Neglected Rupture of the Achilles Tendon Treated With Peroneus Brevis Transfer: A Functional Assessment of 5 Cases Mladen Miskulin, 1 Andrea Miškulin, 2 Hrvoje Klobucˇ ar, 3 and Slobodan Kuvalja 4 The purpose of this study was to review the clinical results of 5 patients who underwent repair of a chronic Achilles tendon rupture using a combination of peroneus brevis transfer and plantaris tendon augmentation. The technique belongs to the group of local tendon transfer procedures making use of the transferred peroneus brevis tendon as strengthening material together with the plantaris tendon as suturing material. There were 4 males and 1 female with an average age of 49.4 years and an average time to presentation postinjury of 19.8 weeks (range 5– 40 wk). All patients underwent Cybex strength testing before and approximately 1 year after surgery. This testing demonstrated a postoperative improvement in peak plantarflexion torque (Newton-meters/body weight) in all cases. The peak torque of plantar flexion increased in all patients (range, 21%– 410%). Four patients were found to have an increase of the dorsal flexors peak torque (range, 31%–290%), whereas one patient showed a decrease (37%). No patient experienced wound closure complications, postoperative pain, or functional limitations. In spite the possibility of residual lateral ankle instability, we found this modification to be a valuable innovation that offers a very good functional result, low morbidity, technical advantages to the surgeon and, most important, a durable and satisfactory result for the patients. ( The Journal of Foot & Ankle Surgery 44(1): 49-56, 2005) Key words: Achilles tendon, neglected rupture, peroneus brevis transfer, plantaris transfer, Cybex isokinetic test T he neglected Achilles tendon rupture refers to a rupture with a delay in diagnosis or treatment of more than than 4 weeks after injury (1). Most authors agree that surgical treatment offers better functional results than conservative measures for these patients (1–20). However, reconstruction of these cases has always been a challenge for surgeons because of the large tendon defect and the many technical difficulties involved in achieving a successful result. Major procedural concerns include tendon retraction, scar tissue bridging the gap, disturbed blood supply following certain procedures (such as the V-Y tendinous flap), and potential wound closure problems (2, 4, 21–25). The surgeon is therefore faced with the difficult decision as to which of the many proposed treatments would best serve the patient. Several surgical methods of treatment have been described and can be divided into 5 major groups: local tissue augmentation with plantaris tendon; V-Y ad- vancement; local tendon transfer (peroneus brevis, flexor digitorum longus, flexor hallucis longus); free tissue trans- fer (fascia lata, free flaps, patellar bone tendon grafts, allo- grafts); and use of synthetic materials such as Dacron vas- cular grafts (Invista, Wichita, KS), carbon fiber composites, proteoglycol threads, or Marlex mesh (Davol, Cranston, RI) (4 –12, 14 –16, 18 –20, 23, 26). Historically, peroneus brevis transfer was proposed as a surgical treatment for the acute Achilles tendon rupture by Teuffer in 1974 (7). Using a similar procedure, Hepp and Blauth (22) confirmed good to excellent results, especially in the difficult cases with large defects and unfavorable anatomic conditions. Turco and Spinella (8) reported results of the direct end-to-end suture of the ruptured Achilles tendon combined with the transfer of the peroneus brevis, passing it through a calcaneal drill hole. The results were satisfactory, but many procedures were performed on the patients who had acute rupture or chronic rupture with little diastasis of tendon ends (27). In recent years, results of the various reconstruction pro- cedures were evaluated, not only by physical examination but also by objective methods—instrumented strength test- ing using Cybex isokinetic dynamometer (Cybex Interna- tional, Inc, Medway, MA) and gait analysis (2, 27–33). We are unaware of any studies that have documented the results of the peroneus brevis transfer procedure. Therefore, the Address correspondence to: Mladen Miskulin, Zelengaj 45 c, 10000 Zagreb, Croatia. E-mail: mladen.miskulin@zg.hinet.hr 1 Sveti Duh Hospital, Zagreb, Croatia. 2 Etela Rehabilitation Center, Zagreb, Croatia. 3 Orthopaedic Department, University of Zagreb, Zagreb, Croatia. 4 Cybex Center, Zagreb, Croatia Copyright © 2005 by the American College of Foot and Ankle Surgeons 1067-2516/05/4401-0008$30.00/0 doi:10.1016/j.jfas.2004.11.003 VOLUME 44, NUMBER 1, JANUARY/FEBRUARY 2005 49