Section: CME Category: Surgery

FHL Transfer for Achilles Rupture and Repair

Wenjay Sung, DPM

Wenjay Sung, DPM discusses the anatomy and clinical examination for patients that present with Achilles tendon ruptures. Dr Sung also reports on the current literature in regards to treatment of neglected Achilles tendon ruptures. He also explains the surgical technique involved with an FHL transfer to help augment an Achilles tendon repair.

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Goals and Objectives
  1. Review the anatomy of the Achilles tendon
  2. Describe physical exam findings related to Achilles tendon ruptures
  3. Describe surgical technique to perform a FHL transfer for augmentation of an Achilles tendon rupture.
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  • CPME (Credits: 0.5)

    PRESENT e-Learning Systems is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. PRESENT e-Learning Systems has approved this activity for a maximum of 0.5 continuing education contact hours

    Release Date: 09/05/2018 Expiration Date: 12/31/2020

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    Wenjay Sung has nothing to disclose.

  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Male Speaker: Our first speaker is actually a new welcomed member to our present team as a major blogger. He is a podiatric physician and surgeon from California and he got out here to get away from all the fires out there. So we got to have to give him a little hot seat anyway here with some of this presentation. But Dr. Wenjay Sung is a board-certified foot-and-ankle surgeon. He is fellowship trained. He is a major contributor to the literature, very much of an academic. And he’s come all this way to be talking about flexor hallucis longus transfer for Achilles rupture and repair. And I think we’re going to see some interesting parts in this presentation and a little bit of opportunity for you to communicate with the speaker at the same time. So please welcome Dr. Wenjay, Sung Jay.

    Wenjay Sung: All right, thank you. Thank you, Dr. Shainhouse. So welcome, guys. Today, we’re going to talk about FHL transfer for the Achilles tendon rupture and repair. So I have no disclosures for this lecture. So one thing I like to do with my lectures is I like to have audience participation.

    So since we all have cellphones today, what I like you to do right now is get out your cellphones very simply, get out your cellphones and text to 37607. If you have a signal, definitely text 37607 and just text my name with one word, Wenjay Sung. Just text one word. And it should pop up with that you’re now entered into my polling application. So again, 37607 and then just text my name to that number. So the first thing I like to ask is, which famous person had an FHL transfer after an Achilles tendon rupture? And you should have these choices for you. The – as you guys enter A, B, C, D, E, F or G, we should be able to get more and more people lined up. Let’s see if this works.

    [02:19]

    Anybody texting?

    All right. Well, I guess no one is interested in texting. Well, the main thing is, nobody, none of them actually have the FHL transfer for Achilles tendon rupture and we’ll talk about why we use FHL transfer. But none of them had. That is very surprising. A lot of people had Achilles tendon ruptures, but none of those people that we talked about, none of those people right here, actually had an FHL transfer.

    Well, that’s okay. No worries.

    All right. So Achilles tendon rupture epidemiology. We tend to have a very – it’s very uncommon in the population. So it does seem to happen a lot more in the media than it does in real life. Obviously, it happens more to males than females for obvious reasons. It tends to happen more in the weak and warrior population which is generally between the third and fifth decade.

    Now, the Achilles tendon is the largest and most powerful tendon in the leg. It is formed by aponeurosis of both the gastrocnemius and the soleus muscles. They’re nothing for you, guys. Hopefully, you guys already know this. But what’s interesting is that it is at this thinnest, about two centimeters width and then also half a centimeter in thickness. So the Achilles tendon is actually a lot – the most – one of the thicker tendons in the body, not just in the leg. All right. And it tends to insert in this middle one-third of the posterior calcaneus and the actions of the Achilles tendon is usually plantar flexion of the ankle.

    [04:02]

    So the vascular supply of the Achilles tendon tends to come from three sources. Proximally, it’s more from the myotendinous junctions and branches from the muscle. The central portion tends to be more from the mesoderm or the – excuse me. The – the mesoderm basically. It tends to get it from the supply, from the tendon itself, from the mesotendon. And then, distally, it tends to get it from the periosteal vessels.

