Review Question - QID 212923

The patient is presenting with a chronic Achilles tendon rupture with retraction of the proximal tendon. Based on the size of the defect and the chronicity a V-Y advancement will most likely be performed of the given answer choices.

The Achilles tendon is the strongest tendon in the body, but can easily rupture in the presence of chronic tendinosis. Chronic ruptures, >6 weeks, pose a challenge to surgical repair in that the proximal tendon stump retracts and becomes immobile, making primary repair difficulty to impossible. Chronic ruptures can be addressed with V-Y advancement, Achilles tendon turndown, and/or FHL transfer. Previous literature has described the use of synthetic graft and peroneus brevis transfers, but there are concerns of graft longevity and eversion weakness with these methods.

Rahm et al. 2013 retrospectively reviewed 40 patients undergoing Achilles tendon repair with FHL transfer, 22 with a transtendinous repair and 18 with a transosseous repair. At follow up there were no significant differences with regards to AOFAS scores and plantar flexion strength. The authors concluded the fixation method of the FHL transfer does not affect the outcomes.

Kraeutler et al. reviewed the treatment of chronic Achilles tendon ruptures. For functionally low demand patients non-operative treatment was proposed. For ruptures with less than 2 cm defect, primary repair was recommended. For ruptures 2-5 cm in length, a V-Y advancement can be performed. Large defects can be repairs with tendon transfers, with the FHL being the most common, and can be augmented with V-Y advancement or Achilles turndown. Additional reconstruction options including allograft have been reported with good results, but are limited to case series.

Bluman et al. discussed the principles of tendon transfers in foot and ankle surgery. The authors recommended tendon transfers be performed based on the needs of the patient, with functionally low demand patients being poor candidates. Donor tendons must be selected on the basis of muscle strength, tendon excursion, tendon expandability, the direction of pull, the phase of the donor muscle, and the integrity. Postoperatively, patients should be immobilized and avoidance of NSAIDs and nicotine are recommended.

Neufeld et al. 2014 reviewed tendon transfer principles for the treatment of Achilles tendon pathologies. For chronic tendonosis and insertional tendonitis transfer of the FHL is recommended when there is greater than 50% of the tendon involved. Additionally, V-Y advancement can be combined with FHL transfers for chronic/neglected Achilles tendon ruptures.

Illustration A demonstrates an intra-op photo of a V-Y advancement procedure.

Incorrect answers:
Answer 1: Flexor digitorum longus transfers are reported in the literature with good success, however, it is not preferred since it is not adjacent to the Achilles as the FHL tendon, and does not provide the same power as an FHL transfer. In a defect of 3 cm, a V-Y advancement would likely be successful and not sacrifice the function of the donor muscle.
Answer 2: Tibialis posterior is an option, but not preferred as it will lead to weakness of the Chopart joint and loss of foot inversion strength.
Answer 4: Synthetic graft augmentation is an option in a combination of an FHL transfer or an Achilles tendon advancement or V-Y advancement. However, alone there are concerns for the longevity of the graft.
Answer 5: Previous literature has described good results with peroneus brevis transfers. Although, this will lead to eversion weakness and the muscle does not replicate the pull of the Achilles.