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Tips and Techniques: Conical Shaping of Structural Allografts for Bone Block Arthrodesis in Failed First Metatarsophalangeal Joint Arthroplasty

by Ronald Belczyk, DPM 1 , Damon Combs, DPM 2, Dane K. Wukich, MD 3

The Foot & Ankle Journal 1 (8): 4

The purpose of this article is to report on a technical tip when performing bone block arthrodesis following failed first metatarsophalangeal arthroplasty. Conical reaming of structural allografts permits proper toe positioning, is reproducible, and has a high rate of fusion.

Key words: Bone block arthrodesis, foot surgery revision, first MPJ fusion

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: July 2008
Published: August 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0108.0004

The use of structural autograft is commonly used in revision first metatarsophalangeal fusion. [1] This article reports a case of a failed metatarsophalangeal arthroplasty and provides a technique by which structural allograft can be prepared with conical reamers to fill a substantial osseous defect created during revision surgical intervention. Radiographs of a healthy 60 year old patient suffering from a painful total joint arthroplasty are shown in Figures 1.


Figures 1   AP and Lateral radiographs of the left foot demonstrating first metatarsophalangeal arthroplasty. The stem of the phalanx prosthesis is partially outside the posterior cortex of the phalanx. The implant was removed to due to pain and instability from the implant.

During revisional surgery of the first metatarsophalangeal joint, a defect is created from both the removal of the implant and preparation of the osseous surfaces. Preoperatively, the void can be estimated by measuring the distance from the proximal and distal bone segments.

The anticipated defect can be filled with an interpositional bone graft. Some considerations with this type of surgery include not only restoring length but also maintaining alignment and providing structural stability. Preparation of an interpositional bone graft is often fashioned in a rectangular or peg- in- hole fashion, but these techniques may limit proper alignment or surface contact area between the bone graft and adjacent bony fragments. Conical reaming of the graft allows for more degrees of motion for toe positioning, is reproducible, and has a higher rate of fusion. [2,3] Traditionally, non-contained defects that require structural graft have been filled with corticocancellous autograft harvested from the iliac crest.

However, there is significant morbidity at the donor site associated with this procedure such as bleeding, infection, nerve injury, and fracture. The use of structural allograft is helpful because there is an unlimited supply, has prolonged storage capacity, and is available in many sizes and shapes. Structural allograft can be obtained from cadaveric iliac crest, femoral head, or fibula. The use of allograft has been documented in tumor surgery and long term studies show no statistically significant difference in the morphology of repair between autograft and allograft. [4,5]

Surgical Technique

Full thickness skin flaps are created over the first metatarsophalangeal joint and the implant is then removed. Proper joint debridement is obtained by removing any fibrous tissue and resecting the proximal and distal bony segments down to bleeding bone edges with the reamer. This is frequently referred to as the paprika sign. If deep infection is suspected but no obvious purulence is visible, soft tissue can be sent for a frozen section. In the absence of neutrophils under high powered field, definitive surgery can be performed safely. The proximal and distal bony segments are resurfaced in the shape of a cup. Figure 2 illustrates how this is performed.

Figure 2 Conical reaming of the structural bone.

A structural allograft of appropriate length can then be obtained. The case presented in this article utilized cadaveric iliac crest. This graft is then fashioned using cup and cone reamers. The graft can then be inserted and the toe properly aligned in the saggittal, frontal and transverse planes. Figures 3 and 4 show how this graft is properly fit and temporary fixated on a corticocancellous saw bone model.

Figure 3  Lateral view of a conically reamed structural bone graft on a corticocancellous saw bone model.

Figure 4 Plantar view of a conically reamed structural bone graft on a corticocancellous saw bone model.

Fixation can then be obtained using a 1/3 tubular plate or locking plate system, preferable placed on the dorsal surface. Postoperatively, the limb is kept unloaded for eight weeks and then partial weight bearing with cast immobilization until radiographic consolidation is present at both graft interfaces. Figures 5 and 6 demonstrate clinical and radiographic appearance of our patient at one year follow-up. In summary, this clinical tip can be useful for the foot and ankle surgeon specializing in revisional surgery.


Figures 5   AP and lateral radiographs of a left foot one year following first metatarsophalangeal fusion using iliac crest allograft that was fashioned with a cup and cone configuration.


Figures 6  Clinical pictures one year following first metatarsophalangeal fusion with interpositional bone graft with iliac crest allograft.

This technique limits morbidity at the donor site and has been used successfully in restoring length, maintaining alignment, and providing structural stability of defects created with this type of surgery.


1. Neufeld S, Uribe J, Myerson M., Use of structural allograft to compensate for bone loss in arthrodesis of the foot and ankle Foot and Ankle Clinics, 7: p. 1-17, 2002.
2. Herr M, Kile T., First Metatarsophalangeal Joint Arthrodesis with Conical Reaming and Crossed Dual Compression with Screw Fixations Techniques in Foot and Ankle Surgery, 4(2): p. 85-94, 2005.
3. Yu G, Gorby P., First metatarsophalangeal joint arthrodesis Clin Podiatr Med Surg, 21:p.65-96, 2004.
4. Goldberg VM, Stevenson S., Natural history of autografts and allografts. Clin Orthop, 225:p.7-16, 1987.
5. Reynolds FC, Oliver DR., Experimental evaluation of homogenous bone grafts. J Bone Joint Surg Am, 32:p.283-297, 1950.

