirds of the medial Achilles tendon.18 Posterior ankle and subtalar releases, as performed in deformities such as clubfoot, may also need to be considered as adjunctive procedures in patients with severe equinus deformity, as well as anterior ankle arthroplasty for patients with osseous equinus.

Hansen advocates open gastrocnemius recession for gastrocnemius tightness, percutaneous Achilles tendon lengthening for Achilles tendon

Medial Calf Tightness
Figure 24.4. Triple hemisection of Hoke; two medial interspaced by one lateral hemisections are made in the Achilles tendon.

tightness, and open Achilles tendon lengthening when precise lengthening is desired or when previous surgery has been performed on the Achilles tendon and a complete rupture of the Achilles tendon using percutaneous lengthening is a potentially greater risk.7 Hansen's percutaneous technique is recommended for diabetics and elderly patients in which wound healing can be an issue. The first incision (distal) is made 1 cm proximal to the Achilles tendon insertion, and, applying a dorsiflexion force, the anterolateral portion of the tendon is divided. A second more proximal incision is made about 3-4 cm proximal to the first one. A vertical midline incision is made, transecting the medial portion of the Achilles tendon (Fig. 24.5A-C). An open Achilles tendon lengthening may be performed with a sagittally based "Z-lengthening" incision. A dorsiflexion force is

Achilles Lengthening Procedure
Figure 24.5. (A) Percutaneous Achilles tenotomy. (B) Distal incision for percutaneous Achilles tenotomy. (C) Proximal incision for percutaneous Achilles tenotomy.

applied to bring the foot out of equinus to the desired amount (Fig. 24.6). Hansen and others, over a period of almost 100 years, have recommended that Achilles tendon or gastrocnemius lengthening be performed for reconstructive foot procedures.4,5,7,10,1618,20,37 Unfortunately, none of these studies document patients' activity level such as participation in sports or even the ability to propulse on their toes, which would be an issue for athletes.

Postoperative regimens for Achilles tendon lengthening vary according to the procedure undertaken. However, generally the foot and ankle are protected with some form of immobilization for 4-6 weeks. Some authors allow diabetic patients to walk without any splint, and others state that protection with a below-knee cast depends on whether other concomitant procedures are performed.1,2,4,5,9,13,16

Though tenotomy is commonly performed on the Achilles tendon, some have noted that excessive weakening or "calcaneal" deformity can occur. Delp and Zajac advised against Achilles tendon lengthening for patients with isolated gas-trocnemius contracture due to excessive weakening of propulsion. One centimeter of lengthening reduces propulsive forces by almost 30%,38 a significant amount for athletic individuals.

Vulpius Recession
Figure 24.6. Open Achilles tendon lengthening.

Other procedures to reduce Achilles tendon contracture have been described. Strayer described an open gastrocnemius recession or tenotomy as a variation of Vulpius and Stoffel's distal gastroc-nemius recession that avoided the main body of the Achilles tendon, as well as "tongue-and-groove" slide techniques.4,5,39-41 In Strayer's procedure, the distal portion of the gastrocnemius aponeurosis is transected (Fig. 24.7A). A posterior midline incision is made, and the sural nerve is identified and protected (Fig. 24.7B). The medial and lateral margins of the gastrocnemius aponeu-rosis are identified and then transected. Improvement in ankle dorsiflexion is then noted (Fig. 24.7C). This procedure is occasionally performed in patients with neglected Achilles tendon ruptures to span a tissue loss of up to five centimeters. Studies on athletic individuals undergoing an open gastrocnemius recession with concomitant Achilles tendon repair are lacking.

Some of the largest studies on Achilles tendon rupture repair and surgical management for chronic tendinopathy fail to yield any authors advocating a lengthening procedure at the time of surgery.24,29-32,42 However, if a tight Achilles tendon is considered a potential contributing factor to the chronic tendinopathy or tear of the Achilles, consideration may be given to a more proximal gas-trocnemius recession.43 This technique can facilitate easier reapproximation or repair of the Achilles tendon at the site of rupture, and results in little loss of Achilles tendon strength clinically. Approximately one centimeter of length can be gained with a proximal gastrocnemius recession in such patients, which can be helpful to avoid repair under tension in the event of tissue loss after debridement or a chronic defect. This situation, however, is generally not seen in patients with an acute tear of the Achilles tendon.

For acute tendon repair, one is advised to maintain the foot in a gravity equinus position, only gradually dorsiflexed to neutral in the following weeks postoperative.44-45 In fact, an overlength-ened position can cause deficits in athletic patients, and one paper describes surgical shortening for this situation. Cannon and Hackney recently described good results with surgical shortening on five athletic and active patients with dysfunctional Achilles tendons with prior treatment for rupture. The average age of their patients was 46

Figure 24.7. (A) Artist's depiction of open gastrocnemius recession (Strayer). (B) Intraoperative view of sural nerve during an open gastrocne-mius recession. (C) Postoperative view of a patient; note incision length.

Figure 24.7. (A) Artist's depiction of open gastrocnemius recession (Strayer). (B) Intraoperative view of sural nerve during an open gastrocne-mius recession. (C) Postoperative view of a patient; note incision length.

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