How To Address The Neglected Achilles Tendon Rupture
- Volume 24 - Issue 11 - November 2011
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Pertinent Pearls On The FHL Transfer
The second surgical option, the FHL transfer, is our most commonly performed procedure for those who have severe disease in greater than 50 percent of the tendon and those who have an elongated Achilles tendon.13 The FHL is adjacent, assessable and sufficiently strong to replace or assist with an ineffective Achilles. The transfer technique is straightforward and quick with some advances in technique over the last few years. These advances include a short single incision harvest and fixation with an interference screw.14
One would access the Achilles with a longitudinal incision at the medial border of the Achilles. The surgeon proceeds to excise the degenerative tendon (often the entire tendon). If a portion of normal appearing tendon remains, it may require advancement of this tendon and a direct repair to shorten the over-lengthened tendon. The deficit may be substantial and one may add a synthetic matrix to avoid a notable dell at closure.
To locate the FHL tendon, incise the deep fascia longitudinally and mobilize the hallux. Follow the FHL tendon along the medial calcaneus. Be sure to isolate just the tendon. Transect the FHL as distal as possible against the calcaneus. Place a whip stitch and pass the tendon through a drill hole created from dorsal to plantar at the most posterior aspect of the calcaneus. Perform appropriate resection of the Achilles in order to allow for FHL placement with an interference screw. It is critical to achieve sufficient tension to afford the FHL a mechanical advantage to replace the much larger Achilles.
One can also perform side-to-side repair with the transferred FHL and the Achilles if a portion of the Achilles tendon remains. The foot should have a plantarflexed attitude and the surgeon should splint this in equinus to protect the transfer. Afterward, patients may notice a decrease in muscle strength, particularly at the hallux interphalangeal joint. However, they should still be able to perform the single heel rise effectively. Will and Galey reported good to excellent outcomes in 19 FHL transfers with no complications.15
Key Post-Op Principles
Regardless of the technique surgeons employ, the postoperative protocol remains the same. Postoperatively, there should be three weeks of non-weightbearing. One should apply a splint in the OR.
This is followed by cast application at visit one and initiation of a removable boot with a heel wedge protocol for three weeks. This includes beginning with three 10-degree heel wedges, removing one weekly and subsequently initiating weightbearing. At six weeks, the patient can begin physical therapy with a return to activities at four months.
The neglected Achilles tendon rupture is a common finding. This is usually a clinical diagnosis with advanced imaging offering final details. At times, conservative efforts can be successful. In regard to determining whether surgical intervention is necessary, it is best to offer an explanation of risks and benefits to the patient, and ascertain the functional goals of the patient. When the patient elects to have surgery, the needs of the particular limb clearly indicate the procedural choice. Direct excision and repair is useful and the FHL transfer is a reproducible, successful procedure.
Dr. Bussewitz is a fellowship-trained foot and ankle surgeon who is currently in private practice in Iowa City, Iowa.
Dr. Philbin is a fellowship-trained foot and ankle surgeon who is currently in private practice in Westerville, Ohio.