a Departamento de Ortopedia, Santa Casa de São Paulo, São Paulo, SP, Brasil
b Serviço de Ortopedia e Traumatologia, Hospital Israelita Albert Einstein, Universidade Federal de São Paulo (Unifesp), São Paulo, SP,Brasil
c Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brasil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
Introduction
Use of the tendon of the semitendinosus muscle in kneeligament reconstruction surgery is well established in theliterature.1It is now also used as a treatment option for surgi-cal reconstruction of foot and ankle tendons.2,3
Foot and ankle tendon tears occur most frequently betweenthe third and fifth decades of life, although they canoccur at any age, with clear predominance of cases amongmen. It is believed that the frequency of these injuries ishigher nowadays because of better physical conditioning andincreased sports practice among middle-aged and elderlyindividuals. The etiology and treatment of these injuriescontinues to be a matter of controversy in the orthope-dic literature. Currently, there is no preferential treatmentmethod.
Among the options for surgical treatment, methods involv-ing primary suturing and reconstructions using the followingtendons have been cited: short fibular muscle,4,5long fibularmuscle,6gracilis muscle, long flexor muscle of the hallux7andsemitendinosus muscle.2,3
The aim of the present study was to evaluate the func-tional results obtained from treating patients who underwenttendon reconstruction surgery with a graft from the tendonof the semitendinosus muscle, emphasizing the incidence ofcomplications in the graft donor and recipient areas and thepatients' degree of satisfaction.
Materials and methods
Thirty-eight patients with a diagnosis of acute or degenera-tive foot or ankle tendon tears between 2006 and 2010 wereselected. Age, sex, tendon affected, type of injury and com-plications were analyzed. Patients with diabetes mellitus andvascular diseases were excluded. The mean length of follow-up was two years.
This study used the questionnaire of the AmericanOrthopaedic Foot and Ankle Society (AOFAS), which analyzesdata on pain, limitation of activities, need for support, walkingdistance and walking abnormalities, sagittal mobility, hind-foot mobility, ankle stability, hindfoot stability and hindfootalignment.
Results
Among the 38 patients selected, 27 presented injuries of thecalcaneal tendon and nine presented injuries of the anteriortibial tendon. In two cases, these injuries were associated withthe long extensor of the toes; in one case, with the long exten-sor of the hallux; and in one case, with both the long extensorof the toes and the long extensor of the hallux. One patientpresented injury to the fibular tendons (short and long) andone, injury to the tendon of the long extensor of the toes.
Three patients who underwent reconstruction of the cal-caneal tendon presented complications of the receptor area(7.8%): superficial skin necrosis, deep necrosis and dehiscenceof the scar. Only one patient presented complications of thedonor area (2.6%), which were reported as pain and insensitiv-ity. The reconstructions of the other tendons did not presentcomplications.
The clinical-functional results obtained through the AOFASscale after the operation were similar to those found in the lit-erature, with a mean of 90 points (variation from 81 to 92).8-10
The mean length of follow-up was two years.By the end of the study period, all of the patients hadresumed their recreational and professional activities withcomplete ranges of motion, except for two cases that evolvedunsatisfactorily (5%) (Table 1).
Discussion
The predominant age group in the present study was concord-ant with data in the literature. There were 28 patients agedbetween 30 and 50 years11and trauma was the main causeof the injuries. The tendon most affected was the calcanealtendon (71%).
Several options for tendon reconstructions in the foot andankle exist.2,4,6Use of the tendon of the semitendinosus mus-cle theoretically offers the following advantages: it is moreresistant than those previously used for transfers; it avoidscompromising of the tibial vascular-nervous bundle or mus-cles of the lateral compartment; and lastly, transferring thetendon of the semitendinosus muscle maintains the normalmuscle balance of the ankle. If the tendon of the short fibularmuscle is used for reconstruction of the calcaneal tendon,4,5
for example, an evertor is used to perform plantar flexion.This type of transfer is less functional, according to the ten-don transfer rules, and partial loss of eversion force can beobserved.
It should be noted that Mafulli et al.,2,3used transfers ofthe tendon of the semitendinosus muscle to repair injuries ofthe calcaneal tendon with a distance between the stumps ofgreater than 6 cm and obtained good results.
In our study, the percentage of complications (10.5%) wasless than what was described by Krueger-Frank et al. Althoughthe latter authors achieved good results from tendon recons-tructions, they had a higher complication rate (15.1%).12
12The importance of the tendon of the semitendinosusmuscle for walking, running or jumping is well known.Nonetheless, its use in knee ligament reconstruction is wellestablished and no functional losses in its absence areobserved.1
1Most of the patients presented excellent results and eventhose with results that were considered good were able to toreturn to their activities without restrictions. The latter werethus classified only because of complications relating to theoperative wound. No repetitions of tears in the reconstructedtendons were observed during the follow-up period.
Conclusion
In cases of foot or ankle tendon tears, functional restorationcan be achieved by means of reconstruction using the ten-don of the semitendinosus muscle. This technique presentsadvantages in relation to others described previously in theliterature. Most of the patients presented excellent or goodresults.
Conflicts of interest
The authors declare no conflicts of interest.
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