Address correspondence to: Dane Wukich, MD. UPMC Comprehensive Foot and Ankle Center. Roesch-Taylor Bldg Ste 7300. 2100 Jane St. Pittsburgh, PA 15203. Phone: 412-586-1546 Fax: 412-586-1544
Email: wukichdk@upmc.edu

1 PGY-4, Fellow, Foot and Ankle Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15203.
2 Resident, Foot and Ankle Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15203.
3 Chief, Foot and Ankle Division, University of Pittsburgh Medical Center Department of Orthopedic Surgery and Assistant Professor, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 15203.

© The Foot & Ankle Journal, 2008

The BRAIN Principle: Managing Wounds After Application of Bioengineered Alternative Tissues to Maximize Incorporation and Wound Healing

by Jonathan Moore, DPM, MS1

The Foot & Ankle Journal 1 (5): 3

The efficacy of bioengineered alternative tissue (BAT) for lower extremity ulcers (diabetic and non-diabetic) is well described in the literature. What is not present in the literature is a concise description of how to manage these fragile biological tissues after application. This paper introduces the BRAIN principle for adjuvant management of wounds after application of bioengineered alternative tissues. Based on the experience of the author, utilizing the principles found in the BRAIN protocol have not only demonstrated improved BAT incorporation rates, it also increased the rate of wound closure.

Key words: Diabetic wounds, bioengineered alternative tissues, wound healing

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org

Accepted: April 1, 2008
Published: May 1, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0105.0003

Bioengineered Alternative Tissues (BAT’s) have revolutionized the science of wound healing. These new technologies offer the wound care specialist an important tool in the battle to prevent nearly 90,000 amputations that occur annually among diabetic patients. [7] However, this technology is of little value when not used as a part of a comprehensive approach to wound healing. This includes assessing nutrition, metabolic status, vascular status, off loading options, and choosing the right wound healing product.

As new bioengeenered alternative tissue products enter the market it is important to consider patient expectations and treat the patient with the best product available for their specific wound. While there are procedures described for many of the better-known BAT’s on the market, they differ in many respects. The table in the study demonstrates the differing protocols for “after-care” following applications of these products. (Table 1)

Table 1 Application and Aftercare Instructions to Providers from the Manufacturer.

Choosing the right BAT along with the appropriate topical wound care agent is critical not only to improve healing times, but to also lower costs.

It has been estimated that 15 to 20 percent of individuals with diabetes will suffer from lower extremity ulceration during their lifetime. [8] Furthermore, half of the diabetic patients who have had a leg amputated will loose the other leg in three to five years. In 1997 it was estimated that total costs for both direct and indirect health care for the persons with diabetes was $98 billion. Of this total, direct medical costs including hospitalization, medical care, and dressing supplies, accounts for $44.1 billion. [9] What is more startling is the annual $5 billion dollar price tag estimated for the cost of dressings for these conditions. With the increased cost of wound care, the wound care specialist should consider using protocols that not only maximize wound healing, but also minimize the risk of BAT failure by providing the best tools to maintain the optimum environment for the wound.

While it is not the purpose of this paper to review every type of BAT on the market, it is vital to understand the characteristics of these products in order to understand how they work and how they should be adjunctively managed after application.

For purposes of defining terms, BAT’s are products that have been produced artificially or modified in some way that alters the biology and its interaction with the wound bed with the goal of creating an optimal environment to stimulate healing.

These tissues include both allograft, xenografts and manufactured/engineered biologic products like Apligraf® (Organogenesis, Inc., Canton, MA). The purpose of these tissues has been well established in the medical literature. However, the primary goal in using a BAT is to stimulate granulation of a chronic wound and augment the wound’s intrinsic healing pathway, thus creating a bridge to epithelialization of the wound.

The literature has well described the process of preparing the wound bed for application of a BAT. The TIME acronym as proposed by the International Wound Bed Preparation Advisory Board provides an exceptional framework for the physician to improve the opportunity for wounds to heal. The TIME principle in essence describes an approach to remove the barriers to the wound-healing process in order to optimize wound repair and healing. Removal of these barriers will not only help to establish a well-vascularized wound bed, but they will also be vital for the incorporation and success of a BAT. (Table 2). [10]

Table 2   International Wound Bed Preparation Advisory Board – TIME principles.

While the principles of TIME described above remains important a new set of principles are needed to assure the BAT has the best chance of incorporation and healing the wound in a timely manner.

Thus, the following acronym called BRAIN is proposed. (Table 3)

Table 3   The BRAIN principles to maximize BAT incorporation and wound healing.

