A Closer Look At Treatment Options For Neglected Achilles Tendon Ruptures
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