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Literature review shows no one treatment for chronic Achilles tendon rupture is best
Patients may have residual weakness and surgeons should counsel appropriately.
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The increased activity levels experienced by the baby boomer population may lead to more cases of chronic Achilles tendon rupture. However, there is a lack of level I and II studies regarding the treatment of this condition.
At the American Orthopaedic Foot and Ankle Society (AOFAS) 24th Annual Meeting., Donald R. Bohay, MD, discussed the surgical treatment options and outcomes for chronic or failed Achilles tendon rupture.
“Chronic ruptures or degeneration of the Achilles tendon should be treated surgically in most cases,” Bohay said. “No one operation has surfaced from the literature to suggest that it is more superior to any other.”
He said that surgeons should use techniques with which they are comfortable. “There will be residual weakness,” he added. “I think most importantly, you need to counsel your patients appropriately and make sure that their expectations match yours.”
Flexor hallucis tendon transfer
Bohay noted that most of the research on chronic Achilles tendon rupture consists of retrospective studies investigating a single technique. “Everybody is using different outcome instruments,” he said. “No one technique can be recommended based on the literature.”
In his research, Bohay and colleagues found that flexor hallucis tendon (FHL) transfer is a safe and reliable technique. Surgeons can use a single or double incision for harvesting the structure, he said.
“We did not find much in the way of donor site morbidity,” he said. “We did identify that patients after this did not have normal gastroc-soleus complex strength, but 90% of the patients that we studied had AOFAS scores higher than 70.”
V-Y lengthening
Researchers have also described the use of V-Y lengthening alone or in conjunction with FHL transfer for the treatment of chronic Achilles rupture. Bohay cited research by Ilan Elias, MD, and colleagues which investigated V-Y lengthening with FHL transfer in patients with rupture gaps greater than 5 cm. “All patients were satisfied in this study but, 22% had a loss of plantar flexion strength and there was a 5° loss in active range of motion,” he said.
E. Pintore, MD, and colleagues investigated peroneus brevis transfer and found that patients were generally satisfied with the procedure. However, they reported that the operation was technically demanding and had higher complication rates and decreased ankle plantar flexion strength in patients with neglected ruptures, Bohay said.
In a study of 21 patients with chronic ruptures and gaps larger than 6 cm who were treated with free gracilis autografts Nicola Maffulli, MD, FRCS, and colleagues found 17 excellent or good results and four fair outcomes.
Freeze-dried Achilles tendon allograft use has been described in a technique paper by Naoki Haraguchi, MD, and colleagues. In their study, the investigators used the grafts in gaps greater than 5 cm, attaching it to the calcaneus with screws distally and proximally to the Achilles, Bohay noted.
He said that multiple retrospective studies have investigated the use of synthetic grafts.
A study by John R. Parsons, PhD, and colleagues investigated 52 total Achilles ruptures that included 27 chronic ruptures. They found two re-ruptures, two deep infections and three superficial infections postoperatively, Bohay said.
For more information:Reference:
- Donald R. Bohay, MD, can be reached at Orthopaedic Associates of Grand Rapids, PC, 1111 Leffingwell NE, Suite 100, Grand Rapids, MI 49525; 616-459-7101; e-mail: dbohay@oagr.com. He is a consultant for Zimmer and Osteotech.
- Bohay, DR. Treating the chronic or failed Achilles rupture. Presented at the American Orthopaedic Foot and Ankle Society 24th Annual Summer Meeting. June 26-28, 2008. Denver.
- Elias I, Besser M, Nazarian LN, et al. Reconstruction for missed or neglected Achilles tendon rupture with V-Y lengthening and flexor hallucis longus tendon transfer through one incision. Foot Ankle Int. 2007;28(12):1238-1248.
- Haraguchi N, Bluman EM, Myerson MS. Reconstruction of Chronic Achilles Tendon Disorders with Achilles Tendon Allografts, Tech Foot Ankle Surg. 2005;4:154-159.
- Maffulli N, Leadbetter WB. Free gracilis tendon graft in neglected tears of the Achilles tendon. Clin J Sport Med. 2005;15(2):56-61.
- Parsons JR, Weiss AB, Schenk RS, et al. F. Long-term follow-up of Achilles tendon repair with an absorbable polymer carbon fiber composite. Foot Ankle. 1989;9(4):179-184.
- Pintore E, Barra V, Pintore R, et al. Peroneus brevis tendon transfer in neglected tears of the Achilles tendon. J Trauma. 2001;50(1):71-78.