The BRAIN Principle

B (Bioburden)

Despite having properly prepared the wound bed before application of the bioengineered tissue through debridement, among other modalities, maintenance of the bioburden after BAT application remains important. Non-cytotoxic antimicrobials should be considered to prevent colonization after application of bioengineered tissues.

Proper assessment to the needs of the wound is vital after application of the BAT in order to reduce the chances of infection. In the event of a clinical infection of a chronic wound, aggressive treatment is recommended to prevent limb loss. The following are recommendations that should be considered after application of a BAT for the prevention of infection:

1. Sharp debridement is the fundamental component in preparing the chronic wound for the BAT, whether it is an allograft or a bioengineered skin equivalent, like Apligraf®. Sharp debridement too early after application of the BAT may result in destruction of the bioengineered tissue or disruption of the materials the BAT was able to establish in the wound bed. Debridement post BAT application should only be considered if there is necrotic or infected tissue present.

2. Application of a topical antimicrobial agent for use on the wound bed prior to application of the BAT (at least 2 weeks prior), in order to decrease bacterial colonization, should be considered for both cellular engineered tissues and allografts. Use of a silver containing antimicrobial agent, as a part of wound bed preparation should not be a problem, as the silver will be inactivated by wound fluid among other wound components. Application of a topical antimicrobial agent post application of a BAT remains controversial

Living skin equivalents like Apligraf® should not be used in conjunction with any silver-based topical antimicrobial agent as these can be, at certain levels, cytotoxic to keratinocytes and fibroblasts.11 While there is debate about other types of topical agents used on or with a living skin equivalent like Apligraf®, I have used Bacitracin ointment as well as AmeriGel®

Hydrogel Saturated Gauze Dressing (Amerx Health Care Corporation, Clearwater, FL) pre and post application of Apligraf® pose no adverse clinical effects. Agents that are known to be cytotoxic to living skin equivalents include: Dakin’s solution, Mafenide Acetate, Scarlet Red Dressing, Tincoban, Zinc Sulfate, Povidone-iodine solution, Polymyxin/Nystatin and Chlorhexidine.

3. Care must be taken to control swelling and edema with careful compression over the BAT site taking care not to compromise circulation. Edema can significantly compromise wound healing and incorporation of the BAT.

4. Systemic antibiotics should be considered in the presence of malodorous drainage, friable necrotic tissue, increased levels of wound exudate, increasing pain, surrounding cellulitis, crepitus, necrosis and lymphadenopathy. Fever, chills, malaise, leukocytosis, and an elevated erythrocyte sedimentation rate are also common systemic manifestations of wound infection. Superficial contaminants are not always representative of the wound status, as healing wounds will have some contamination. Macerated tissue culture or curettage is a reliable way to determine the etiology of a serious wound infection. Infected wounds will typically respond to aggressive debridement with appropriate systemic antibiotic therapy. Indiscriminate use of oral antibiotics will not decrease infection rates, but can result in resistance. Gram-negative bacterial infections can be severe and need to be treated aggressively. [12]

R (Reduction of pressure and shear force)

In order for incorporation of the BAT to take place in the chronic wound, excess pressure, motion and shearing must be eliminated. Unless the bioengineered tissue maintains adherence to the wound bed with proper pressure redistribution, BAT incorporation will fail. The medical literature is replete with articles that stress the importance of offloading during wound healing. [13]

Although there are many devices on the market that can be employed to remove plantar pressure {Bledsoe® Walker (Bledsoe Brace Systems, Grand Prairie, TX), DH Walker® (Royce Medical, Inc., Camarillo, CA) or total contact casting}, care must further be taken when applying the BAT to the wound site.

Although most BAT manufacturers recommend some type of anchoring of the bioengineered tissue to the wound (i.e. sutures, staples, etc.), specific protocols are lacking. The following are recommendations to consider for the development of your protocols:

1. Determine the best and the most secure application method based upon the quality of the tissues and the location of the BAT. Plantar pressures will deteriorate the BAT unless properly offloaded and secured. With dorsal wounds, anything creating pressure or shear over the site will also result in the failure of the BAT.

2. Although suturing the BAT to the wound bed is ideal, in cases of severe tissue atrophy or poor skin perfusion, Steri-Strips™ (3M, St Paul, MN) should be considered to prevent worsening of the wound site.

3. If sutures or staples are employed, be careful to make sure the bioengineered tissue has been adequately fenestrated in order to prevent hematoma or seroma formation under the BAT.

4. Plantar ulcers MUST be offloaded in order for the BAT to incorporate. Ideally, no pressure should be applied to the wound site, if possible. Surgical shoes with a Velcro®(Velcro Industries B.V., Manchester, NH) latch should be considered for dorsal foot wounds in order to prevent rubbing or shearing forces.

5. Regular shoes, flip-flops or any like footwear are contraindicated after application of any BAT and should NOT be employed.

A (Adapting to the moisture needs of the wound and the bioengineered tissue.)