    Now, what’s interesting is that centrally, obviously, this is where most of the ruptures occur about 70% of the time. But these vessels, the mesoderm vessels, are usually on the anterior or the deep portion of the tendon. So not the posterior or the outside portion of the tendon, the more superficial portion of the tendon. So sometimes, we can have partial tears just distally and – excuse me. Just posteriorly which is more superficial in the tendon rather than just completely through and through. So that’s interesting to know and you know that because you know the anatomy.

    Now, the causes of Achilles tendon ruptures can both – be both indirect and direct. Mechanical stress is generally the most common and intratendinous degeneration. Now, the location of these, again, the tears, tend to be between the two centimeters and six centimeters superior calcaneus, that water-shed area where there’s poorest blood supply. But also, what’s interesting is that as we increase in age, the blood supply also decreases. So with physical examination, when we try to look for these, obviously, the patient would come in and say, “Ouch, you know, somebody hit my calf. I felt like somebody kicked in the back.”

    That tends to happen and Kobe Bryant when he had a – his Achilles rupture and I think that was just done after a playoff game. I think millions of people watched it. He literally felt that someone – he kind of flailed and, you know, did a flop, thinking that somebody hit him in the back. But actually nobody was around him. He just had an Achilles tendon rupture, it’s like, “Who kicked me in the back?”

    So what we tend to get is weakness of the plantar flexion, the palpable gap, but generally a palpable gap, however again, if you have a partial tear, you will have that palpable gap as prominent.

    [06:00]

    Now positive Thompson test, again, squeezing the calf and seeing if there’s any, again, for an acute Achilles rupture, a positive Thomson test meaning that there will not be any movement to the – there will be not be any plantar flexion when you squeeze the calf, but sometimes you get false negatives because the plantar flexors such as the FHL and some of the other longest nerves, excuse me, longest tendons are still attached.

    So sometimes you get a false positive when it comes to the Thompson test. So what we tend to look for, mostly, is the gap in the tendon and also weakness in plantar flexion when it comes to Achilles tendon ruptures.

    Imaging is generally not necessary. When you have an Achilles tendon rupture, everything kind of falls in line, it’s one of the easiest diagnosis to make just for visually and also with the clinical exam, but it doesn’t hurt to get an MRI or an ultrasound if need be.

    Now, while we’re talking about flexor hallucis longus, tendon transfer, it’s not for acute, well it’s actually for neglected Achilles tendon ruptures. Now again, I’m going to just have you guys raise your hands, okay.

    So in Greek mythology, this is going to be on your boards. In Greek mythology, what was the name of the river Achilles’ mother dipped him in, in Greek mythology? You know, he held him by his Achilles, so what was the name of the river?

    How many say A, Styx, Slayer, B, Metallica, Jimmy Buffet, and Katy Perry. Believe it or not, there are actually people believed it was Katy Perry last I gave this lecture. So obviously it’s the River Styx, if you know your Greek mythology.

    A neglected rupture is actually a rupture in the Achilles tendon that’s about four weeks or longer. So you can have people coming in four years after or four week after. So non-operative therapy generally does work but it depends on what your success rate is.

    [08:00]

    And so to get a functional type of foot, a functional type of gait, yes, it does work. Non-operative therapy, basically casting, doing massage, doing physical therapy, it does work. However, surgical success is obviously a lot higher when it comes to neglected Achilles tendon ruptures.

    Now, the pathophysiology of a tendon, generally after a neglected Achilles tendon rupture is a thickened, adherent, very scarred up tissue, because no matter how, even it’s retracted, you get a scar tissue, a scar ball in the area.

    Even if you fill dell, there’s still a nice, scarred ball there that is not viable tendon, which makes the plantar flexion weak, which makes the Achilles tendon weak itself. Generally we do have this hypertrophied ball if you look in their ultrasound, a hypertrophied ball, and if you tend to do a surgery, you see this hypertrophied ball right there.

