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Fig. 8.18 (a) Percutaneous lengthening of the Achilles tendon-triple hemisection. Proposed cuts in tendon. From Sanders (1997) with permission from Elsevier Science, (b) Dorsiflexion of foot after triple hemisection.

hemisections of the tendon are performed, two medial and one lateral. The distance between the hemisections is determined by the overall size of the tendon and the amount of lengthening desired. An alternative procedure, attributed to Hoke, incorporates two posterior and one anterior hemisections of the Achilles tendon, and is performed in the frontal plane through a medial approach.

The patient is placed in a prone position on the operating room table. Local anaesthesia is infiltrated just above the Achilles tendon on the back of the leg. A tourniquet is not required for this procedure. The surgeon stands at the end of the operating table facing the foot, which hangs over the end of the table. The plantar surface of the foot is placed against the abdomen of the surgeon and gently dorsiflexed while palpating the Achilles tendon. A skin marker is used to define the borders of the tendon, from its insertion into the calcaneus, to its proximal myotendin-ous junction. The proposed cuts in the tendon are drawn on the skin, as shown in Fig. 8.18a. These marks help the surgeon to remember the direction of the cuts. The distal cut is made 1.0-2.5 cm superior to the tendon's insertion into the calcaneal tuberosity. A Beaver No. 64 mini-blade is introduced through the skin and tendon in a perpendicular manner, bisecting the tendon. The tendon is then lifted away from the leg, and the blade turned medially. Hemisection of the tendon is accomplished by gently working the blade against the tendon until its fibres are completely cut. When satisfactorily performed a gap can be palpated in the tendon. Avoid forcefully pushing the blade against the tendon as this may result in tenotomy, with rapid loss of resistance, followed by uncontrolled movement of the blade and subsequent laceration of the skin or the surgeon's finger. This procedure is repeated in the opposite direction, 2.5-4.0 cm more proximally, and then again 2.5-4.0 cm more proximal to the second cut. The foot is then firmly dorsiflexed to an angle greater than 90°, generally 5° above neutral (Fig. 8.18b). Overcorrection should be avoided, as this may lead to rupture of the tendon or a calcaneus deformity. The stab wounds are generally so small that they do not require sutures. However, if desired, a single interrupted 5-0 nylon suture can be used.

Dressings and postoperative care

Dressings consist of non-adherent fine mesh gauze (petrolatum, 3%Xeroform™ or Adaptic™), and dry sterile gauze dressing. A well-padded plaster splint is applied to immobilize the foot and ankle, and to maintain the ankle in approximately 5° of dorsiflexion. At the first dressing change, the patient is placed in either a short-leg walking cast or a walking brace for 6 weeks. The decision to cast or brace should be determined on an individual basis, based upon the surgeon's assessment of patient compliance.

Advantages

• Simple to perform

• Minimally invasive procedure

• Effective for relieving elevated forefoot plantar pressures. Disadvantages

• Over lengthening of the tendon can result in a calcaneus gait.

Complications

• Tendon rupture

• Development of a plantar heel ulcer

• In cases with moderate to severe shortening of the Achilles tendon, open lengthening of the tendon may be necessary.

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