ANKLE

Chronic Achilles tendon rupture reconstruction using a freesemitendinosus tendon graft transfer

Mohammad Mahdi Sarzaeem •

Mohammad Mahdi Bagherian Lemraski •

Farshad Safdari

Received: 1 May 2011 / Accepted: 4 October 2011 / Published online: 29 October 2011

� Springer-Verlag 2011

Abstract

Purpose The purpose of this study was to evaluate the

outcomes following reconstruction of the chronic Achilles

tendon ruptures with large gaps ([6 cm) using free semi-

tendinosus tendon graft transfer.

Methods There were 11 consecutive patients underwent

the above-mentioned surgical technique for the treatment

of chronically ruptured Achilles tendon contributed in

current study and were followed up prospectively for a

mean of 25 ± 3 months. The intraoperative tendon defect

was greater than 6 cm in all of the patients. Functional and

clinical assessment was performed using The American

Orthopaedic Foot and Ankle Society (AOFAS) and

Achilles Tendon Rupture Score (ATRS).

Results The average AOFAS and ATRS improved sig-

nificantly from 70 ± 5 and 32 ± 6 preoperatively, to

92 ± 5 and 89 ± 4 points post-operatively (P = 0.001).

The range of dorsiflexion was significantly limited on the

operated side (13 ± 4� vs. 17 ± 4�) (P = 0.04). All

patients were able to stand on the tiptoe of injured leg, and

no patient walked with a visible limp. Post-operative

complications included one patient with symptomatic

DVT and 2 patients with superficial infection treated

nonoperatively.

Conclusions The technique offers good clinical and

functional outcomes and is safe. Reconstruction of the

chronic Achilles tendon ruptures with free semitendinosus

tendon graft in patients with defects greater than 6 cm is

recommended.

Level of evidence IV.

Keywords Achilles tendon � Chronic rupture �Semitendinosus � Tendon autograft � Surgery

Introduction

Achilles tendon is the most commonly ruptured tendon in

the human body [18]. Although clinical examination is

sufficient to diagnose Achilles tendon rupture after injury,

about 10–25% of complete acute ruptures are neglected

initially and diagnosed late [10, 17–21, 30]. Rupture is

classified as chronic if it has been present at least for

4–6 weeks [6, 12, 21, 25, 28]. It is difficult to treat a

chronically ruptured Achilles tendon as there is usually a

gap between the ends of the tendon, scarring, retraction of

calf muscles and loss of contractility of the triceps surae

[5, 6, 11, 14, 18, 20, 29, 30]. These problems make the

treatment of chronic ruptures of Achilles tendon different

from that of acute ruptures [11, 18, 30]. Therefore, various

techniques have been described to repair or augment the

tendon including tendon augmentation with autologous

free grafts such as gracilis [17], semitendinosus [7, 18],

free gastrocnemius aponeurosis flap [21] synthetic grafts

such as Marlex mesh [24] and polyester tape [6], flap tissue

turn down [28], transfer of the tendon of flexor halucis

longus [12, 20, 30] peroneus brevis [19, 26] and percuta-

neous suturing [10].

In some patients, there is a large gap (greater than 6 cm)

between the ends of the tendon despite maximal plantar

flexion of the ankle and traction on the Achilles tendon

M. M. Sarzaeem (&) � M. M. B. Lemraski

Department of Orthopaedics, Imam Hosein Hospital,

Shahid Beheshti Medical University, Tehran, Iran

e-mail: mmszaeem@gmail.com

F. Safdari

Akhtar Orthopaedic Research Center, Akhtar Orthopaedic

Hospital, Shahid Beheshti Medical University, Tehran, Iran

123

Knee Surg Sports Traumatol Arthrosc (2012) 20:1386–1391

DOI 10.1007/s00167-011-1703-x

stumps and the local tendons are insufficient to bridge the

gap. Maffulli et al. suggested that in such instances,

reconstruction with ipsilateral hamstring tendon is a suit-

able option [15, 16, 18, 19].

The purpose of this study was to investigate clinical and

functional outcomes of chronic Achilles tendon rupture

reconstruction with a free tendon graft from semitendino-

sus. It was hypothesized that reconstruction with this

method is a good option for patients with gaps larger than

6 cm.

Materials and methods

Between 2004 and 2008, there were 11 consecutive

patients (all men) with chronic Achilles tendon rupture

underwent surgical reconstruction with free tendon graft

from semitendinosus. The characteristics of the patients are

presented in Table 1. The chief complaint included sig-

nificant disability and weakness in performing activities of

daily living and limping. On physical examination, there

was a gap at the site of the ruptured tendon and calf

squeeze test was positive in all of the patients. None of

them could stand on tiptoe. Magnetic resonance imaging

confirmed the diagnosis. The interval between injury and

surgical reconstruction was greater than 6 weeks (range

3–36 months).