Any BAT must stay hydrated in order to achieve wound incorporation. Early desiccation of the wound bed and the surrounding tissues will ultimately lead to BAT failure and subsequent slower healing times. The concept of keeping wounds moist in order to accelerate wound healing has been known now for over 50 years. [14,15] Contrary to conventional wisdom, keeping the wound site and the BAT moist does not increase the risk of infection. In fact, a moist wound environment has been shown to improve wound healing by up to 50% compared with exposure to air. [16]

Many factors will determine the amount of wound fluid present in the wound bed. Venous ulcers, for instance, are more likely to produce more moisture than an ulcer on the top of the foot. Close assessment of the moisture balance in the wound is critical for the success of the BAT. Fluid from chronic wounds will block cellular proliferation and angiogenesis, and will ultimately impair wound healing through the build up of excessive amounts of matrix metalloproteinases (MMPs) that break down critical matrix proteins. [17]

The dressing choice after the application of the BAT to the wound site is vital in order to properly adapt to the moisture needs of the wound. Here are some considerations:

1. Upon review of many bioengineered tissue dressing protocols, as provided by the manufacturers of the top BAT’s on the market, regular gauze is recommended as a secondary dressing in nearly all. (Table 1) Although the purpose of the gauze is understood to provide some level of absorption of drainage from the wound, this concept is not ideal for several reasons. No matter how much hydrogel or mineral oil you use under a regular piece of dry gauze, most of this will be absorbed by the gauze and thus provide minimal moisture to the wound bed over time.

Regular gauze alone, even with a nonadherent dressing of some sort, cannot provide consistent and long lasting moisture to the wound site. Hydrogels and hydrogel impregnated gauzes formulated with substrates allowing for longer and controlled moisture balance reduces the incidence of adhesion to the BAT and wound site. Saline or glycerin-based hydrogels or hydrogel impregnated gauzes frequently result in premature desiccation and should be avoided.

2. In those cases where excessive wound fluid is evident, more frequent dressing changes is recommended.

3. In cases of severe exudate and draining from the wound site, the presence of infection needs to be addressed and antibiotics should be prescribed.

4. The ideal wound dressing will remove the excess amounts of wound exudates while retaining a moist environment that accelerates wound healing.

Keep in mind that healing wounds are always characterized by high mitogenic activity, low inflammatory cytokines (less chronic wound fluid), low proteases, mitotically competent cells and a moist environment.

I ( Incorporation and Identification)

Successful incorporation of a BAT hinges upon the molecular environment of the wound. Incorporation of the acellular BAT into the wound bed through a collagen matrix allows for the recruitment of cells into the wound and facilitates the induction and expression of growth factors and cytokines necessary for wound healing. The balance between collagen degradation and synthesis can be disrupted by disease states like diabetes. This can result in defective collagen metabolism and disrupted wound healing.

In contrast, cellular BAT’s are designed to accelerate tissue regeneration by stimulating the recipient’s own wound bed derived skin cells. [18,19] Some authors have called the BAT an interactive “drug” delivery system by the transfer of MMPs and cytokines from the BAT into the wound. [20] Acellular BAT’s work by effectively providing a cover for the wound that prohibits desiccation and fluid loss within the wound, thus decreasing the bacterial burden and promoting angiogenesis and allowing vascular ingrowth into the dermal layer of the allograft.

Identification and correction of factors that can cause tissue damage is essential after application of a BAT. Keep in mind that cellular bioengineered alternative tissues work by biochemically balancing the wound environment to promote tissue regeneration. This provides the “primordial soup” of mediators and growth factors. [21]

Among the many things that can impair wound healing (systemic steroids, non-steroidal anti-inflammatories, immunosuppressive drugs), several other factors must be recognized:

1. Localized edema from venous insufficiency or lymphedema must be addressed before and after application of a BAT. Compression therapy or a referral to a certified lymphedema specialist should be considered.

2. Low albumin can have a significant impact on wound healing. A deficiency in serum albumin, which accounts for more than 50% of total serum proteins, impairs the inflammatory and proliferative stages of wound healing while also decreasing wound perfusion.22 A dietary or nutritional consult should be ordered to maximize the body’s own potential to heal.

3. Autonomic Neuropathy resulting in over drying of the wound and surrounding tissues will impair wound healing in many ways. Desiccation within the wound site will slow epithelial cell migration and thus prevent the incorporation of the BAT.

4. Infection within the wound site can present many challenges to the incorporation of the BAT. Infection must be treated without delay through either debridement, antibiotics, wound cleansing, or wound disinfection.

5. Hyperglycemia must be addressed in order to have successful incorporation of the BAT. Although the wound care specialist may not be able to directly influence this factor, all efforts need to be made to communicate with the primary care provider and patient to gain better control the patient’s blood sugar. Behavior modification regarding diet and exercise is always an immense challenge in the diabetic population. [23]

N ( Nonadherent Dressing)

It has been said that the choice of the wound dressing at one stage of the wound may well influence subsequent events in the later phases of healing. [24] In reviewing the protocols set forth by most BAT manufacturers, the one common denominator among all of them is the recommendation of a “nonadherent dressing” as the primary dressing to be used over the bioengineered tissue. (Table 1)

While the goal of the nonadherent dressing is to prevent trauma or adhesion of the secondary dressing to the BAT (or underlying tissues), few of these products possess the characteristics ideal for covering a bioengineered tissue. While it is possible for several different types of dressings to be employed over the BAT at once (i.e. petrolatum impregnated gauze, antibiotic cream, hydrogel, mineral oil followed by an absorptive 4” X 4” pad or a foam), this is impractical and expensive.