    Now, sometimes a plantaris is attached if it is present. I don’t know if you any of you have treated a plantaris tear before. I myself had a plantaris tear. I do Muay Thai kickboxing myself, and actually had a plantaris tear.

    I felt somebody kicked me in the back of the calf and there was nobody behind me. It was literally just textbook, like, “Oh crap, I tore my plantaris,” and it was sore, and you could feel it retracting, and it’s really painful actually, but thank God it wasn’t Achilles tendon.

    Now the plantaris tends to be our canary in the coalmine. If you have somebody with a plantaris tear, it’s not a big deal. You don’t need to do a surgery, you don’t need to cast him or really treat him.

    I just did my own home physical therapy, but it is a canary in the coalmine. People with the plantaris tear tend to have more Achilles tendon pathology, tend to have signals that say, “Hey soreness is happening in the Achilles. You’re at risk for a possible tear.”

    So it is your canary in the coalmine if you have somebody with a history of plantaris tear. Now, the thickening of the scar, again, the thickening of the scar tissue, as we talked about, this is not repairable tissues.

    [10:02]

    You have to be able – when you do surgical repair of or any type of surgical options for a neglected Achilles tendon rupture, you have to understand, a thickening scar is not viable tissue at all.

    This has to be debrided, completely debrided, and that’s when you actually can measure the distance between the Achilles, a viable Achilles, distantly and proximally. Again, clinical exam for a neglected Achilles tendon rupture, wasting of the calf, generally you see an increase in the muscular hypertrophy of the FHL and also the FTL, but you also see some secondary effects with clawing toes and also some cavus foot.

    That’s very secondary. Sometimes you don’t really see that appreciation at all, especially the older they are. But now this is interesting. We have a negative Thompson test because the FHL and the FTL are already accommodating it after four weeks.

    You have a positive Matles test and a negative O’Brien needle test. None of these are actually systematically studied, this is just something that we’ve talked about clinically, yes, there’s papers regarding it, but none of them has systematically been studied, so we just take it with a grain of salt.

    Advanced imaging, I tend to do this for my neglected Achilles tendon ruptures, just because you get an idea of how much you need to debride out, and the reason is because you want to know, kind of get in there, make your incision, you don’t want to keep coming back, back, and back, and back. You need to know how long your incision is going to be in order to debride out the Achilles tendon that’s non-viable.

    Post-operatively, what you want to look for is a respiration of a single leg heel rise. And that’s really what you want, a strong, propulsive gait, but also, a single leg heel rise that’s kind of equal or equal to the other leg.

    Now again, surgical considerations, the average gap in a neglected Achilles tendon ruptures between three and five centimeters.

    [12:00]

    So understanding that, that’s probably how much you’re going to need to debride and be able to measure out. Also, understand that with any type of repair, you tend to get usually a 25% – 23% strength deficit. So even if you had the most successful repair, you’re still going to lose strength about 25%.

    So what minimal gap link do you think authors suggest when it comes to fascial advancement procedures? This is like a VHL – excuse me, a VY procedure, FHL turned-on procedure. How many say A, two centimeters? All right. How many say B, three to four? C, five to six? Six – D, six or more? What’s a fascial advancement? Well, the answer actually, believe it or not, is two.

    So the reason is because most people do not believe if it’s greater than two centimeters that you can actually bring in viable tissue end-to-end procedures. Even if you do Krackow stitch or Bunnell or whatever stitch, the end-to-end procedure just won’t be strong enough and will actually rip out, even if you’re using whatever suture you prefer to use. So some type of fascial advancement, whether a gastrocnemius turn-down, a V-Y slide and so forth, tends to be recommended if it’s a greater than two-centimeter deficit.

    Now, the FHL transfer kind of takes all this into one by using the Achilles tendon as – not so much as the main tendon but actually it’s transferring it out. Just like what you do for a posterior tibial tendon transfer and then using the FA – FTL, you are now using a different tendon in the same line as the Achilles. With this, they have been studied many, many times as a well-known, well-published procedure, not announcing anything new.