To evaluate the preoperative functional and clinical sta-

tus, the AOFAS (American Orthopaedic Foot and Ankle

Society) Ankle/Hindfoot Scale [9] and ATRS (The Achilles

Tendon Rupture Score) [22] were determined for all of the

patients.

The surgical procedure was performed with the patient

prone under spinal or general anaesthesia. Initially, while

the ankle was plantar-flexed, a longitudinal posterior

midline incision was made over the heel cord to expose the

stumps and rupture site of the Achilles tendon. The prox-

imal stump pulled down using gentle traction applied by a

tendon clamp to minimize the residual gap. In addition to

scar tissue in the gap between the stumps, the ends of the

tendon were excised achieving viable tendon tissue, and the

length of the tendon defect was measured. If the gap was

greater than 6 cm, the tendon of the semitendinosus was

harvested via a vertical incision over the pes anserinus. If

not, the Achilles tendon was repaired using flexor halucis

longus or peroneus brevis tendon transfer and the patient

was excluded. After harvesting the tendon of the semi-

tendinosus, the graft was passed through a small incision in

the substance of the proximal stump of the Achilles tendon

in a mediolateral direction. The graft was then pulled

downward in a cross manner and passed through a small

incision in the substance of the distal stump in the same

direction (Fig. 1). Finally, the graft was pulled upward in

the same manner to form a figure of eight. The tendon of

the semitendinosus was sutured to the Achilles tendon at

each entry and exit point (Fig. 2). The wound was closed

and dressed and the limb immobilized in a below knee cast

in 20� of plantar flexion of the ankle.

After surgery, patients were followed up for

25 ± 3 months (range 18–30) and the AOFAS Ankle/

Hindfoot Scale and ATRS were determined for all of them

again to compare with the preoperative scores. Also, ankle

range of motion (plantar flexion and dorsiflexion) and calf

Table 1 Demographic and clinical characteristics of the patients

evaluated in present study

Number 11

Age (year) 30 ± 4 (range 25–39)

Sex

Male 11

Female –

Side

Right 7

Left 4

Injury mechanism

Sport injury 10

Slipping on the floor 1

BMI (Kg/m2) 26 ± 3 (range 22.9–31.7)

Months between injury to surgery 12 ± 10 (range 3–36)

Length of the gap (cm) 8.3 ± 2 (range 6–12)

Fig. 1 The free graft of the tendon of semitendinosus has been

passed through the substance of the proximal and distal stumps of the

ruptured Achilles tendon in a manner to form a figure of eight

Knee Surg Sports Traumatol Arthrosc (2012) 20:1386–1391 1387

123

circumference (15 cm below the patella) were measured

and compared with the unaffected side.

Patients’ range of dorsi/plantar flexion was measured by

an orthopaedic surgeon (M.M.B.L) using a goniometer.

The patients were prone with their feet hanging off the side

of the table. The examiner marked the head of the fifth

metatarsal and the line dividing the fibula in half. The fixed

arm of the goniometer was then positioned over the fibula

and the moveable arm over the head of the fifth metatarsal.

The fulcrum of the goniometer was secondarily located

below the lateral malleolus, which corresponded to the axis

of the joint. The ankle was placed in the neutral position,

and then, the patient was instructed to make an active

dorsiflexion or plantar flexion movement of the ankle. The

measurements were repeated consecutively three times for

each patient, and the data were registered. The average of

the above 3 values was recorded as the range of motion.

In the final follow-up, patients were asked about

returning to their previous job or sporting activity, presence

or absence of pain using a visual analogue scale (VAS) and

limitations with footwear.

Statistical analysis

Statistical analysis was performed with SPSS statistical

software (version 15.0; SPSS, Chicago, IL). Paired t test was

utilized to compare the pre- and post-operative variables.

Also, the variables were compared between injured and

uninjured limbs using independent samples t test. In order to

evaluate the correlation between chronicity of the rupture

and ankle range of motion, AOFAS Ankle/Hindfoot Scale,

ATRS and any complications, Pearson’s correlation coeffi-

cient (r) and Spearman’s rank correlation coefficient (rho)

were used. P value\0.05 was considered significant.

Results

The average AOFAS and ATRS scores significantly

improved post-operatively (P = 0.001) (Table 2). There

was no statistically meaningful difference between the

average calf circumference of injured and uninjured sides.

Although the range of plantar flexion was similar on the

both sides, dorsiflexion was significantly limited on the

operated side (P = 0.046) (Table 3).

