A Closer Look At Treatment Options For Neglected Achilles Tendon Ruptures
- Volume 26 - Issue 11 - November 2013
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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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