Ideal Characteristics of the Primary Dressing for Coverage over a BAT:

1. Nonadhesive
2. Antimicrobial
3. Ability to absorb exudate
4. Maintains moisture on the BAT and within the wound site
5. Non-cytotoxic
6. Cost-effective

Of the myriad of different dressing options available that meet some of the criteria mentioned above, the AmeriGel® Hydrogel Saturated Gauze Dressing is an excellent option that meets most if not all of the characteristics above.

Case Example using the BRAIN Principal

A 47 year-old diabetic patient with profound peripheral neuropathy developed a blister on the plantar aspect of her right heel that became recalcitrant to conservative treatment. The patient’s wound was debrided weekly and had Promogran™ (Johnson & Johnson Wound Management, Somerville, NJ) applied to the site until the wound developed a healthy granular base. Apligraf® was chosen to close the wound, secured in place by Steri-Strips™. AmeriGel® Hydrogel Saturated Gauze Dressing covered the BAT to provide an antimicrobial barrier. A dry sterile secondary dressing was then applied. The bioburden of the BRAIN principle had been accomplished. (Fig. 1)

Figure 1  The Bioburden of the wound has been addressed with debridement and diligent local wound care.

To achieve the reduction of pressure and shear force, a Bledsoe® boot was utilized along with a wheel chair. Due to the patient’s severe neuropathy, as well as other balance concerns, the patient could not use crutches. The primary and secondary dressings remained dry and intact for one week. (Fig. 2)

Figure 2  Reduction of pressure and shear force is essential for incorporation of the BAT.

Once the AmeriGel® Hydrogel Saturated Gauze Dressing was removed, the absorptive capability was evident as well as its ability to maintain a moist wound environment. (Fig. 3) This demonstrates adapting to the moisture needs of the BAT and of the wound.

Figure 3  Adapting to the moisture needs of the wound.  Here, a healthy moisture balance has been achieved using AmeriGel® Hydrogel Saturated Gauze Dressing after BAT application.

The patient returned at two weeks and Incorporation was achieved. The wound had already started to reduce in size and was considered to be a healthy granulating wound. There was no evidence of bleeding or absence of tissue caused by traumatic dressing changes. (Fig. 4)

Figure 4  Incorporation of the Apligraf®.  Reduction of wound size is already appreciated.

At 4 weeks and 4 days, after daily applications of the AmeriGel® Hydrogel Saturated Gauze Dressing and dry sterile gauze as the secondary dressing, the wound was healed.

The nonadherent secondary dressing played a significant role in healing this wound quickly and without the need for subsequent applications of the BAT. (Fig. 5)

Figure 5  Nonadherence of the surrounding secondary dressings will help ensure the viability of the BAT.  Using the AmeriGel® Hydrogel Saturated Gauze Dressing as a secondary dressing provides a non adherent and antimicrobial barrier to facilitate rapid wound healing.


Effective management of lower extremity ulcerations using bioengineered alternative tissues requires a multidisciplinary approach, patient involvement and the right use of the proper adjunctive tools available to the wound care specialist.

Diabetic foot ulceration is a limb and life threatening condition that requires the establishment of sound, evidence-based protocols. It is the hope of the author that protocols be established in every wound care clinic that are based upon patient outcomes, cost and ease of use for the wound care specialist and the patient.

A protocol as described above certainly may be modified depending on many factors that may or may not be present in the wound, however the core principles as presented in the acronym BRAIN should provide a road map to maximizing the effectiveness of bioengineered tissues before, during and after BAT application.