One patient developed symptomatic deep vein throm-

bosis (DVT) and two patients had superficial wound

infection (18%) and were managed nonoperatively. Addi-

tionally, three patients had difficulty wearing shoes and

were managed by slight footwear modifications. In the final

follow-up, all patients were able to stand on tiptoe and

walk without a visible limp. No patient experienced any

problem with the incision used to harvest the tendon of

semitendinosus. No patient had any limitation in activities

of daily living and all of them, except the professional

athlete, returned to their previous job or recreational

activities within 6 months after operation.

There was no statistical correlation between chronicity

of the rupture and AOFAS Ankle/Hindfoot Scale, ATRS,

ankle range of motions and complications.

Discussion

The principal finding in the present study was that at a mid-

term follow-up (a mean of 25 months), reconstruction of

Fig. 2 Achilles tendon at the end of the reconstruction; the integrity

of the flexor apparatus was reconstituted with the graft filled the large

gap

Table 2 Comparison of preoperative and final AOFAS and ATRS

scores

AOFAS ATRS P value

Mean ± SD Range Mean ± SD Range

Preoperative 70 ± 5 61–78 32 ± 6 24–39 0.001

Final

follow-up

92 ± 5 83–97 89 ± 4 82–95 0.001

Table 3 Ankle range of motion and calf circumference in operated

and healthy sides

Operated side Healthy side P value

Mean ± SD Range Mean ± SD Range

Calf circumference(cm)

36 ± 3 30–42 38 ± 4 33–45 n.s.

Ankle motion (�)

Plantar flexion 36 ± 8 22–50 39 ± 6 30–50 n.s.

Dorsiflexion 13 ± 4 5–20 17 ± 4 10–25 0.046

ns non significant (P C 0.05)

1388 Knee Surg Sports Traumatol Arthrosc (2012) 20:1386–1391

123

the chronic ruptures of the Achilles tendon with a free

tendon graft from semitendinosus provides tendon healing

and good clinical and functional outcomes. Although, the

range of dorsiflexion was decreased significantly in the

affected side but there was no functional deficit in spite of

the large gap seen in Achilles tendon and the results were

satisfactory in all of our patients.

Several operations have been described for the recon-

struction of the chronic Achilles tendon rupture, each with

some advantages and disadvantages [6, 10–12, 21, 28].

However, the most appropriate technique remains contro-

versial [11, 20].

In some patients, tendon ends are markedly retracted

and atrophic, and there is a large gap (greater than 6 cm)

to bridge, which makes the viable local tendons insuffi-

cient to provide a strong graft [15, 17, 18]. In addition,

there are some studies reported functional imbalances in

the foot following the use of local tendons [1, 4, 26, 27].

In these cases, reconstruction using turn down flaps have

been advocated [2, 14]. However, the proximal stump

often has poor quality to prepare the turn down flaps and

reinforcement with other tendons, which can thicken the

tendon at the site of the reconstruction, may be necessary

[14]. It had recently shown that in Achilles tendon

ruptures, the whole of the tendon exhibit profound bio-

chemical and gene expression changes and cannot be

considered normal [8]. Moreover, closure of the calf

wound over the bulky reconstruction may result in

excess tension over the skin, increasing the risk of

dehiscence [24]. Some authors are concerned about the

reconstruction of the chronic Achilles tendon ruptures

using synthetic materials because of the increased theo-

retical risk of infection and high complication rates [15,

17]. Repair of the Achilles tendon ruptures with Dacron

graft or a polyethylene mesh was associated with scar-

ring resulted in affected range of motion [3, 13]. Also,

these materials are more expensive than autologous

grafts [17]. Therefore, ipsilateral semitendinosus tendon

graft can be an appropriate option in patients with large

gaps (greater than 6 cm) between the stumps of the

tendon.

The long and strong tendon of semitendinosus makes it

possible to reconstruct the chronic Achilles tendon ruptures

with a large gap between the stumps. Harvesting the tendon

is easy and associated with no functional deficit. Further-

more, our study showed this technique is safe and we had

no injury in neurovascular structures such as sural nerve.

Also, the post-operative improvement in the AOFAS

Ankle/Hindfoot Scale and ATRS scores suggest that the

outcomes were gratifying and patients regained their ability

to perform activities of daily living. Only one patient, the

professional soccer player, had moderate pain during heavy

physical exercises and had to leave competitive sports.

Although reconstruction of the chronic Achilles tendon

rupture using the tendon of semitendinosus was described

in previous studies [7, 18], but to our knowledge, this is the

first time that the use of a free semitendinosus tendon graft

has been described in a series of patients with large gap

(mean 8.3 cm). Ji et al. described semitendinosus tendon

augmentation for reconstruction of Achilles tendon rupture

with large gap in 2 patients [7]. Also, Maffulli et al.

described two minimally invasive techniques to reconstruct

chronic tears of the Achilles tendon and chronic avulsion of

the Achilles tendon using ipsilateral free semitendinosus

tendon graft [16, 18].

