This article is more than 5 years old. Information may no longer be current.
A 76-year-old man with failed nonoperative management of Achilles tendon rupture
Click Here to Manage Email Alerts
The patient is a 76-year-old man with a history of coronary artery ectasia on Coumadin (warfarin, Bristol-Myers Squibb), hyperlipidemia, hypertension and gout, who sustained a right Achilles tendon rupture 5 months prior to evaluation. He was managed non-surgically by another practice using cast immobilization in equinus with gradual dorsiflexion for about 6 to 8 weeks, during which time he was non-weight-bearing. He was transitioned to boot immobilization with a conservative, graduated physical therapy until he was weaned from the boot. At presentation, his shoe wear is normal, but he complains of persistent limitations in his gait, strength, and ability to return to prior activities despite 2 months of physical therapy.
On exam, the patient is 5 feet 7 inches tall and weighs 145 lbs. He has fullness, tenderness, and swelling around the mid-substance of the Achilles tendon. He has ankle or foot pain with gentle range of motion (ROM), however he develops discomfort localized to the Achilles tendon at maximum dorsiflexion of 20°. Dorsiflexion on the affected side is about 15° greater than the contralateral side. The patient has significant weakness in plantarflexion strength and a positive Thompson test. He is neurovascularly intact throughout the limb.
Source: David I. Pedowitz, MS, MD
Plain radiographs demonstrate no osseous abnormalities. MRI of his right ankle demonstrates significant increased signal on T2 within the Achilles substance about 4 cm to 6 cm proximal to the insertion (Figure 1) indicating poor tendon healing and degeneration of the tendon substance.
What is your diagnosis?
See answer on next page.
Lengthened Achilles tendon after nonoperative care for a rupture with persistent weakness, gait dysfunction
This patient’s clinical picture is consistent with lengthening of a nonoperatively managed Achilles rupture. The patient had been treated with a prolonged course of immobilization and non-weight-bearing prior to initiating a rehabilitation protocol. Increased dorsiflexion relative to the contralateral ankle provided evidence of insufficient tension within the Achilles and MRI demonstrated significant edema within the tendon, and a 4-cm defect within the tendon itself. The patient was offered continued nonoperative management or secondary repair with shortening of the Achilles and flexor hallucis longus (FHL) transfer. The patient desired to regain strength and after shared decision-making, decided to undergo operative fixation.
Surgical technique
Prior to the procedure, popliteal and saphenous blocks were placed. The patient was placed in a prone position and a high-calf tourniquet was placed. The right lower extremity was draped and prepped. A bump was placed under the anterior ankle.
A 15-blade scalpel was used to make a 3-cm incision over the Achilles defect at about 4 cm above the calcaneal tuberosity. Inspection of the Achilles tendon demonstrated 2 cm of poor-quality tissue at the proximal and distal tendon stumps and this tissue was resected from each end (Figure 2). A Krackow suture using #2 nonabsorbable suture tape with four locking arms on each side of the tendon was then placed into the proximal Achilles stump (Figure 3). Tension was held on the proximal Achilles to allow for stretching of the gastrocnemius-soleus and it was then cycled with repetitive traction to minimize further creep after repair. The deep posterior compartment was visualized and entered and the FHL tendon was identified. The FHL was traced down to its fibrous-osseous tunnel and transected with the ankle and great toe in maximum plantar-flexion. Care was taken to make this cut in a medial to lateral fashion to protect the neurovascular structures. The FHL was tagged with a nonabsorbable suture. The distal Achilles stump was reflected posteriorly so the superior margin of the calcaneal tuberosity could be palpated. A Beath pin was placed into the tuberosity directly anterior to the distal Achilles insertion, and care was taken to place it centrally in the coronal plane. A 7.0-mm reamer was placed over the Beath pin and advanced to the planar cortex without penetrating it. The FHL tendon was transferred through the calcaneus and secured with a 7-mm x 22-mm Polyether-ether-ketone interference screw with the ankle held in maximal plantar-flexion.
