GraftJacket Augmentation of Chronic Achilles Tendon Ruptures

The Achilles tendon is capable of withstanding loads up to 60 MPa, and is one of the strongest tendons in the human body. Despite its strength, the Achilles tendon remains one of the more frequently injured major tendons. Acute Achilles tendon ruptures may go undiagnosed as often as 25% of the time, which results in a chronic or neglected rupture and creates unique challenges during repair.¹

While the differentiation between acute and chronic Achilles tendon ruptures remains ill-defined, it has been generally accepted that acute ruptures are identified and treated within 48 hours of injury. Contraction of the gastrocnemius-soleus complex has been demonstrated as early as 3-4 days.² Generally, chronic Achilles tendon ruptures are defined as an injury that has existed from days to weeks, and the viable ends of the tendon do not lend themselves well to primary repair. In these cases, tendon augmentation with free grafts (ie, patellar tendon, fascia lata), tendon transfer (ie, flexor hallucis longus, flexor digitorum longus, plantaris, gastroc-soleus), or synthetic grafts (ie, Marlex Mesh [Bard Cardiosurgery Division, Bellerica, Mass], collagen tendon prosthesis) is often required to provide adequate tendon bulk for repair.^3-8 Tendon autografts and transfers have the disadvantage of donor morbidity, while synthetic grafts can lead to an inflammatory response.^9,10

A novel scaffold has been developed that is derived from the human dermal layer. GraftJacket (Wright Medical Technology, Inc, Arlington, Tenn) is an immunologically inert acellular tissue replacement matrix consisting of collagen and extracellular protein matrixes. Rapid revascularization and cellular repopulation is possible due to the GraftJacket scaffold that is composed of elastin, collagen, proteoglycans, and preserved blood vessel channels. Additionally, exceptional biocompatibility, strength, and handling properties have been observed in preclinical and clinical models.^11,12 Histological studies have confirmed conversion of the tissue matrix to be indistinguishable from surrounding host tissues.^12,13 GraftJacket has been demonstrated to have superior tensile strength and suture retention than freeze dried fascia lata allograft.¹⁴ Augmentation of chronic Achilles tendon rupture repair with this unique acellular tissue replacement matrix is described.

Case Report

A 64-year-old woman presented with pain and weakness of the right lower extremity. She had a long history of Achilles tendonitis and experienced a “pop” in her leg shortly after being injected with dexamethasone by another provider. Clinical evaluation revealed weakness with plantarflexion, and a Thompson’s test was positive. There was a palpable defect approximately 6-8 cm proximal to the calcaneal insertion. Achilles tendon repair was recommended.

Surgical Technique

The patient was placed in the prone position, with the foot placed off the end of the bed to allow for ankle plantarflexion and dorsiflexion as necessary. A thigh tourniquet was used under general anesthesia. A linear incision was made directly posterior extending from the musculotendinous junction to the superior border of the posterior calcaneus. Care was taken to identify and protect the sural nerve and lesser saphenous vein, which course obliquely from midline to lateral over the gastrocnemius aponeurosis. The paratenon was then incised in a linear fashion and elevated from the tendon medially and laterally.

The chronic Achilles tendon rupture was identified and inspected (Figure 1). Debridement of all nonviable tissue was performed, creating a defect within the Achilles that was 7 cm in length. The gastrocnemius aponeurosis was isolated and a turndown recession flap (2-3 cm in width) was elevated from the central portion of the aponeurosis (Figure 2). Adequate aponeurosis on either side was left for closure of the donor site defect. Care was taken to determine the appropriate length of the turndown flap to ensure that the flap was adequate to reach the distal tendon stump. Two centimeters of the flap overlapped with the proximal stump to protect from proximal rupture. The proximal overlap was reinforced with nonabsorbable suture. The gastrocnemius turndown flap was directly repaired to the distal tendon stump using a modified Krachow stitch. The repair was performed with the ankle in neutral to slight plantarflexion.

Figure 2: Gastrocnemius recession turndown flap.	Figure 3: GraftJacket with paper backing (A). GraftJacket after removal of paper backing from the reticular surface (B).

The GraftJacket was prepared for augmentation by placing the graft in normal sterile saline for 10 minutes. The paper backing was removed from the reticular surface and this side was placed against the gastrocnemius turndown flap (Figure 3). Ideally, the GraftJacket should span from the proximal rotational overlap to the distal stump repair. The graft was sutured to the aponeurosis flap along one edge from proximal to distal using an absorbable stitch (Figure 4). The graft was then rotated around the repair, and then again onto itself. The final edge of the GraftJacket was sutured upon itself and the gastrocnemius flap (Figure 5). The paratenon was repaired using an absorbable stitch and the skin was repaired with a nonabsorbable stitch.

The patient was placed in an above-the-knee cast with the ankle in neutral position, to slight plantarflexion for 2 weeks. Sutures were removed at 2 weeks and the extremity was placed in a below-the-knee cast for 3 weeks. Five weeks postoperatively, range of motion and weight bearing was initiated in a walking boot. Physical therapy was also initiated at week 5. Eight to 10 weeks postoperatively, the patient progressed into normal shoe gear and activities were increased according to tolerance. At 6 months postoperatively, the patient’s double heel rise was nearly equal and symmetrical with no subjective complaints of weakness (Figure 6).

Discussion

As early as 1929, surgery has been proposed as the best treatment for repair of Achilles tendon ruptures.¹⁵ Early reports demonstrated better results in patients treated operatively compared with conservative treatment.^1,16 There is still controversy as to the most appropriate method for repairing chronic Achilles tendon ruptures. Tendon apposition with primary repair¹⁷ or in combination with augmentation¹⁸ has its advocates, but both approaches have disadvantages. If extensive tendon debridement is necessary, an end-to-end primary repair may create significant tension through the repair and the tendon may be prone to rerupture. Augmentation with autograft can result in donor morbidity.⁹ Tendon allografts are costly and have limited availability.¹⁹ Augmentation with a synthetic product can result in an inflammatory response.¹⁰

GraftJacket, a regenerative tissue matrix, provides a tissue alternative for repair of chronic Achilles tendon ruptures. The acellular nature of the matrix eliminates the components that cause an immune response. The matrix is derived from human dermis. Therefore, the remaining matrix components such as collagen and elastin are not degraded as occurs with xenografts.²⁰ Superior biocompatibility, rapid cellular repopulation, and revascularization allow the graft to quickly become indistinguishable from surrounding host tissues, while providing superior tensile strength and suture retention compared to other allograft materials.¹⁴

In this case, the GraftJacket serves as a source of tissue for augmentation of a gastrocnemius recession repair for a chronic Achilles tendon rupture. GraftJacket augmentation allowed for adequate repair without the tendon transfer or free tendon graft. Early return to activity and good plantarflexion strength have been noted postoperatively. Further evaluation of this technique for Achilles tendon ruptures is warranted.

References

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Authors

From the McFarland Clinic, Marshalltown, Iowa.