JFAS 33(1): 46-52, 1994

Repair of Neglected Achilles Tendon Ruptures-Procedure and Functional Results

Surgical repair of neglected Achilles tendon ruptures presents the challenge of restoring
the function of the Achilles tendon complex while repairing the large defect that is
created by the delay in appropriate treatment. The authors present their preferred
technique for delayed repair, and the results of four patients who were available for
complete follow-up evaluation. The method of repair includes: V to Y gastrocnemius
recession or advancement, excision of the fibroadipose defect, end-to-end anastomosis,
plantaris tendon weaving to reinforce the anastomosis, and use of a pullout-wire suture.
Each of the four patients were interviewed, examined clinically, and examined via Cybex
(Cybex Corporation, Long Island, New York) isokinetic strength testing. All patients
related satisfaction with results, and no reruptures were encountered. All four patients
have been able to return to their preinjury activities. Cybex isokinetic strength testing
demonstrated peak torque deficiencies in plantar flexion ranging from 22% to 30% as
compared with the unaffected limb. This deficit is believed to be the result of the
gastrocnemius recession. The overall results of the described techniques indicate that
very satisfactory function of a neglected tendo Achilles rupture can be obtained. A
strong, clinically functional Achilles tendon complex is restored at the cost of some
decrease in peak strength as detected by Cybex.

Charles G. Kissel, DPM, FACFAS1

Douglas K. Blacklidge, DPM2
David L. Crowley, PT, AT, C3

Upon initial presentation, an acute Achilles tendon rupture may be overlooked in as many
as 25% of the cases (1). In addition, many patients with Achilles tendon ruptures either
delay seeking medical attention, or may undergo a failed course of conservative care.
These scenarios account for the challenging cases of "neglected" Achilles tendon
ruptures. Neglected ruptures of the Achilles tendon pose difficulty to the surgeon wishing
to restore functional anatomy to the triceps surae. Delay in surgical repair allows the
tendonous ends to contract and atrophy while leaving a wide separation which becomes
occupied by fibroadipose scar tissue. Difficulty is encountered attempting to perform
end-to-end anastomosis after excising the intervening scar tissue.
Different surgical procedures have been described attempting to restore continuity
of the tendon by bridging the defect with grafts. The graft materials include fascia lata (2-
5), woven aponeurosis of the gastrocnemius (6,7), an aponeurotic tube (8), plantaris
tendon reinforcement (9), plantaris tendon weaving (10), peroneus brevis tendon transfer
(11), allograft (12), carbon fiber synthetic graft (13), and Marlex4 mesh graft (14, 15).
These procedures succeed in replacing the defect, but do not provide for intrinsic tendon
healing. Primary tendon healing enhances gliding and restoration of normal elasticity and
strength, which are important for a functional repair (16-18). Furthermore, defect
replacement procedures do not correct the contracted state of the triceps surae. Other
procedures have attempted to restore the resting tension of the musculotendinous unit by
distal translation of the proximal tendon stump and end-to-end repair (19-21). Use of
pullout-wire sutures have also been advocated to make the repair more secure (5, 22).

___________________________________________________________
From the Section of Podiatric Surgery, Hutzel
Hospital-Detroit Medical Center, Detroit, Michigan.
1067-2516/94/3301-0046$3.00/0
Copyright © 1994 by the American College of Foot and Ankle Surgeons

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The senior author has combined a variety of previously described techniques to

repair neglected ruptures of the Achilles tendon. This combined procedure includes: a V
to Y gastrocnemius recession, excision of fibroadipose tissue, end-to-end tendon
anastomosis, plantaris tendon weaving to reinforce the anastomosis, and use of a pullout-
wire retention suture (23). The results of this combined procedure approach are evaluated
in this paper.

