How To Address The Neglected Achilles Tendon Rupture
A Guide To Excision With Direct Repair
When it comes to neglected Achilles tendon ruptures, we target two surgical strategies. The first option is excision with direct repair and possible proximal lengthening. The second option is excision and tendon transfer. Surgeons may utilize biologics, including acellular matrices and bone marrow aspirate/stem cells, with any of the techniques to increase healing potential.
For the subset of patients with localized, persistent mid-substance pain and no functional deficit, one would perform a direct repair. The goal is resection of the degenerative segment and removal of adhesions surrounding the tendon. The technique we employ is a slightly medial to midline longitudinal incision overlying the degenerative segment and down to the paratenon.
One would subsequently observe the paratenon and incise it in line with the tendon. Surgeons will often encounter adhesions and can utilize a combination of sharp and blunt dissection methods to free them. Pay attention to the ventral surface as well as adhesions and inflamed tissue that may be present.
Split the tendon longitudinally at the bulbous section. One can subsequently view the diseased portion of the Achilles and excise it as an ellipse. Be sure to extend proximal and distal enough to normal appearing tendon. Assess the extent and nature of the tendon. If there is minimal damage and sufficient strength and diameter of tendon remain, one can repair the tendon with a running vicryl suture and include paratenon repair during the full thickness closure.
When the tendon has more extensive damage, surgeons may employ biologic augmentation. One may apply the acellular matrix in one of two methods. Surgeons can incorporate the matrix into the substance of the tendon at the elliptical excision site and perform a subsequent repair with the remaining tendon. We call this the “prosciutto’”method.
Alternately, the surgeon can apply and secure the matrix to the repaired tendon. One can also add bone marrow aspirate to the matrix to facilitate matrix activation. This brings in the necessary healing agents to an otherwise avascular zone. In addition, surgeons may perform a longitudinal deep fasciotomy to allow for added envelope for closure and increased blood flow to the repair.
The variant direct repair option addresses the diseased tendon by completely excising a segment of tendon. The amount of tendon one removes depends upon the tendon appearance, the amount of over-lengthening and involvement on preoperative MRI. The surgeon then performs a primary, end-to-end tendon repair, similar to an open acute rupture repair. We utilize a classic Krackow technique. If the resection is too extensive due to the diseased portion, one would perform a V to Y lengthening in a more proximal direction. Again, surgeons would often perform an adjunctive deep fasciotomy and utilize biologic augmentation.
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.