Review Question - QID 215427

Achilles Tendon Rupture Treatment Operative QID: 215427 (OBQ20.16)

QID 215427 (Type "215427" in App Search)

A 53-year-old man presents to your clinic with posterior ankle pain and weakness during ambulation for 6 months. He wishes to undergo surgical treatment. MRI is shown in Figure A. Which of the following intraoperative findings would most support performing a V-Y lengthening with end-to-end suture repair?

Type & Select Correct Answer

Type in at least one full word to see suggestions list

Insertional tear off the calcaneus

6/1428

A 0.5 cm defect with an additional 1.0 cm of interposed scar tissue

78/1428

A 1.5 cm defect after with no additional interposed scar tissue

29%

412/1428

A 1.5 cm defect with an additional 1.0 cm of interposed scar tissue

50%

715/1428

A 3.0 cm defect with an additional 2.5 cm of interposed scar tissue

15%

208/1428

Select Answer to see Preferred Response

An Achilles tendon gap of less than 3 cm after scar tissue debridement is most appropriate for V-Y lengthening and end-to-end suture repair.

Chronic Achilles tendon tears develop interposed scar tissue that requires debridement back to healthy tendon edges. The residual gap after scar tissue debridement is used to determine what method of tendon fixation is most appropriate. Treatment is on a continuum and there is case by case variation, however, the literature generally supports small defects (< 2 cm) are amenable to end-to-end repair. With increasing defect size (2-5 cm), mobilization with fascial advancements (V-Y lengthening) or local tendon transfers are indicated. Larger defects (>5-6 cm) may require a combination of techniques of fascial turndown with tendon transfer or allograft reconstruction.

Chen et al. reviewed the reconstructive techniques for chronic Achilles tendon ruptures. Primary repair was advocated for ruptures with a defect of <2 cm after debridement. For defects of 2-5 cm after debridement, V-Y lengthening with possible tendon transfer was recommended. For defects of >5 cm, tendon transfer with V-Y advancement or turndown was recommended.

Schweitzer et al. reviewed the repair and reconstructive options for chronic Achilles tendon ruptures. For minimal tendon defects (<2-3 cm), a direct end-to-end repair can be used with good outcomes. For intermediate tendon defects (2-6 cm), a combination of fascial advancements and local tendon transfers are utilized. For large tendon defects (>5-6 cm), either combined local soft tissue or a free tendon autograft/allograft should be used.

Figure A is a T1-weighted sagittal MRI of the ankle that demonstrates a chronic mid-substance Achilles tendon tear.

Incorrect Answers:
Answer 1: tears from the calcaneal insertion are not amenable to end-to-end suture repair.
Answer 2: A gap of 0.5 cm with an additional 1.0 cm of scar tissue will lead to a 1.5 cm defect. Defects of <2 cm can generally be treated with direct end-to-end repair.
Answer 3: A defect of <2 cm can generally be treated with direct end-to-end repair without V-Y advancement.
Answer 5: A gap of 3 cm with an additional 2.5 cm of scar tissue will lead to a 5.5 cm defect. Defects of >5 cm will likely need combination lengthening and tendon transfer procedures.