Operative Procedure

The patient is taken to the operating room where either spinal or general
anesthesia is administered. The patient is positioned prone and a rolled towel is placed
under the anterior ankle. A well-padded pneumatic thigh tourniquet is inflated to
maintain hemostasis.
Attention is then directed to the posterior aspect of the leg where a 25 to 30 cm.
linear incision is performed. The incision extends from the middle one third of the
gastrocnemius muscle belly distally to the posteromedial insertion of the tendo Achillis.
The incision is deepened by sharp dissection through the subcutaneous tissue, while
carefully retracting the sural nerve and lesser saphenous vein laterally. Once the
paratenon is identified, it is sharply incised and reflected to expose the tendon and
aponeurosis. The defects are typically 3 to 6 cm. proximal to the Achilles' insertion into
the calcaneus. Depending upon the length of the delay, the gap will range from 4 to 6
cm., and will be either loosely formed hemorrhagic tissue or fibroadipose tissue. The
dystrophic tendon ends are sharply excised to reveal healthy, viable tendon stumps that
can be reanastomosed. The debridement may increase the defect by I to 2 cm.
When present, the plantaris tendon is identified distal medially and followed
proximally, deep to the medial head of the gastrocnemius. Near the level of the plantaris'
myotendonous junction, it is sharply incised. The distal insertion into the calcaneus is left
intact, and the 20 cm. plantaris tendon graft is wrapped in a saline-soaked gauze.
A "V" incision is then performed in the proximal gastrocnemius aponeurosis with
its apex proximal (Fig. 1). The arms of the "V" are approximately 9 cm. in length, or
about one and one half times the length of the defect, to allow for sufficient lengthening.
The proximal stump of the tendo Achillis is then pulled distally until it can bridge the gap
with the foot held in 10 degrees of plantar flexion. Next, a Bunnell-type5 pull-out suture
of 24 gauge monofilament stainless steel wire is threaded from proximal to distal across
the reapposed tendon ends and through the calcaneus following a path from superior to
inferior formed by 0.062 inch Kirschner wires. The two wire ends are then tightened
down to the plantar heel through a wellpadded two-hole button (Fig. 2). This draws the
tendon stumps together with the foot held in 10 degrees of plantar flexion. The free end
of the plantaris tendon is then threaded through a Galle needle and woven in a box-like
fashion across the repaired rupture site (Fig. 3). The weaving is performed through the
anterior one third of the tendo Achillis to avoid creating a possible source of irritation
posteriorly. The remaining free end of the plantaris tendon graft is then fanned out and
sutured with 3-0 absorbable material into the posterior aspect of the tendo Achillis
insertion.
The "V to Y" tenoplasty is closed using 3-0 absorbable suture. The end-to-end
Achilles tendon repair is reinforced with 3-0 braided polyester suture in a simple
interrupted fashion. The paratenon is then repaired using 4-0 absorbable suture and the
subcutaneous tissues are repaired with 4-0 absorbable suture.

Figure 1. V to Y gastrocnemius recession allowing distal translation of the

proximal tendon and end-to-end anastomosis.

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The skin edges are then repproximated with the surgeons' choice of materials. A fluffy
sterile compressive dressing is applied followed by deflation of the thigh tourniquet. The
lower extremity is then immobilized in an above-the-knee cast with the ankle at 90
degrees or slight equinus and the knee in 30 degrees of flexion.

Postoperative Management

Postoperative management includes a change of cast with removal of the skin

sutures at 14 days. With each cast change, the foot is dorsiflexed to tension, eventually
attaining 90 degrees to the leg. After 2 to 4 weeks, the patient may be placed in a below-
the-knee cast. The final cast is removed at 6 to 8 weeks, as is the pull-out monofilament
retention wire. The patient is then allowed full weightbearing in a removable walking cast
and physical therapy is initiated. Physical therapy includes passive and active ranges of
motion, as well as strengthening exercises. After 2 to 3 weeks of therapy, the patient is
allowed full unaided weightbearing, and is gradually returned to full activity.

