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Achilles tendon reconstruction after 2 failed surgeries-FHL transfer and other options

Discussion in 'Foot Surgery' started by frida, Feb 24, 2010.

  1. frida

    frida Welcome New Poster


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    Dear all,

    I have a patient that has undergone two failed failed surgeries on her Achilles tendon. MRI shows significant thickening of AS with signs of tendiopathy. Gastro-soleus-complex is lengthened (I think about 5-8 degrees). Plantarflexion deficit is 50% compared to non-operated foot (Cybex). Walks with limp. Sports (except for swimming) not possible.
    My reasearch shows that the only surgical option could be an FHL transfer. However, also other reconstruction is suggested in literature: fascia lata, gracilis . Do not know if muscles will come back. Have referred patient to university prof. , but patient comes back and asks for advice on the different options.

    Patient is 40 years old, otherwise healthy. Any reliable studies out there?

    Thanks for any comments.
    Frida
     
  2. drsarbes

    drsarbes Well-Known Member

    Hi Frida:
    When you say two failed surgeries on her AT, was it for a rupture?

    THe law of decreasing returns may be in play here with repeated repair attempt. Did she have the same surgeon for both procedures?

    Depending: an FHL transfer will not replace an AT, only augment. If a primary repair is no longer possible a graft is required, such as a Graft Jacket or other allografts or xenografts (Pegasus for instance) . A portion of the Gastroc can also be used in a flap fashion to augment. Through all or a combination of these structures a usable AT can be fashioned. If there is still an issue with the length the distal attachment can be made slightly more proximal on the os calcis.

    The other problem will be, after two failed attempts, the chronicity of her condition and subsequent atrophy of the Gastroc Soleus as well as all the other muscles of the leg.

    Good Luck

    Steve
     
    Last edited: Feb 24, 2010
  3. frida

    frida Welcome New Poster

    Thanks Steve,

    first there was a rupture. And no, she did not have the same surgeon.
    Turn down is not possible anymore (was done and failed).
    My finding is also that the gastro-soleus complex is somewhat lengthened.
    Does someone has experience with this FHL transfer surgery? I know there is no Gold standard for this problem and plus I do not know how reliable the published studies are (bid sceptical). Have studied the ones that are published here.
    In Europe this surgery is not so common yet. Surgeons say that this salvage procedure can have a severere effect on the function, gait because toe function is gone.

    Does anyone know someone who has a lot of experience with this that I could contact for her? She says she would travel to the U.S. if necessary and let surgery be done there.

    Thanks,
    Frida
     
  4. drsarbes

    drsarbes Well-Known Member

    Hi Frida:

    I don't want to beat a dead horse, but if she has a large defect, an FHL transfer is not the answer.
    She would require a graft.

    Another question that needs to be addressed is why did she have two failed repairs? An AT repair is fairly straight forward and most failures are re ruptures or non compliant patients. I know from both professional and personal experience with ruptured achilles that the post operative care is at least as important as the surgery itself.

    Steve
     
  5. Jeff S

    Jeff S Active Member

    Hi Frida -

    Obviously your patient has a serious issue that needs to be addressed surgically, especially since she is young. As we all know, the biomechanical ramifications of a non/dysfunctional Achilles can be devastating. And now she is faced with revision surgery in an area that is compromised because of the 2 prior procedures and the location. Procedure choices would depend on prior procedures performed, the quality of the tendon that we have to work with and as Dr. Arbes mentioned, the gap distance once the tendon is debrided.

    The patient needs to know that no procedure will restore 100% of the tendon strength. So its hard to make a specific recommendation without the data, but these would be my three options: if mild destruction and <3cm gap - a long FHL transfer and Topaz coblation: If moderate destruction and 3-6 cm gap - Add plantaris w/Fascia lata or ham string autograft and if severe scarring and/or >10 cm gap - add Calcaneal-Achilles Allograft. I am assuming that we can't do another G. recession. I hope this helps and Best of Luck!