    But with the FHL transfer, there’s still some loss in plantar flexion, obviously, about 22%, and however the AoFA scores. And people clinically, afterwards, are very satisfied with their outcomes.

    [14:03]

    What’s great about the FHL, it is a work course. If you need something to replace the Achilles tendon, it is a good work course. It is ideal piece – it is in line – it’s in line with the Achilles tendon, meaning it’s more in line than, say, using an extensor tendon, obviously. But it’s right there.

    Just more statistics, more paper saying that the FHL is actually a great tendon to use.

    Now, Maffulli – if anybody follows any papers or reads a lot of literature, Maffulli is a great surgeon that publishes a lot on sports medicine, especially on Achilles tendon tendinopathy. What he did was he did a systematic review and also gave some recommendations for the journal of the JBJS, American back in the day. It used to be called American, now, it’s just JBJS.

    Well, what they found is that there’s a lot evidence for it, but just not enough to actually clinically give it a B or a higher rating. So it still needs more evidence regarding using FHL for a transfer – for neglected Achilles tendon ruptures. So we still need a lot more research out there.

    So surgical technique. You see here, this is – let me just go back one. You see, after you debride the Achilles tendon, there’s a big gap after you debride a neglected Achilles tendon. There’s a big gap there between – here’s the heel and here’s what’s left of the viable Achilles tendon. And you see there’s not much there.

    This is the fascia in between the Achilles tendon and the deeper ligaments – excuse me, deeper tendons. So if you lift this up, it kind of looks like the monster from Alien, you know, you just lift it up. And from there, you can then take your scissors, take your Mayo scissors and make an incision on there.

    For acute Achilles tendon ruptures, if you treat an acute Achilles tendon rupture, sometimes, we tend to recommend to open this fascia up, all right. The reason is sometimes you can have an injury to your FHL. And that’s why sometimes we open this up to look at the FHL, look at the FDL sometimes, especially for acute, like, real, high-powered injuries, such as, you know, falling off from a high story or some type of a high-speed accident.

    [16:08]

    We tend to look at the FHL just in case, and you just suture back up if everything is okay.

    So you cut this fascia, you open it up, and then you’re able to expose the FHL , and you just pull it all the way. And it’s okay, you can pull it all away. Obviously, you see the toes curl. What you want to see is, obviously, the big toe move. So you pull it – you need to make sure you get the right tendon, so make sure to follow the big toe. And you pull it as far as you can. Why do you pull it as far as you can? To get as much distance.

    So – then once you’re able to get as far as you can, take your 15 blade and make a separate incision right here – excuse me, sever the tendon right there. And then sometimes, you can tuberize it, some people, like, they just do an end-to-end. But then – mark this tendon right here, you have the link, pull it out, the link, you can see some tuberization going on here. And then you can use any bio tin-adhesive screw, there’s a lot of different products out there, whatever floats your boat.

    So drill your hole, pull the tendon through the hole, through the canal. Pull your tendon – I’m a big plantar flexion – I’m a big believer in physical therapy in plantar flexion, so I like to put the foot in maximum plantar flexion. So whatever you can get maximum plantar flexion and then put the tendon in here. Obviously, we’re so – we’re doing this for the picture, but if you pull this all the way and also you’re pulling the tendon as much as you can, maximum plantar flexor foot and then lock it in with your bio tin-adhesive screw. And again, suture is back up.

    Now, you can use whatever is left for the Achilles tendon and whatever is left for that stump. And if you want to, you can then suture it on top. You don’t need to, however, some people do, just to add a little extra umph to it. But technically, it’s not something that is needed to be done because the FHL is capable of handling it on its own.

    So post-operatively, you want to be very aggressive with this. Post-operatively, meaning range of motion, strengthening, non-weight bearing. So even if they’re not weight-bearing get amount of the boot. You know, range of motion, teach them some exercises. You got to do some resistance exercises the first three weeks.