1. Kim PJ, Dybowski KS, Steinberg JS. A Closer Look at Bioengineered Alternative Tissues. Podiatry Today – ISSN: 1045-7860 – Volume 19 – Issue 7 – Pages: 38 – 55, July 2006.
2. Pham HT, Rich J, Veves A, Using Living Skin Equivalents for Diabetic Foot Ulceration: Lower Extremity Wound 1(1);27-32, 2002.
3. Falanga V, Sabolinski M. A bilayered living skin equivalent construct (Apligraf) accelerates complete closure of hard to heal venous ulcers. Wound Repair Regen 7:201-7, 1999.
4. Bello YM, Falabella AF, Eaglstein WH. Tissue-engineered skin, current status in wound healing. Am J. Clin Dermatol 2(5):303-313, 2001.
5. Claxton MJ, Armstrong DG, Boulton AJM. Healing the diabetic wound and keeping it healed: modalities for the early 21st century. Cur Diab Rep. 2(6):510-8, Dec 2002.
6. Lee KH. Tissue-engineered human skin substitutes; development and clinical application. Yonsei Medical Journal 41(6):774-779, 2000.
7. Reiber GE: Epidemiology and health care costs of diabetic foot problems. From: The Diabetic Foot: Medical and Surgical Management, edited by Veves A, Giurini JM, LoGerfo FW, Humana Press, Totowa NJ, 2002
8. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Diabetes in America, Second Edition. Washington, DC: National Diabetes Data Group, National Institutes of Health, 409-28, 1995.
9. American Diabetes Association. Economic consequences of diabetes mellitus in the U.S.in 1997. Diabetes Care 21:296–309, 1998.
10. Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, Sibbald D, Preparing the Wound Bed-Debridement, Bacterial Balance and Moisture Balance. Ostomy Wound Mgt 46: 14-35, 2000.
11. Poon, VKM, Burd A. In vitro cytoxicity of silver: Implications for clinical Wound Care. Burns 30: 140-147, 2004.
12. Edmonds, ME, Foster AM, Sanders L A. Practical Manual of Diabetic Footcare. Oxford: Blackwell Publishing, 2004.
13. Armstrong, DG, Ngugen, HC, Lavery LA, et al. Offloading the diabetic foot wound: a randomized clinical trial. Diabetes Care 24:1019-1022, 2001.
14. Winter GD: Formation of scab and rate of epithelialization of superficial wounds in the skin of the young domestic pig. Nature 193:293-294, 1962.
15. Haimowitz JE, Margolis DJ: Moist wound healing, in Krasner D, Kane D (eds): Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Wayne, PA, Health Management Publications, 49-55, 1997.
16. Geronemus RG, Robin P. The effect of two new dressings on epidermal wound healing. J Derm Surg Oncol 8:850-2, 1982.
17. Bucalo B, Eaglstein WH, Falanga V. Inhibition of cell proliferation by chronic wound fluid. Wound Rep Reg 1:181-6, 1993.
18. Coulomb B, Dubertret L. Skin cell culture and wound healing. Wound Repair Regen 10:109-12, 2002.
19. Rosales MA, Bruntz M, Armstrong DG. Gamma-irradiated human skin allograft; a potential treatment modality for lower extremity ulcers. Int. Wound J 1:201-206, 2004.
20. Shen JT, Falanga V. Innovative therapies in wound healing. J Cutan Med Surg 7(3):217-24, May-Jun 2003.
21. Eisenbud D. Huang, NF, Luke S. Silberklang M. Skin Substitutes and Wound Healing: Current Status and Challenges. Wounds 16(1): 2-17, 2004.
22. Sussman C, Bates-Jensen B. Wound healing biology and chronic wound healing. In: Wound Care- A Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, Md.: Aspen Publication 49–82, 1998.
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24. Kerstein MD. The scientific basis of healing. Adv Wound Care 10:30-6, 1997.

Address correspondence to: Jonathan Moore, DPM, MS, Cumberland Foot & Ankle Center. 117 Tradepark Drive, Somerset, KY 42503

1Cumberland Foot & Ankle Center. 117 Tradepark Drive, Somerset, KY 42503.

© The Foot & Ankle Journal, 2008

Repair of Nelgected Achilles Tendon Rupture with Monofilament Polypropylene Mesh: A Case Study of 12 Patients

by Robert Fridman, DPM, AACFAS1, Fred Rahimi, DPM, FACFAS2, Paul Lucas, DPM, FACFAS3, Rob Daugherty, DPM, AACFAS4, Heidi Hoffmann, DPM5

The Foot & Ankle Journal 1 (5): 2

The purpose of this study is to evaluate the effectiveness of polypropylene mesh as an alternative to autogenous grafts and/or tendon transfers for neglected Achilles tendon rupture. Twelve patients with neglected Achilles tendon rupture underwent surgical repair using monofilament polypropylene mesh graft from 1999-2003. The average follow-up was 1.5 years. All patients were placed in a non-weight bearing, below-knee cast for 3 weeks, followed by 3 weeks of partial weight bearing in walking boot. All patients healed uneventfully, with three patients complaining of mild pain, one of moderate pain, and five with stiffness that resolved with physical therapy. The adjunctive use of monofilament polypropylene mesh is an appropriate method for the treatment of neglected Achilles tendon ruptures.

Key words: Achilles Tendon Rupture, Achilles Tendon Repair, Marlex ® Mesh

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org

Accepted: April 1, 2008
Published: May 1, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0105.0002

Degeneration, tendon contracture, and a high re-rupture rate are frequent sources of failure in non-operative treatment of neglected Achilles tendon ruptures. [1] Bosworth previously noted that retraction of the gastrocnemius-soleus complex may occur within three days of injury, making re-approximation of the tendon ends difficult. [2] Current clinical practice supports surgical repair of the tendon in this condition. End-to-end [3], percutaneous [4] and limited-open repairs [5] may not be as effective in neglected ruptures due to excessive tendon contracture and degeneration of the tendon ends.