Methods

Four patients were available for complete evaluation and functional testing of
their affected versus unaffected gastrocnemius-soleus complex. All four patients
underwent the identical surgical procedure as described, including plantaris tendon
weaving. All examinations were performed by author D.C. The evaluation included
questioning the patient regarding: residual discomfort; pain, or swelling; ability to
perform preinjury activities; ability to walk, run, jump, and climb stairs; and compliance
with physical therapy.

Figure 2. End-to-end tendon anastomosis and placement of the pullout-wire

suture.

Figure 3. Plantaris tendon weaving to augment the repair site.

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The patients were also examined and tested for function of their affected ankle versus the
unaffected. This included: calf measurements, gait analysis, ability to perform heel raises,
as well as ability to hop on the affected leg. Ranges of motion of the ankle joints were
also assessed prior to evaluation by isokinetic strength testing.
Cybex isokinetic strength testing was performed on both lower extremities for
comparison. Each limb was tested with the knee at approximately 10 degrees of flexion.
This knee position was chosen versus a greater degree of knee flexion so as not to negate
the significance of the gastrocnemius recession. Each limb performed five rapid ranges of
motion at each of three different machine settings. The settings found to be most
appropriate for evaluating differences between the limbs were 60°, 90°, and 180° per
second. The peak torque deficits for dorsiflexion and plantar flexion of the affected
versus the unaffected limb were calculated at each setting. Fig. 4 demonstrates example
tracings of the right versus left extremities for each patient at 60° per second. The deficits
of peak torque for the affected versus the unaffected limbs from the three settings were
then averaged and reported in Table 1.

Results

Table 1 demonstrates the responses to the patient questionnaire. The time elapsed
from rupture to surgical repair ranged from 2 to 8.5 weeks, and time from operation to
evaluation ranged from 8 to 38 months. No patients complained of significant residual
pain or swelling of the affected calf. All patients have been able to fully return to their
preinjury activity level. It should be noted, however, that each was slightly hesitant to
perform the activity that resulted in the rupture simply because of fear of re-rupture. All
patients related normal ability to walk, run, jump, and climb stairs.
The evaluation data are also included in Table 1. The mid-calf circumference
deficit of affected versus unaffected limbs ranges from 1.0 to 3.0 cm. This measurement
is at approximately the level of V to Y gastrocnemius recession, so it should represent the
greatest deficit. All patients demonstrated a symmetrical and propulsive gait. Each of the
patients were also able to perform one leg heel raises and walk on their toes. Upon
maximal toe walking, a slight decrease in heel height was noted on all of the affected
limbs compared with the contralateral side. All patients were able to hop on one limb;
however, a slight degree of guarding was noted during the affected limb hop in three of
the patients. Ankle joint range of motion was assessed for all of the affected versus
unaffected limbs. None of the patients demonstrated significant degrees of equinus or
calcaneus.
Cybex isokinetic strength testing was performed on ankles at low (60° per sec.),
intermediate (90° per sec.), and high (180° per sec.) settings. The average peak torque
deficiency of the combined settings was calculated for each affected ankle versus the
contralateral one. The peak torque deficiencies in plantar flexion range from
approximately 22% to 30%.

