A Closer Look At Treatment Options For Neglected Achilles Tendon Ruptures
Achilles tendon rupture occurs frequently and if it is neglected, there may be significant long-term disability. Early diagnosis of an acute rupture and prompt initiation of treatment will generally lead to optimal results. Acute Achilles tendon ruptures may be misdiagnosed up to 25 percent of the time.1 In other cases, patients may not seek immediate medical care if they are able to ambulate and the pain is tolerable. It may be weeks or months before the patient receives a referral or decides to pursue treatment. Ultimately, continued functional impairment and alterations in gait cause the patient to seek medical attention.
An Achilles rupture is considered chronic if treatment is delayed greater than four weeks.2,3 Contraction of the gastrocnemius-soleus complex may occur as early as three to four days after rupture.4 As a result, any delay in diagnosis and treatment will worsen the outcome and treatment options become more limited.
Pertinent Diagnostic Principles
Patients will often complain of pain along the posterior lower leg and present with an antalgic gait. They often report difficulty with stairs, complain of weakness and instability, and are unable to jog or run.
The physical exam may reveal a palpable gap. However, with delayed presentation, one may palpate a bulbous segment. This bulbous segment represents disorganized, irregular scar tissue and, over time, as the calf muscle contracts, the fibrous scar tissue stretches and heals in an elongated position. As a result, one will note weakness due to a loss of mechanical efficiency of the triceps surae complex.5
On the clinical exam, there is increased dorsiflexion with weakened plantarflexory strength in comparison to the contralateral limb. There is often calf atrophy and the patient is unable to perform a single leg heel raise. The Thompson test, in which the patient lies prone with his or her feet hanging over the edge of the exam table and the clinician squeezes the calf muscle to stimulate contraction, may not be as reliable. Thompson and Doherty noted that in chronic Achilles tendon ruptures, the tendon might adhere to surrounding structures, leading to a weak plantarflexion response when one squeezes the calf, leading to a false negative finding.6
Physical exam findings are fairly consistent and are often all that is needed for acute Achilles tendon ruptures. However, in the case of a chronic rupture, magnetic resonance imaging (MRI) is helpful in determining the extent of injury. Magnetic resonance imaging is an essential component of the surgical plan as the distance between tendon ends will have a direct impact on the surgical decision.
Essential Treatment Considerations
One should consider surgical management for active individuals. The treatment should restore the continuity of the tendon with as close to normal length-tension relationship. When it comes to neglected ruptures, the large gap between tendon ends often makes end-to-end repair impossible. In a series of patients treated four to 12 weeks from the time of injury, Porter and colleagues found an average gap of 3 to 5 cm between the tendon ends after removal of the fibrous scar tissue.7
Surgeons often repair smaller gaps (less than or equal to 2 cm) with an end-to-end technique.8 One may also attempt an end-to-end repair for gaps up to 3 cm. In these cases, surgeons may perform tendon mobilization by placing a Krackow locking stitch at the proximal segment and applying distal manual tension. However, the surgeon is cautioned against repairing the tendon with excessive tension and therefore should not hesitate to perform a fascial advancement to close the gap.9,10
Gaps greater than 3 cm will likely require a fascial advancement. A number of options are available with the most common being the gastrocnemius recession, V-Y advancement and a turndown flap.9 For smaller defects (2 to 3 cm), a gastrocnemius recession usually permits end-to-end repair. For larger defects (greater than 3 cm), a V-Y advancement or a turndown flap is often required to restore continuity to the tendon.
Advancement of more than 5 cm is thought to result in marked muscle weakness. Takao and colleagues reported strength deficits up to 23 percent on 10 patients treated with gastrocnemius fascial flaps for neglected Achilles ruptures.11 Us and coworkers noted a reduction in peak torque of up to 23 percent in patients treated with a V-Y lengthening.12 Therefore, one should consider augmenting the V-Y advancement with a tendon transfer.
The flexor hallucis longus (FHL) tendon is an ideal tendon to use to augment chronic Achilles tendon repairs.10 The FHL tendon offers stronger plantarflexion and its axis of contraction is more in line with the Achilles than the flexor digitorum longus (FDL) and peroneus brevis tendons.13 The relative proximity to the Achilles and ease of harvest further support its use, and there is little functional impairment with harvest.9
Case Study: When A Patient Presents With Posterior Lower Leg And Ankle Pain Five Weeks After The Initial Injury
A 42-year-old male presented to the office with ongoing posterior lower leg and ankle pain. He first noticed the pain while playing basketball five weeks earlier but he did not initially seek medical care because he was able to ambulate and the pain was tolerable.
