Review Question - QID 4781

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Achilles Tendon Rupture Treatment Operative QID: 4781 (OBQ13.146)

QID 4781 (Type "4781" in App Search)

A 58-year-old male with a history of chronic posterior ankle pain feels a "pop" and experiences a sharp pain in the back of his heel after jumping off a step. He is placed in a splint and is subsequently lost to follow-up. Six months later he presents complaining of weakness and pain. Examination reveals weakness to ankle plantarflexion and increased passive ankle dorsiflexion. An MRI of his ankle is shown in Figure A. Intraoperatively, a tendon defect a is measured to be 4cm in length. What is the most appropriate treatment plan:

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Equinus casting for 6 to 8 weeks

52/4837

Surgical repair through an percutaneous approach with plantaris transfer

41/4837

Surgical reconstruction through an open approach with Achilles allograft

18%

870/4837

Surgical repair through an open approach with flexor hallucis longus transfer

78%

3792/4837

Surgical repair through an limited open approach with peroneus longus transfer

42/4837

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This patient has chronic Achilles tendon rupture (>4wks) with a large defect (>3cm). Surgical repair with FHL transfer is indicated. An open approach (an extended incision, allowing visualization of the tendon rupture ends and suture placement sites) is necessary.

For neglected ruptures with a <3cm defect and <3 months old, direct repair may be attempted. For ruptures with a defect >3cm, augmentation with local tissue transfer should be considered. Local tissue transfer options include FHL, FDL, peroneus brevis (PB). Augmentation may include medial/lateral fascial turndown flaps, sliding VY advancement, and fascia lata.

Reddy et al. reviewed surgical treatment for chronic Achilles tendon disease. They advocate for FHL tendon transfer because it is stronger than FDL and PB, its axis of force is closer to the native Achilles than the FDL, is isophasic with the gastrocnemius-soleus complex, and preserves the normal muscle balance of the foot.

Arastu et al. examined optimal screw positioning in FHL transfer using a 3D computer model. They found that anterior attachment on the calcaneus allows for greater range of plantarflexion, while posterior attachment provides greater force (longer lever arm). They advocate for a more posterior attachment.

Mahajan et al. examined the clinical results of FHL transfer for chronic Achilles ruptures. They found mean improvement in AOFAS score was 19. Overall their study showed there were 28 excellent results, and 8 fair results.

Figure A is a sagittal T2-weighted MRI showing Achilles tendon rupture with a large tendon gap.

Incorrect Answers:
Answer 1: In chronic injuries, tendon ends are retracted and no amount of equinus positioning will increase apposition. The patient is symptomatic after 6 months of non-operative treatment and surgical intervention is warranted.
Answer 2: The plantaris is not robust enough for tissue transfer. It is also absent in 10% of the population. A percutaneous approach (without direct exposure of the tendon rupture site) will not allow adequate visualization.
Answer 3: Allografts may be used for large defects (>10cm) that are not suitable for tendon transfer. Allografts are less preferred for small defects, and overall, because of concerns regarding the introduction of a foreign body into an area with poor healing capacity.
Answer 5: The peroneus brevis is acceptable tissue for transfer (not peroneus longus). A limited open approach (small incision allowing visualization of tendon rupture ends) is inadequate.