Reconstruction of the chronically ruptured Achilles

tendon is not free from complications [10, 12, 29], and

Wound breakdown, infection (9%) and DVT are well-

known complications of surgical repair [23, 26]. Unfortu-

nately, there were 2 patients with superficial wound

infection (18%) and one with DVT (10%) in present study.

Although there are some studies in which no patient had

such complications, however, the occurrence of these

problems following open reconstruction of chronic Achil-

les tendon ruptures seems to be high enough to justify the

use of minimally invasive techniques in these patients

which need to be more investigated to determine their

clinical and functional outcomes. The incidence of wound-

related complications in other studies is presented in

Table 4.

Although, it is difficult to compare the results of

various studies due to various surgical techniques,

assessment tools and small sample sizes, it is obvious

that in spite of large gaps seen in our patients (mean

8.3 cm), which were not previously reported, the results

of the current study are comparable with those of the

others (Table 4).

The present study was limited by the small patient

population and the mid-term duration of follow-up. In

addition, the study was a case series, and no comparison of

clinical and functional outcome was made. However,

clinical trials could be difficult to perform because patients

with large gaps (defect greater than 6 cm) are not com-

monly encountered. Also, we did not evaluate the strength

of the plantar flexion of the affected foot to compare with

sound side that seems to provide useful information about

the technique.

Conclusion

Based on the findings of current study, we recommend

reconstruction of chronic Achilles tendon ruptures with

free semitendinosus tendon graft in patients with large

defects (over 6 cm) which is associated with good clinical

and functional outcomes.

Knee Surg Sports Traumatol Arthrosc (2012) 20:1386–1391 1389

123

Table 4 Summary of the outcomes of some studies on reconstruction of the chronic Achilles tendon ruptures using AOFAS and ATRS

Authors No. of

patients

Technique of reconstruction

or augmentation

AT

defect

(cm)

Follow-up

(months)

AOFAS

(post-op)

ATRS

(post-op)

Surgical wound

complications

Comments

El Shewy

et al. [2]

11 Two intratendinous flaps

from the proximal

gastrocnemius-soleus

complex

7.3 From 72

to 108

99 – 3 patients with

small wound

gapping

2 patients with

superficial

wound

infection

No decrease in

the strength

of the calf

muscles

Ibrahim

et al. [5]

13 Peroneus brevis and the

Ligament Advanced

Reinforcement System

(LARS) ligament

– 36 86 – 2 patients

(15.4%) with

skin necrosis

–

Jennings

Sefton [6]

16 Polyester tape – 36 3 patients

(18.7%) with

superficial

surgery

Two patients

unable to

stand on

tiptoe

Kosanovic

Brilej [10]

22 Percutaneous suture

technique

– 67 – – No wound

healing

complication

One patient

developed

DVT

Two patients

with sural

nerve injury

One patient

with CRPS1

Lee et al.

[12]

3 patients

(4

tendons)

Interposed scar tissue repair

combined with flexor

hallucis longus tendon

transfer

5.2 20 97 83 No wound

complication

–

Maffulli

Leadbetter

[17]

21 Free gracilis tendon graft 6.8 28 – – 5 patients

(23.8%) with

superficial

infection

Good clinical

and

functional

outcome

Maffulli

et al. [19]

32 Less invasive reconstruction

using a peroneus brevis

tendon transfer

Less than

6 cm in

all

patients

48 – 92 5 patients with

superficial

infection (15%)

2 patients with

hypertrophic

scar

Mahajan

et al. [20]

36 Flexor hallucis longus

tendon transfer

– 12 88 – 5 patients

(13.9%) with

surgical wound

complications

–

Nilsson-

Helander

et al. [21]

28 Augmentation with a free

gastrocnemius

aponeurosis flap

– 29

(median)

– 83 6 patients

(21.4%) with

surgical wound

complications

–

Takao et al.

[28]

10 Gastrocnemius fascial flaps – 75 98 – No wound

complication

–

Tay et al.

[29]

9 Two turn down flaps and

flexor hallucis longus

augmentation

– 24 94 – No wound

complication

–

Wegrzyn

et al. [30]

11 Flexor hallucis longus

transfer with augmentation

with fibrous scar stump

7.4 79 98 – No wound

healing

complication

Loss of active

hallux IP

ROM in all

patients

The present

study

11 Free semitendinosus tendon

graft

8.3 25 92 88 2 patients (18%)

with superficial

infection

One patient

with

symptomatic

DVT

1390 Knee Surg Sports Traumatol Arthrosc (2012) 20:1386–1391

123

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