On the physical exam, he had an obvious antalgic gait and increased dorsiflexion with weakened plantarflexory strength in comparison to the contralateral limb. He was unable to perform a single leg heel raise. I evaluated the resting tension position of both feet and his affected foot was in slight dorsiflexion in comparison to the uninjured side.
Physical exam findings were consistent with an Achilles tendon rupture. Given that it was a neglected rupture, I obtained a MRI for a more detailed evaluation and to assist in determining the size of the gap.
After appropriate workup and surgical planning, I scheduled the patient for operative management. We ensured prone positioning of the patient and employed a well-padded thigh tourniquet as well as appropriate prepping and draping from the knee down.
I made an incision proximally at the myotendinous junction and extended it distally along the posterior medial aspect of the Achilles tendon. Placing the incision medial avoids the sural nerve and allows for easier access to the flexor hallucis longus tendon for harvest. One carries the incision down to the paratenon, minimizing undermining and using a no-touch technique for the skin edges. I resected the interposing scar tissue to the level of normal tendon fibers, resulting in a 6 cm gap between tendon ends.
I harvested the flexor hallucis longus tendon through the same incision and secured the transfer into the calcaneus with an interference screw.9,14,15 Using a heavy braided, nonabsorbable suture, I placed a Krakow locking stitch on the proximal tendon end. There was proximal exposure of the gastrocnemius aponeurosis in preparation for a V-Y advancement. I proceeded to make an inverted V incision through the gastrocneumius aponeurosis, leaving the underlying muscle fibers intact. I placed the apex of the V midline at the proximal aspect of the aponeurosis, extended the arms distally and exited the medial and lateral borders of the tendon. Each arm measures approximately 1.5 times the length of the gap. With more extensive gaps (larger than 5 cm), one may need to extend the length of the limbs to two times the measured gap.14
One then places a Krackow locking stitch on the distal end of the Achilles tendon. I applied slow, gentle, consistent traction to the proximal tendon stump to advance the tendon distally and continued manual traction until an end-to-end repair was possible. It is important to minimize disruption to the underlying muscle fibers. After reducing the gap, I completed the end-to-end repair and closed the proximal site, creating an inverted Y.
Performing a layered closure, I took care to preserve the integrity of the peritendinous structures in order to increase the healing potential and reduce adhesions.15 After dressing the incision, I applied a bulky compressive dressing with a posterior splint to the affected leg. This generally stays intact for two weeks. We emphasize non-weightbearing and provide detailed postoperative instructions.
After two to three weeks, one usually removes the sutures and transitions the patient into a walking boot with heel lifts. Patients are permitted to perform protected weightbearing in the boot with crutches and begin an individualized rehabilitation program, which includes active plantarflexion and dorsiflexion to neutral.
At four weeks, patients may begin to bear weight as tolerated in the walking boot. One can remove the heel lifts as tolerated and after eight weeks, patients may begin to wean off the boot. With physical therapy, patients continue to progress through range of motion, strength, endurance and proprioception.
In conclusion, it is best to manage Achilles tendon ruptures acutely. Neglected Achilles tendon ruptures are disabling injuries and one must appreciate the increased complexity of the situation. Surgical management is recommended for active individuals. I have found that a V-Y advancement flap and flexor hallucis longus tendon transfer are reliable, and able to achieve good clinical outcomes for large defects.10
Dr. Bevilacqua is a foot and ankle surgeon with North Jersey Orthopaedic Specialists in Teaneck, New Jersey. He is board certified in both foot surgery and reconstructive rearfoot and ankle surgery. He is a Fellow of the American College of Foot and Ankle Surgeons.
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12. Us AK, Bilgin ss, Aydin T, Mergen E. Repair of neglected Achilles tendon ruptures: procedures and functional results. Arch Orthop Trauma Surg. 1997,116(6-7):408-11.
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14. Elias I, Besser M, Nazarian LN, Raikin SM. Reconstruction for missed or neglected Achilles tendon rupture with V-Y lengthening and flexor hallucis longus tendon transfer through one incision. Foot Ankle Int. 2007; 28(12):1238-1248.
15. Cottom JM, Hyer CF, Berlet GC, Lee TH. Flexor hallucis tendon transfer with an interference screw for chronic Achilles tendinosis: a report of 62 cases. Foot Ankle Spec. 2008;1(5):280-287.
16. Schuberth J. Achilles tendon trauma. In: Scurran BL (ed): Foot and Ankle Trauma, Churchill Livingstone, New York, 1996, pp. 205-231.
For further reading, see “How To Address The Neglected Achilles Tendon Rupture” in the November 2011 issue of Podiatry Today, “Current Concepts In Treating Achilles Tendon Ruptures” in the September 2009 issue or the DPM Blog “A Closer Look At Surgical Options For Neglected Tendon Ruptures” at http://tinyurl.com/nj8m5xb .