    S. Jeffrey Siegel, DPM, FACFAS
    Philadelphia, PA
    [email protected]
     
  6. frida

    frida Welcome New Poster

    Jeff & Steve,

    thanks for this. I took a foto from patient in November, still looks the same.

    Patient knows that no procedure will restore 100% of function. Now, she has 50% and has difficulties with daily activities (e.g. walking downstaris, hip problems, other achilles tendon tendiopathy on nonoperated achilles - mild). The goal would be to get what is left from the gastroc soleus into function.
    First surgery wasn’nt done well I think and she got this trauma leading to a partical second rerupture (while in the cast!!). I think the reason why the second surgery failed is because Gastro-soleus complex was too long from the beginning and later on lengthened as one would expect. I also think that rehab program was too agressive. Also, from the surgery report I see that there was no significant debridement done. The second surgery was not done in Germany, but in Switzerland with an experienced surgeon.

    But now:
    Another turn down from Gastroc is not possible due to the atrophy. From MRI I think that the gap to be bridged is about 7 cm but of course one needs to go in to see the gap to its fully extend.

    I am not sure about the objections against the FHL-transfer to augment the tendon alone.

    I studied FHL transfer in the literature since it is not so common in Europe to treat chronic Achilles disorders. With the long harvest I have my problems because of possible nerve injury through the incision that is necessary. Also, one should leave knot of Henry as is to have a little bid of hallux function left. It is soo important for the balance. Short harvest with interference screw would be my first option.
    I have heard about Allograft. However, this is not possible to do Germany or Switzerland (I think whole Europe is the same).
    Who in the US has most experience with treating chronic achilles tendon ruptures?

    Most important question for you:
    Why do you think that FHL-transfer w/o additional allograft or autograft would not be enough?

    Thanks again folks,

    Frida
     

    Attached Files:

  7. Jeff S

    Jeff S Active Member

    Hi Frida - Great case! Significant calf atrophy and tendon thickening. So. lets talk about the long harvest:

    3-4 cm incision over the nav tuberosity. Both FDL and FHL seen about1-2 cm under the nav. Anastamose the 2 proximal to their crossing then tenotomize the FHL and pull up from the posterior ankle joint. The distal anastamosis is usually enough to stabilize the hallux - but, if not, later on can do hipj arthrodesis which will maximize short flexor function. In my experience, I have not had a problem with PT nerve related issues.

    Next: If there is a question of "over" lengthening, this could certainly be addressed simply by closing the gap a bit to its physiological length or -5 degrees dorsiflexion. In revisions, I prefer a little equinus and then stretch it out in PT once well healed. Nice and tight - a solid repair will yield improved function.


    Next: "Anecdotally" I've seen 20-30 percent improved strength and the combined transfer of the FHL muscle belly's rich blood supply w/TOPAZ coblation will heal the tendinopathy to prevent recurrence. Patient do very well.

    I do this surgery on a regular basis both there are many Podiatric Foot and ankle surgeons across the US who are very talented and experienced to choose from. Hope this helps

    Jeff
    [email protected]
     
  8. frida

    frida Welcome New Poster

    Hi Jeff,

    thanks for this.

    how much equinus, i.e. tension do you usually do? Is 5% more than to the non-operated side enough?

    • Is FHL alone enough or should one use Fascia Lata or Gracilis as well? Of course it depends on size of gap, 8 cm at least in this case (MRI)
      • what is the impact on the hallux function,isnt this like amputation?

        Thanks

        Frida
     
  9. Jeff S

    Jeff S Active Member

    Hi Frida -

    5-10% of non-operated side; error on the side of slightly tight. FHL and graft as stated above. Just restoring physiologic tension will help emmensly. If you have hallux function concerns, fuse the HIP joint. She won't loose significant function. Revision surgery sometime calls for drastic actions.

    JS
     
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