Therefore, tendon augmentation is routinely employed in cases of neglected rupture. The flexor hallucis longus tendon is most commonly used to augment reconstruction. [6,7,8] Mann and others described using the tendon of the flexor digitorum longus as a graft. [9] Fascia lata, [10] peroneus brevis, [11] gracilis, [12] and plantaris [13] tendon grafts have also been described in the literature.
Synthetic grafts may also be used to augment the surgical repair in situations where surrounding autogenous tissues are weak or unable to span the defect. The advantages of synthetic grafts over autogenous grafts include absent donor site morbidity and unlimited material available for sizable defects.

A distinct disadvantage of synthetic grafts is possible foreign body reaction after implantation. Dacron® vascular graft, [14] carbon fiber composites, [15] collagen tendon prosthesis, [16] and GraftJacket® [17] have all been described as alternatives to autogenous grafts. Ozaki, et al, reported that polypropylene mesh had little to no tissue reaction when implanted during rotator cuff repair [18] and subsequently used this material for repair of Achilles tendon with satisfactory results. [19] This case study reports on a series of neglected Achilles ruptures repaired with Marlex ® polypropylene mesh.

Materials and Methods

Twelve patients with neglected Achilles tendon rupture were treated surgically by the same surgeon using Marlex ® polypropylene mesh (Davol Inc., Rhode Island, USA) as described by Ozaki, et al. The diagnosis of neglected Achilles tendon rupture was based on history, clinical and MRI findings.

Neglected tears were defined as a closed rupture of 10 or more days duration without previous surgical treatment for the affected tendon. MRI findings were all indicitive for complete rupture of the Achilles tendon with fatty degeneration. (Fig.1)

Figure 1  MRI of neglected rupture of Achilles tendon shows significant gapping and degeneration of tendon ends.

The average patient age was 52.5 years (range = 31 to 70 years). There were 8 males and 4 females included in the study, with an average follow-up period of 1.5 years (range = 0.5 – 4 years). Table 1 summarizes the demographic data.

TABLE 1  Demographics of 12 patients with neglected Achilles tendon rupture.

Patients were either contacted by telephone or interviewed in the clinic. A modified VISA-A Questionnaire was used for clinical evaluation.20 (Table 2)

TABLE 2  The modified VISA-A (Victorian Institute of Sport Assessment-Achilles) Questionnaire.

Surgical Procedure

The procedure is performed under general anesthesia with a pneumatic thigh tourniquet. Both lower extremities are prepped and draped, so as to have an appropriate reference point when tensioning the repaired tendon. Prophylactic antibiotics are given prior to inflating the tourniquet. The patient is positioned prone and local anesthetic is infiltrated into the surgical site. A posteromedial incision is made along the Achilles tendon extending proximally and distally past the defect (Fig. 2).

Figure 2   A posteromedial incision is made along the Achilles tendon extending proximally and distally past the defect.

The sural nerve is retracted laterally, and the paratenon is incised and tagged for later closure. The ruptured ends of the tendon are identified, and fibrotic and/or degenerated tendon is excised (Fig. 3).

Figure 3   The ruptured ends of the tendon are identified and degenerated tendon is removed.

The tendon ends are prepared for insertion into the mesh graft by incising the tendon 2-3 cm in the frontal plane. The mesh is prepared by tri-folding it to a slightly smaller width than the tendon itself. The folds are secured with 3-0 non-absorbable suture (Fig. 4).

Figure 4  The mesh is prepared by folding it 3 times to a slightly smaller width than the tendon itself.  The folds are secured with 3-0 non-absorbable suture.

To assess the length of graft, the gastrocnemius-soleus complex is pulled distally and then compared to the resting tension of the contralateral limb. The mesh is then measured and cut to fit the defect. The mesh is held in place with heavy non-absorbable suture, securing all knots anteriorly to prevent scarring and stenosis with the underlying superficial fascia and skin. The proximal portion is secured first (Fig.5), which allows for easier tensioning adjustments prior to securing the distal end.

Figure 5  The proximal portion of the mesh-tendon interface is first secured. 

A portion of the plantaris tendon is resected and fanned out to cover the anterior and posterior portion of the graft, and is secured using 3-0 non-absorbable suture (Fig. 6).

Figure 6  A portion of the plantaris tendon is resected and fanned out to cover the anterior and posterior portion of the graft and is secured.

The tendon and graft are reinforced with calcaneal bone anchors inserted medially and laterally (Fig. 7).

Figure 7  Bone anchors secure the repaired tendon to the calcaneus.

The anchor sutures are then braided along the sides of the tendon creating a finger-trap stitch. The paratenon is repaired with an interlocking baseball stitch and the skin is reapproximated using 5.0 absorbable suture. (Figs. 8,9)

Figure 8 The paratenon is reapproximated.

Figure 9  Absorbable suture is used for closure and surgical strips are placed across the surgery site.

All patients were placed in a non-weight bearing, short leg cast in gravity equinus for 3 weeks, and then advanced to a non-weight bearing walking boot with passive range of motion exercises for an additional 3 weeks. Progressive weight bearing with active physical therapy was initiated post-operatively at 6 weeks.