Figure 3. Nonabsorbable suture tape with a Krackow stitch is placed through the FHL and proximal Achilles tendon as shown.
Figure 4. A soft-tissue passer is used for the double-row fixation.
With the ankle in 20° of plantar flexion, and traction on the previously placed suture in the proximal stump, apposition of the tendon ends was achieved. Two incisions, with a length of about 1-cm each, were placed distally at the midline of the calcaneal tuberosity in the sagittal plane and each incision was about 1.5 cm to 2 cm from the midline. The calcaneus was drilled using a 3.5-mm drill and tapped in preparation for two 4.75-mm bioabsorbable anchors. A Nitinol suture passer was advanced through these incisions in retrograde fashion through the substance of the distal Achilles stump (Figure 4). The medial and lateral arms of the suture in the proximal stump were pulled through the distal incisions using this technique (Figure 5). The ankle was placed into 20° plantar flexion to allow for tendon apposition. The sutures through this distal site were tensioned to maintain this position and the bioabsorbable knotless anchors were then placed (Figure 6).
The ankle was then placed through a gentle ROM and found to obtain appropriate dorsiflexion without undue tension or gapping at the repair site. Layered closure was then performed with 3-0 Vicryl (Ethicon) and 3-0 nylon sutures in standard fashion and a posterior splint was applied with the ankle in resting plantar-flexion.
Discussion
The Achilles tendon is the largest tendon in the body and is formed by the confluence of the soleus muscle and gastrocnemius tendons. It obtains its blood supply from the posterior tibial artery, however a well-described hypovascular region exists about 4 cm to 6 cm proximal to the insertion in the calcaneus. Injury is more common in men between the ages of 30 and 40 years, particularly in episodic athletes.
This patient presented after non-surgical management of his Achilles rupture. Rupture of the Achilles tendon is considered chronic if untreated for more than 4 to 6 weeks. A meta-analysis by Soroceanu and colleagues found that if functional rehabilitation with early ROM was employed, re-rupture rates were equivalent between patients treated surgically and non-surgically. This study demonstrated that if functional rehabilitation was not employed, it resulted in an increased risk of failure, as was the case in the patient presented. The researchers also found no significant difference in regard to strength or functional outcomes. The patient treated in this case review had failure of nonoperative management due to weakness and decreased function and loss of the functional length of the Achilles tendon. He was therefore indicated for operative management consisting of secondary repair and FHL augmentation. Surgical intervention in this patient allowed for restoration of appropriate Achilles tension, the addition of strength with the tendon transfer and restoration of acceptable clinical function.
- References:
- Chiodo CP, et al. J Am Acad Orthop Surg. 2010;18:503-510.
- Kraeutler MJ, et al. Foot Ankle Int. 2017;doi:10.1177/1071100717709570.
- Soroceanu A, et al. J Bone Joint Surg Am. 2012;doi:10.2106/JBJS.K.00917.
- For more information:
- Rabun S. Fox, MD; David I. Pedowitz, MS, MD; and Zachary T. Wilt, MD, can be reached at Thomas Jefferson University Hospital and Rothman Orthopaedic Institute, 1025 Walnut St., Suite 516, Philadelphia, PA 19107; Dr. Fox’s email: rabun.fox@rothmanortho.com. Dr. Pedowitz’ email: david.pedowitz@rothmanortho.com. Dr. Wilt’s email: ztw001@jefferson.edu.
- Edited by Michael C. Ciccotti, MD, and Michael C. Fu, MD, MHS. Ciccotti is a chief resident in the department of orthopaedic surgery at Thomas Jefferson University and Rothman Orthopaedic Institute and will be a sports medicine fellow at the Steadman Phillipon Research Institute in Vail, Colorado following residency. Fu is a chief resident at Hospital for Special Surgery and will be a sports medicine and shoulder surgery fellow at Rush University Medical Center following residency. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
Disclosures: Pedowitz reports he is a consultant and speaker for Arthrex; is a consultant and speaker for and receives royalties from Integra and Zimmer Biomet; and is a consultant for MiRus. Fox and Wilt report no relevant financial disclosures.