Chronic Achillies Tendon Rupture

The Achilles(TA) is the strongest and thickest tendon in the body as well as the most commonly injured tendon. There is a 25% incidence of missed ruptures on initial evaluation, so a high index of suspicion is necessary on the part of the physician. Patients are usually misled by the inconsequential nature of the trauma, lack of significant pain, and patient’s ability to weakly plantar flex the ankle.Those patients who sustain undiagnosed Achilles ruptures may go on to be considered chronic or neglected ruptures.

Presenting Symptoms

Symptoms are vague and not necessarily localized to the Achilles tendon region.

  • A sense of fatigue or weakness with prolonged ambulation.
  • Inability to get up onto their toes, difficulty climbing stairs and walking uphill.

Treatment Options

Non Operative Methods

In non-operative treatment, improvement may take years and can be accompanied by a period of pain until healing is complete.It can be considered for those patients who have associated comorbidities, such as peripheral vascular disease.Non-operative treatment is also indicated for those patients who do nothave any significant functional deficits.

Surgical Options

Minimal or No Tendon Incontinuity
  • Z-shortening to restore the resting length of the gastro-soleus complex.
  • Tendon end freshening with end to end repair.
With Tendon Incontinuity
    • Tendon Mobilization : Can be used to bridge smaller gaps such as around 2 cm..
    • Turndown Flaps : Aflap that is raised from the proximal tendon fragment and turned down to cover the defect.
    • Tendon Advancement : A V-Y tendinous flapwhich can be used to bridge a gap of 5 to 6 cm between ends.

turndown_flap
TURNDOWN FLAP

  • Tendon transfers
    • Peroneus Brevis tendon transfer.
    • Flexor DigitorumLongus (FDL) tendon transfer.
    • Flexor Hallucis Longus (FHL) tendon transfer.
Complications Of Open Repair

Main complication is wound healing due to the long big incision and also because it is difficult to achieve tension free skin closure after reconstruction. Associated risk factors such as steroid and tobacco use, female sex, older age, diabetic and obesity give rise to higher incidence of wound complications.

Arthroscopic FHL Transfer

This technique is recommended chronic TA ruptures, particularly in patients with co-morbidities, as it is less invasive and could potentially reduce the risk of postoperative wound infection which is the most important drawback of the open technique.

short_harvest_tendon
SHORT HARVEST OF THE TENDON

whip_stitched_attached
THE STUMP OF FHL WITH THE WHIP-STITCH ATTACHED IS DELIVERED INTO THE BONE TUNNEL