Discussion

The choice of surgical versus non-surgical treatment for complete ruptures of the
tendo Achillis has been debated but the evidence supports surgical repair (1). Ideally the
surgical repair should be performed very soon after the rupture occurs, so that the
difficulty of bridging a defect is avoided. As a rupture remains untreated for many days to
weeks, the challenge of restoring the tendon's integrity and ability to function becomes
greater.
Many procedures have previously been utilized to repair neglected tendo Achillis
ruptures. The use of the gastrocnemius V to Y recession to enable end-to-end
anastomosis of the ruptured tendon ends has specific advantages. It allows for intrinsic
healing of the tendon to occur resulting in a tendon with enhanced elasticity, strength, and
mobility deep to the visible scar (16-18). This procedure does not require an additional
surgical site as do those procedures that harvest fascia lata for the defect replacement.
The gastrocnemius recession allows for bridging of the defect without requiring the
sacrifice of other significant lower limb tendons (i.e., the peroneals). The plantaris tendon
is employed to augment the repair site. Utilizing this procedure is also advantageous in
that it employs no exogenous materials and poses no immunologically related
complications.
A degree of decrease in plantarflexory strength secondary to recession of the
gastrocnemius muscle is expected; however, the gastrocnemius muscle retains significant
function because the muscle is not transected, but rather is advanced in a V to Y fashion.
This V to Y gastrocnemius recession allows for end-to-end anastomosis, and anatomical
tendon healing. This is at the cost of a measurable decrease in plantarflexory strength,
which is of minimal clinical significance.
The use of the retention suture is for temporary protection of the healing tendon
ends from tension. The wire suture should transfer any tensile forces to a level well above
the repair site, minimizing disruption of the repair. The initial above-the-knee cast, as
well as the wire suture, should adequately protect the repair site allowing for primary
tendon healing.
The clinical results obtained in this study are very promising, despite the
relatively small sample size. All of the patients interviewed related complete satisfaction
with the outcome of their surgical repair, and none has experienced rerupture. One patient
had a superficial suture abscess; however, no other wound complications were
encountered.

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Figure 4. From top to bottom, patients: TK, WM, RP, JM. PL = plantar flexion;
DO = dorsiflexion. Sample Cybex tracings of five repititions-right versus left lower
extremity. Note peak torques generated by active dorsiflexion and plantar flexion at 600
per sec. machine setting of affected versus unaffected.

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All have been able to return to their pre-rupture activities, with only some hesitancy to
perform the exact act that caused the rupture. The patients demonstrated near normal
clinical range of motion and function of their affected ankles. The affected limb
demonstrated some decrease in plantarflexory strength at the end of plantar flexion of the
ankle. This was demonstrated by the decrease in heel height while walking on toes, and
may also be a significant factor in the Cybex results. The gastrocnemius recession may be
responsible for this, as the knee is in complete extension during this exercise and the
gastrocnemius should be maximally contracting.
The Cybex isokinetic strength testing demonstrated the peak torque deficiencies
of the affected limb plantar flexion as compared to the unaffected. The average percent
deficits are presented in Table 1. This testing was performed with patient positioning and
machine velocities that would reveal the greatest deficit. In this study, handedness was
not considered. The normal variants for right versus left in the Cybex isokinetic strength
testing are up to ten percent (1).
The clinical results of the described technique for repair of neglected tendo
Achillis ruptures indicates that very satisfactory results can be obtained. The Cybex
results of 22% to 30% deficit may reflect the influence of the gastrocnemius recession on
the gastrocnemius-soleus complex's ability to function at peak demand. Detailed
comparison of our method of repairing the defect created by neglected ruptures versus
other "defect replacement" procedures has not been performed, but it is felt by the authors
that V to Y gastrocnemius recession in combination with the plantaris weaving and
retention suture offers a most acceptable restoration of the gastrocnemius-soleus
complex.