    [18:11]

    Why? Because you want to make sure they have strength. Because plantar flexion and getting that equal strength is very important in the first initial phase after surgery. Once the sutures are removed, again, get them into more of a wedge type of weight-bearing and start doing more physical therapy. The earlier the better.

    All right. Lastly, see if you can try the text now. I want to see if you try it now. If you rupture yourAchilles tendon, would you have surgery to repair it? Anybody? All right, cast yourself for four to six weeks? Hey, there you go. Somebody will actually have surgery. More people would have surgery.

    All right. So the one guy applied for workers call, that one guy. Directors, look out for this guy.

    Oh, that’s good. So, thank you.

    So one of the best things about – why I like to lecture is that I like to share my lectures. So, another thing, since everybody has their camera – everybody has their phone, take out your phone and turn the camera app on, all right? So focus on this, all right? Focus on this, and when you focus on this, a link should pop down. Don’t take a picture, just focus on that. A link should pop down, it should be a Dropbox link. You can therefore download my lecture today, if you like the lecture. If you don’t like it, you don’t need to. You can take a picture of here, if you want. But this one, you can actually take my lectures and keep them with you, so you can take them home.

    This picture down here, I had the privilege of being a judge at a Miss Asian beauty pageant in Vegas just a few weeks ago, and this week I’m here with you guys, so. Any questions? Yes?

    [20:09]

    [OFF-MIC]

    Speaker: – and still remain below the malleoli, is there a surgical technique that could be used to do that?
    Wenjay Sung: Legality-wise, probably not. Just because the location of the rupture, unlikely. Most of the surgeries I do, I get them based in California. We go about six centimeters probably above the malleoli with our incision. So if it’s probably based on incision, probably not.

    Yes, sir?

    [OFF-MIC]

    Wenjay Sung: So, great question. There’s a lot of different companies out there. It’s something that I have a debate about with different practitioners. That’s for different lecture, but yeah.

    Any other questions?

    Speaker: Jay, a really good lecture, thank you. My question is about the – your advanced – with your fascial advancements. So I’ve had a few where I’ve done like a V to Y kind of thing, like a vulbious type, and get a little bit of more weakness. Repair the Achilles part of thing seems okay, but the gastroc portion of it seems to weaken it a little bit, sort of like, you know, if you’re doing a gastroc for a flat foot or something like that. Have you noticed that and how do you prevent that from happening?

    Wenjay Sung: I do more of a – so the V to Y is yeah, you actually get a lot more weakness. Obviously, you’re making a lot more dissection, and the fibers just don’t – once you release some of the fibers, the blood supply obviously weakens the tendon, and now you have more of a – less of lever arm because you’re lengthening it out.

    [22:04]

    Sometimes we just need to stretch it. Sometimes we don’t need a fascial advancement that much. Like a V to Y, I think it’s something for greater than six, centimeters. Mostly, I’ve turned to a turned to a turn-down now, so I’ve just used a turn-down. But there’s still weakness. There will always be at least a 25% of weakness, you got to just make sure the patients understand that. The lever arm is just never going to be the same.

    Any other questions? All right. Sir?

    [OFF-MIC]

    Speaker: – the Lindholm procedure.

    Wenjay Sung: The what?

    Speaker: Lindholm, the Lindholm procedure for repair of a big deficit, as you can flap down twice from the gastroc.

    Wenjay Sung: Anything that you have to do – anything with more dissection, you’re just going to lose more and more lever arm strength and more strength to the Achilles to – excuse me, the gastroc. It’s always complex. That’s why it’s a big advantage to use the FHO. The FHO is right there. It does provide enough strength. Obviously, not equivalent, but enough strength, about 25% close to 75% of the Achilles tendon. So the FHO is right there, it’s a great go-to.

    Last question, anybody? Thank you.


    TAPE ENDS [0:23:18]