Primary Repair Without Augmentation for Early Neglected Achilles Tendon Ruptures in the Recreational Athlete

Abstract

From 1987 to 1994, the senior author performed 41 Achilles tendon repairs. We identified 11 patients during this period (age, 35.3 years; range, 26-60 years) who fit the criterion for neglected Achilles tendon rupture (repair > or = 4 weeks and < or = 12 weeks from injury). All patients underwent proximal release of the gastrocsoleus complex, imbrication of the early fibrous scar without excision of any local tissue, and primary repair of the tendinous ends with two No. 5 Ticron sutures (5R, 6L). Several (three to five) No. 0 Vicryl sutures were used to augment the repair. The ankle was placed in a 20 degree plantarflexion nonweightbearing short leg cast for 3 weeks. All skin closures were primary. At 3 weeks, weightbearing as tolerated was initiated in a short leg cast. The cast was discontinued at 6 weeks, and physical therapy was initiated, consisting of range of motion exercises and closed kinetic exercises, progressing to functional exercises as swelling, strength, and pain allowed. Minimal follow-up was 18 months (mean, 3.5 years; range, 1.5-5.8 years). There have been no subsequent ruptures to date. All patients returned to a preinjury level of activity at a mean of 5.8 months (range, 2.5-9 months). Total range of motion was not different (P > 0.05) between the involved (67 degree) and uninvolved (74 degree) ankle. Plantarflexion loss of strength in the involved ankle was the same (98.4%, 88.1%, and 87.6% respectively, involved to uninvolved) as that seen after acute repair at all speeds tested. Visual analog pain scale (0 to 10) revealed a mean score of 0.7 (range 0-2) during activities of daily living and 1.0 (range, 0-3) during sports activity. The subjective and objective outcome was similar (P > 0.05) to that seen after an acute repair by the same surgeon. There were no complications including skin sloughs or nerve damage. We believe this is the first article to report the results after primary repair without augmentation for the neglected Achilles tendon rupture. We conclude that this approach can result in excellent clinical and functional outcome, a low rate of subsequent rupture, and a high rate of return to sports in the recreational athlete whose repair is performed between 4 and 12 weeks after injury.

Chronic Achilles tendon rupture reconstruction using a modified flexor hallucis longus transfer

“…In our series, fibrous scar tissue of AT stumps was preserved to restore some thickness with suture on the FHL transfer. Preserving this interposition scar tissue between tendon stumps has been shown to have the capacity to form tendon-like repair tissue, and previous studies concluded that it is suitable for repairing chronic AT ruptures [20,29]. Similarly, in a recent study, Lee et al showed on histological examination of fibrous scar stump biopsies that this tissue was composed of thick collagen fibers running parallel to the tendon axis with highly cellular fibrovascular tissue, altogether improving tendon healing [15].…”

MRI is Unnecessary for Diagnosing Acute Achilles Tendon Ruptures: Clinical Diagnostic Criteria

“…These delays reportedly compromise the end clinical result [4,5,7,18,21,22]. If an acute rupture is missed and becomes chronic, there is 20% less endurance of the muscle and the treatment becomes more difficult [19].…”

“…Delay in treatment, whether operative or nonoperative, reportedly has detrimental effects on the final outcomes [4,5,7,18,21,22]. Therefore, it is important to accurately diagnose an acute injury and begin the treatment early.…”

Hypertrophy of the flexor hallucis longus muscle after tendon transfer in patients with chronic Achilles tendon rupture

“…Some authors propose the complete excision of the degenerative Achilles due to better pain relief [4]. In recent series, however, preservation of the fibrous scar tissue has been suggested to make the tendon length assessment easier and the scar tissue is thought to work as a scaffold for the transferred FHLT [5,6,8].In fact, this scar tissue has been shown to have the capacity to form a tendon like repair tissue [16][17][18]. In our study, the tendon stumps were preserved, and possible deficits were bridged with single strand of FHL tendon only.…”

“…No failure of the FHLT transfer occurred during the follow-up period. Also all previous studies with FHLT transfer, despite the single or double incision technique, preserving or not the scar tissue, have shown very low failure rates [5,6,8,9,12,[16][17][18].…”