The average time for follow-up was 1.5 years (range 0.5 – 4 years; mean = 2 years; standard deviation 1.515; median 1.5 years; 25th percentile = 0.75 years; 75th percentile = 4 years). There were no cases of foreign body reaction following implantation of the mesh graft. All patients were able to return to work or to their level of activity before the injury. Of the twelve patients involved in the study, eight related no pain at the time of the interview.

Three patients related mild pain. One patient presented to the surgeon five months after surgery complaining of moderate pain at the operative site, and stated that he heard a “pop” when ambulating and began to experience pain at the surgical site. This patient was immobilized in a non-weightbearing walking boot with crutches and follow-up MRI showed evidence of diffuse thickening at the site of the repair with no evidence of a recurrent tear. He then returned to pre-operative activities of daily living without incident. Five patients related mild ankle joint stiffness upon waking in the morning. Two patients complained of mild weakness to the calf muscle.

Four patients stated that they were limited in their shoe gear, with one patient stating that she was no longer able to wear high heel shoes. All patients were satisfied with the overall results of the procedure. (Table 3)

TABLE 3 Data Results.


A number of surgical techniques have been described for the repair of neglected Achilles tendon ruptures. Autogenous grafts in the form of local tendons or free fascia may be used when the donor tissue is healthy and where the gaps are manageable. Synthetics grafts are useful when autogenous grafts cannot be used.

Lieberman, et al, [14] described repair of Achilles tendon ruptures with Dacron® vascular graft in 7 patients, with a follow-up of ten to 38 months. The graft was woven from distal to proximal and across the rupture in a Bunnell-type fashion, and the patients were immobilized in a short-leg cast for two weeks and then fitted with a posterior fiberglass splint.

Patients were allowed to return to their normal level of activity approximately five months after surgery. There was no incidence of re-rupture, wound infection, or skin adhesion. All of the patients had normal gait, normal range of motion of the ankle, and had returned to their pre-injury level of activity. Two patients noted weakness in the injured leg and two years after the repair; however, their activity levels had not been altered. Another patient complained of tightness in the tendon area and discomfort after a significant amount of exercise.

Parsons, et al, [15] described repair of Achilles tendon using a composite carbon implant in 48 patients/51 procedures with an average follow-up of 2.1 years. Three cohort groups were observed on a temporal basis and quantitatively evaluated at 1 year (N = 29), 18 months (N = 22), and 2 years (N = 20), respectively. These three groups demonstrated continuous improvement during the first postoperative year, with 86% having a good to excellent result. A high level of function was maintained throughout the second year.

Lee [17] described a case-report using GraftJacket ® for augmentation of a gastrocnemius recession repair in a chronic Achilles rupture. The augmentation obviated the need for tendon transfer or free tendon graft, and early return to activity and good plantarflexion strength was noted postoperatively.

This series reports on 12 patients who were repaired using Marlex ® polypropylene mesh. This material has been extensively used in general and cardiovascular surgery with predictable results. Hosey, et al, studied the Marlex ® -tendon complex in rabbits and reported that it had similar physical properties to a normal tendo Achilles. [20] There was no reported incidence of foreign body reaction. The potential risk of donor site morbidity was eliminated through use of a synthetic graft. All patients were satisfied or very satisfied with their surgical outcome. Ozaki [19] and Choskey [22] reported findings that were similar to those in our set.

There are a number of limitations in this study. The sample size is small, and our results are compared to historical controls, which inherently introduces bias between the two groups. Additionally, we did not consider any independent variables, such as weight or length of the tendon defect, which may have added confounders or bias to the overall outcome of the study.

The VISA-A (Victorian Institute of Sport Assessment-Achilles) questionnaire provides a valid and reliable index of severity of Achilles tendinopathy. [20] It was modified in this study to include questions about return to work and footwear restrictions. Additionally, it qualifies VISA-A pain, stiffness, and weakness score of 0 as none, 1-3 as mild, 4-6 as moderate, and 7-10 as severe. This modification may alter the operating characteristics of the questionnaire, however, it is quite unlikely.

In conclusion, the results demonstrated above suggest that polypropylene mesh graft is an effective alternative to autogenous grafts and/or tendon transfers in the treatment of neglected Achilles tendon rupture.

This investigation was not funded by any commercial or other outside agency or corporation. The investigators do not have any potential conflicts of interest, actual or perceived, to this investigation.


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Address correspondence to: Robert Fridman, DPM, AACFAS, Department of Orthopaedics, New York-Presbyterian Hospital, University Hospitals of Columbia and Cornell, New York, NY.

1Private Practice, Foot Associates of New York, New York, NY.
2Fahey Medical Center, Des Plaines, IL.
3Alexian Brothers Medical Center, Hoffman Estates, IL.
4Private Practice, Daugherty Foot and Ankle Clinic, Cape Girardeau, MI.
5Private Practice, Northwest Suburban Podiatry, Arlington Heights, IL.

© The Foot & Ankle Journal, 2008