Table 1. Questionnaire and Evaluation

References
 1. Ingliss, A. E., Scott, N., Sculco, T. P., Patterson, A. H. Ruptures of the tendo
Achillis. An objective assessment of surgical and non-surgical treatment. J. Bone Joint
Surg. 58A:990-993, 1976.
2. Zadek, I. Repair of old rupture of the tendo Achilles by means of fascia lata. J.
Bone Joint Surg. 22:1070-1071, 1940.
3. Tobin, W. Repair of the neglected ruptured and severed Achilles tendons. J.
Trauma 9:247-249, 1969.
4. Lawrence, G. H., Cave, E. F., O'Connor, H. Injury to the Achilles tendon. Am.
J. Surg. 89:795-802, 1955.
5. Bugg, E., Boyd, B. Repair of neglected rupture or laceration of the Achilles
tendon. Clin. Orthop. 56:73-75, 1968.
6. Arner, O., Lindholm, A. Subcutaneous rupture of the Achilles tendon: a study
of 92 cases. Acta. Chir. Scand. (Suppl.) 239, 1959.
7. Bosworth, D. M. Repair of defects in the tendo Achillis. J. Bone Joint Surg. 38-
A:111-114, 1956.
8. Rush, J. H. Operative repair of neglected rupture of the tendo Achillis. Aust. N.
Z. J. Surg. 50:420-422, 1980.
9. Lynn, T. Repair of the torn Achilles tendon using the plantaris tendon as a
reinforcing membrane. J. Bone Joint Surg. 48-A:268-272, 1966.
10. Quigley, T. B., Scholler, A. D. Surgical repair of the ruptured Achilles tendon.
Am. J. Sports Med. 8:244-250, 1980.
11. White, R. K., Kraynick, B. M. Surgical uses of the peroneus brevis tendon.
Surg. Gyn. Obstet. 108:117-121, 1959.
12. Nikitin, G. D., Linnik, S. A. Combined alloplasty of the Achilles tendon.
Vestnik Khirurgii Imeni I-I-Grekova. 123:106-108, 1979.
13. Howard, C. B., Winston, I., Bell, W., Mackie, I., Jenkius, D. H. R. Late repair
of the calcaneal tendon with carbon fiber. J. Bone Joint Surg. 66-B:206-209, 1984.
14. Ozaki, J., Fujiki, J., Sugimoto, K., Tamai, S., Masohara, K. Reconstruction of
neglected Achilles tendon rupture with Marlex mesh. Clin. Orthop. 238:204-208, 1989.
15. Hosey, G., Kowalchik, E., Tesoro, D., Balazsy, J. Klocek, J., Pederson, B.,
Wertheimer, S. J. Comparison of the mechanical and histologic properties of Achilles
tendons in New Zealand white rabbits secondarily repaired with Marlex mesh. J. Foot
Surg. 30:214-233, 1991.
16. Ketchum, L. D. Primary tendon healing: A Review. J. Hand Surg. 2:428-535,
1977.
17. Kleinert, H. E., Smith, D. J. Primary and secondary repairs of flexor and
extensor tendon injuries. In Hand Surgery, 3rd ed., pp. 220-242, edited by J. E. Flynn,
Williams & Wilkins, Baltimore, 1982.
18. Hattrup, S. J., Johnson, K. A. A review of ruptures of the Achilles tendon.
Foot Ankle 6:34-38, 1986.
19. Strayer, L. M. Recession of the gastrocnemius. J. Bone Joint Surg. 32-A:671-
676, 1950.
20. Fulp, M., McGlamry, E. D. Gastrocnemius tendon recessions. J. A. P. A.
64:163-171, 1974.
21. Abraham, E., Pankovich, A. M. Neglected rupture of the Achilles tendon. J.
Bone Joint Surg. 57-A:253-255, 1975.
 22. Ralston, E. L., Schmidt, E. R., Jr. Repair of the ruptured Achilles tendon. J.
Trauma 11:15-21, 1971.
23. Kissel, C. G., Sundareson, A. S., Unroe, B. J. Spontaneous Achilles tendon
rupture in a patient with systemic lupus erythematosis. J. Foot Surg. 30:390-397, 1991.

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Additional References

Kuwada, G. T. Classification of tendo Achillis rupture with consideration of

surgical repair techniques. J. Foot Surg. 29:361-365, 1990.
Mahan, K. T., Carter, S. R. Multiple ruptures of the tendo Achillis. J. Foot Surg.
31:548-559, 1992.
Schuberth, J. M. Management of Achilles tendon trauma. In Foot and Ankle
Trauma, pp. 191-218, edited by B. L. Scurran, Churchill Livingstone, New York, 1989.

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