Treatment of the chronic elongated achilles tendon with anatomic reconstruction

Abstract

Although ruptures of the Achilles tendon are relatively common, a delayed or missed diagnosis by the primary treating physician is a frequent occurrence. Inglis and Sculco 1 reported that 38 (23%) of 167 Achilles tendon ruptureswere initially misdiagnosed. This consequently leads to an inappropriate primary treatment that results in an incomplete or deficient healing, typically associated with elongation and either a partial or complete chronic rupture of the tendon. Similar disabling conditions may also result from a degenerative disease of the tendon. Treatment of the resulting condition is often demanding, and bridging the resulting gap may require extensive surgical approaches. For this purpose, various procedures have been described that can be divided into three groups: 1. Primary repair, which may be possible for defects up to 2 cm 2. Augmentation with either a fascia advancement (V-Y-plasty or gastroc-soleus fascia turn-down graft) or a local tendon transfer 3. Synthetic or allograft reconstruction Descriptions of tendon grafts include reconstruction with the peroneus brevis tendon, the flexor digitorum longus tendon, or the flexor hallucis longus tendon. The disadvantage of these procedures is that other healthy structures (e.g., a flexor tendon) need to be sacrificed. Loss of the harvested structures may consequently lead to residual ankle instability and gait changes with loss of push-off power. Techniques for anatomic reconstruction have been described by Abraham and Pankovich, who suggested a V-Y advancement, and by Bosworth, who proposed a turn-down procedure. Both of these techniques may be complemented with a plantaris tendon enforcement. Finally, some attempts have been made to use allografts of synthetic and biologic materials. There are, however, no long-term studies published on these techniques. © Springer Science+Business Media, LLC 2009.