Revision Achilles Reconstruction with Hamstring Autograft and FHL Tendon Transfer in an Athlete

Achilles tendon injuries are very common, with a reported incidence of 18 ruptures per every 100,000 people [5, 9]. While there is evidence supporting both operative and non-operative management for acute ruptures, current evidence supports operative repair as the best treatment option in young, active people, hoping to return to an active lifestyle [6]. The most common complications reported following operative treatment include re-ruptures, wound breakdown, and deep infection [4]. Among the literature, the rates of re-rupture are reported to be between 2 and 8% of patients treated operatively for Achilles ruptures [1, 6, 12, 15]. In cases of re-rupture, infection of the tissue can be present as an underlying cause that either contributed to, or caused the failure of the initial operation [7]. In one report, a 20% incidence of complications following primary Achilles repair is reported, with the majority of these complications related to wound healing [5]. Pajala et al. retrospectively reviewed 409 patients treated in one facility for primary repair of a ruptured Achilles and found that there was a 2.2% incidence of deep infection [12]. When considering revision surgery following a re-ruptured Achilles tendon, there are many possible options, including: a V-Y tendon flap, augmentation with the peroneus longus, peroneus brevis, flexor digitorum longus (FDL), flexor halluces longus (FHL), gracillis, plantaris, fascia lata, allografts, and synthetic grafts [1]. When considering these options, one must also be mindful of the associated morbidity of transferring these tendons which have important functions in normal foot and ankle mechanics. The Achilles tendon has a naturally low blood supply and thus when deciding between options during a revision procedure, one must consider how the blood supply of the grafted tendon will be [1]. If using a donor tendon, it is important to choose a tendon that is in phase with the ruptured tendon, that will involve little morbidity from the transfer, and that is strong enough to do the work that will be required of it [10]. The FHL has had successful reported clinical results and is the current gold standard. It is a biologically intact tendon that is a strong plantarflexor, has a muscle belly that extends distally into the avascular zone of the Achilles (which leads to an increased blood supply to the repaired Achilles), and does not disrupt the normal muscle balance of the ankle [7, 9]. Though the FHL has been reported most successfully for chronic Achilles reconstruction, several recent reports exist that discuss the potential benefit of using a semitendinosus autograft, in isolation, to reconstruct chronic Achilles ruptures [3, 4, 8, 11]. Furthermore, two previous reports, both by Piontek et al., present two different techniques to reconstruct the Achilles tendon using both a semitendinosus and gracilis autograft [13, 14]. These authors advocate the use of a hamstring autograft due to the weakening of the foot and decrease in hallux flexion strength that is associated with FHL tendon transfers [3, 4, 8, 11, 13]. We report a case of a re-rupture with an infection of the Achilles tendon treated with a combination reconstruction using gracilis and semitendinosus transfer and augmented with an FHL transfer. We believe that this is the first report of a case of this nature.