Chronic Achilles Tendon Rupture

 

Introduction

  • 4-6 weeks is widely accepted as the time when acute ruptures become "chronic" 
  • > 20% of acute injuries are misdiagnosed, leading to a chronic rupture
  • management of chronic ruptures is technically more demanding as primary repair is not generally possible
  • reconstructive options are generally preferred

 

Clinical Presentation and Assessment

The diagnosis of chronic Achilles tendon rupture is different from acute ruptures:

  • a tendon gap may be absent because of scar tissue formation
  • active plantar flexion of the foot may be preserved (due to function of tib post, plantaris, peroneals, long flexors) but may be unable to single heel raise
  • calf muscle weakness, Achilles tendon elongation and a limp can be observed
  • compare calf squeeze test with opposite leg

 

​Imaging​

  • x-ray: may reveal an irregular appearance of Kager's fat pad
  • ultrasound: may show an acoustic vacuum with thick irregular edges
  • MRI: T1 shows disruption of signal within the tendon substance; T2 shows generalized high signal intensity

​

Conservative Treatment

May be preferable for:

  • low-demand patients
  • poor skin condition (incl. soft tissue complications from previous surgery)
  • history of smoking
  • poorly-controlled diabetes
  • compromised anaesthetic or surgical fitness

Includes:

  • exercises and physio to build up compensatory muscles
  • lace-up or custom ankle brace
  • AFO in severe Achilles dysfunction
  • functional rehab in a velcro boot

Evidence is lacking to compare non-operative versus operative treatment for chronic Achilles tendon rupture.

 

Surgical Treatment

The best functional outcomes are achieved through surgical reconstruction, with many different techniques described:

  • fascial advancement 
  • tendon transfers (peroneus brevis, FDL or FHL)
  • graft augmentation
  • ankle fusion

Surgery may be planned based on tendon gap size:

  • small gaps (2-3 cm): gastrocnemius recession, or V-Y advancement may provide the necessary length for end-to-end repair
  • moderate gaps (4-5 cm): may require fascial advancement with a central turndown flap
  • large gaps (>5 cm) often require reconstruction such as fascial advancement, tendon transfer, graft augmentation, or tendon allograft

The main concerns of these techniques include wound breakdown and infection, which may require plastic surgical input.

A good result is the ability to perform a single limb heel-rise, usually at around 6 months postoperatively.

 

Surgical Options

 

FHL transfer

  • increasingly popular technique
  • stronger than PB or FDL
  • works 'in-phase' and preserves normal ankle function
  • good results reported
  • short tendon harvest (same incison, al level of ankle) - tenodesis into calcaneum
  • long tendon harvest (at big toe or knot of Henry) - can be drilled through calc and looped back on itself or Achilles
  • may be controversial in high-level athletes due to subtle loss of big toe push-off strength 

 

Peroneus Brevis transfer

  • another strong, local tendon
  • can be transferred into calcaneum
  • less popular now due to reports of weakened eversion
  • PB normally contributes ~30% of total eversion force

 

FDL tendon transfer

  • limited evidence
  • reasonable option in absence of alternatives
  • local tendon harvest, in-phase, no eversion loss

 

Semitendinosus tendon graft

  • ipsilateral, free graft harvest
  • strong and robust
  • can be used to bridge large gaps

 

Synthetic graft

  • advantageous in avoiding donor morbidity and functional loss
  • several materials have been reported: vascular grafts, carbon fiber composites, polyglycol threads, polyester mesh
  • concerns regarding foreign body reaction and wound healing
  • more recently, acellular dermal matrix grafts have become popular

 

Complications

  • Wound problems are common:
    • precarious local blood supply
    • further disruption through surgery, skin tension, foreign materials
  • Over / under tensioning
    • reduced function
    • inability to plantigrade foot
  • Re-rupture
    • incidence of re-rupture is far less after chronic repair compared to acute repair

 

References

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  • Gallant GG, Massie C, Turco VJ. Assessment of eversion and plantar flexion strength after repair of Achilles tendon rupture using peroneus brevis tendon transfer. Am J Orthop 1995; 24(3): 257-61.
  • Elias I et al. Reconstruction for missed or neglected achilles tendon rupture with v-y lengthening and flexor hallucis longus transfer through one incision. Foot Ankle Int 2007;29:1238-48.
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  • Tashjian R et al (2003). Flexor hallucis longus transfer for repair.
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  • Arshad Z, Bhatia M (2022). Non-Operative Management of Chronic Achilles Tendon Ruptures: Short Term Outcomes. Foot & Ankle Orthopaedics Jan 7(1)
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