Repair of Achilles Tendon Ruptures with Peroneus Brevis Tendon Augmentation

To the Editor: In the article by Singh et al,1 may the authors clarify: 1. Records of 6 women and 19 men (25 patients) who underwent repair of Achilles tendon ruptures with peroneus brevis tendon augmentation were reviewed, but the outcomes of only 22 patients were reported. 2. Selection of treatment method for Achilles tendon repair depends on the type and size of the defect. What were the authors’ criteria for this? 3. Reconstruction of chronic Achilles tendon rupture with transfer of the peroneus brevis tendon is suitable in patients with a gap of <6.5 cm between ruptured ends.2,3 The gap is usually larger in chronic and neglected patients who have a habit of squatting that widens the defect. Was peroneus brevis augmentation alone sufficient? We usually augment the repair with gastrocnemius aponeurotic reverse flap and/ or tensor fascia graft. What was the authors’ experience in repairing larger defects? 4. The flexor hallucis longus (FHL) tendon is a plantar flexor and is stronger than peroneus brevis and flexor digitorum longus tendons.4 Its axis of contractility resembles that of the Achilles tendon, and it works in phase with the gastrocnemiussoleus complex and thus can maintain the normal muscle balance of the ankle. It can be transferred without neurovascular interference. A complete integration of the FHL tendon is reported in 60% of the patients,5 and the tendon increases blood supply to the repaired tendon.6 Modified FHL transfer with fibrous Achilles tendon stump reinforcement has demonstrated excellent outcome.6 Morbidity associated with FHL transfer is clinically insignificant, even for good push-off or balance in running sports.7,8 What led the authors to choose peroneus brevis as their first choice for augmentation? 5. Turco and Spinella modification9 can be beneficial if a long distal stump is present. Did the authors use the same modification? During negotiation of peroneus brevis through a mid-coronal slit in the distal stump of the Achilles tendon, the stump might split. Did the authors experience this? What are the key factors to prevent this? 6. The authors evaluated patients at 3, 9, and 12 months using the Foot and Ankle Outcome Score (FAOS). At 3 and 9 months, the cohort was small. What were the causes for these dropouts? Were the patients lost to follow-up? 7. The small cohort prevents generalisation of the findings and leads to type-II errors.10 We appreciate the authors’ comment on this concern. 8. Were there any contraindications and/or limitations of peroneus brevis augmentation in terms of aetiology and/or critical size defect? We appreciate the authors’ comments on this concern.