Tag Archives: Neglected Achilles tendon rupture

Neglected Achilles tendon rupture and repair with cadaver allograft, extracellular matrix, and platelet enriched plasma

by Al Kline, DPM1*pdflrg

The Foot and Ankle Online Journal 9 (3): 8

Neglected Achilles tendon ruptures can be challenging to repair. A case report is presented using a cadaver allograft supplemented with an acellular dermal extracellular matrix and platelet enriched plasma in a neglected, chronic Achilles tendon rupture of over 5 years old. Graft sterilization, rejection, incorporation, and the use of supplemental materials such as dermal matrix and the benefits of platelet enriched plasma are discussed. This report emphasizes the viability and success of using a cadaver graft and supplemental materials with platelet enriched plasma to help restore Achilles tendon function in a neglected Achilles tendon rupture.

Keywords: Neglected Achilles tendon rupture, cadaver allograft, dermal extracellular matrix, platelet enriched plasma

ISSN 1941-6806
doi: 10.3827/faoj.2016.0903.0008

1 – Podiatry Staff, Doctors Regional Medical Center, Corpus Christi, Texas.
* – Corresponding author: alklinedpm@gmail.com

Acute rupture of the Achilles tendon is often a surgical emergency that requires primary repair. There has been a long history of surgical versus non-surgical repair of the Achilles tendon. And, depending on the extent of rupture, sometimes, immobilization and non-surgical treatment, such as casting, is preferred and even indicated over surgical repair. If surgical repair is chosen, it is preferable to do the repair within a week of the rupture.

Unfortunately, there is a 10-25% misdiagnosis of early Achilles ruptures. This can be the result of misdiagnosis, failure of conservative treatment or degeneration of the tendon causing improper healing [1].

A chronic Achilles rupture is defined as a tendon rupture that is older than 4 weeks [2]. Presently, I have found very few documented cases of repairs performed on the Achilles tendon using Allografts that are over 5 years old.

The trouble with delaying treatment of the Achilles rupture is contracture. In severe cases, the tendon can retract significantly causing a palpable gap on examination along the tendon course. Clinical symptoms can include pain, failure to toe off and trouble walking up-hill or along an incline.

This is a recent case involving a neglected Achilles rupture that occurred 5 years prior to presentation. The tendon was successfully reconstructed with a cadaver Achilles tendon and supplemented with an extracellular matrix and platelet enriched plasma.

Case Report

A 62-year-old male with a history of chronic right Achilles tendon that ruptured over 5 years ago. He sustained the injury after trying to climb up into his truck and instantly felt and heard a loud ‘pop’ to the back of the right leg. He initially went to an orthopedic surgeon who placed him in a walking boot.  He states he did not have surgery for fear of termination from his job.  

He has a history of diabetes mellitus and is well controlled. He finds it difficult to walk and states it affects his balance and he has since had a partial rupture of the left Achilles tendon.  

Clinically, there is some muscle and plantarflexory strength on range of motion (+2/5).  This could be due to an intact and hypertrophied plantaris tendon which was confirmed in surgery.  He lacks a proper toe raise and limps during gait.

There is a large palpatory ‘knot’ with a distal gap of approximately 5 cm along the course of the right Achilles tendon.  MRI reported a 5cm gap with complete rupture of the Achilles tendon.   

The MRI report states: “There is complete rupture of the Achilles tendon from the distal insertion with a small avulsion fracture of the calcaneus at the insertion site of the Achilles tendon. There is about a 4.7  cm retraction of the ruptured Achilles tendon. The Achilles tendon is markedly thickened with increased signal, and finding consistent with severe tendinopathy. There is a prominent plantaris longus tendon seen along the medial side of the Achilles tendon, which inserts to the posteromedial aspect of the calcaneus.

Our surgical plan included reconstruction of the tendon using a fresh frozen allograft with reinforcement using decellularized extracellular dermis (Arthrex GRAFTJACKET®) and infusing the graft using the patient’s own platelets.   

The patient underwent primary repair and reconstruction of the right Achilles tendon using an allograft Achilles tendon with calcaneus cadaver graft and implant system using the Arthrex BioComposite Achilles SpeedBridge™ system with decellularized dermis for Achilles repair.  All grafts were infused with platelet enriched plasma.

Operative Course

The patient underwent a reconstructive surgery replacing and reinforcing a large section of his retracted Achilles tendon. An incision was made exposing the ruptured Achilles tendon and atrophic tendon ball (Figure 1).

figure-1a figure-1b

Figure 1A and 1B  Once the tendon sheath is incised, a large proximal Achilles tendon ball is exposed with atrophic changes to the end of the tendon rupture.  The end was calcified and hardened.  This was resected prior to repair (A).  The plantaris tendon remains intact after rupture, but is thickened.  This was the only remaining attachment along the posterior compartment (B).

Along the insertion of the native Achilles tendon, there was very little tendon attachment.  The end of the retracted tendon ball was then resected down a few centimeters to viable tendon fiber.  The allograft tendon was then prepared.  The bone was removed from the cadaver tendon (a portion of the calcaneus) and then left to thaw in saline.  Once the tendon was supple, it was dropped into a basin of the patients own enriched plasma.  It was left to infuse for several minutes (Figure 2).


Figure 2 The Allograft tendon after platelet infusion.  It is measured and then sutured into the native proximal tendon.  It is important to secure some tension into the tendon, bringing the foot to about 90 degrees to the ankle, ensuring not to overstretch or place too much tension through the Allograft.

Once prepared, the tendon was then sutured into the proximal native Achilles tendon.  Distally, the tendon is then plicated into bone using the BioComposite Achilles SpeedBridge™ system by Arthrex.  A 4.7mm swivel-lock anchor (x2) is used with fibertape to secure the tendon with proper tension into the calcaneus.  The suture is then used to repair the thickened tendon sheath to encase the distal tendon (Figure 3A).  

Proximally, the tendon is sutured into the native portion with fiberwire.  Once the tendon is tensioned properly, it can then be supplemented and reinforced decellularized extracellular dermis (GraftJacket-Arthrex) (Figure 3B).

figure-3a figure-3b

Figure 3A and 3B  Once the Allograft tendon is tensioned, the distal portion is placed and sutured into the bone of the calcaneus using the BioComposite Achilles SpeedBridge™ (A).  Once secure, the proximal portion of the tendon is encased in the extracellular matrix to give the proximal anastomosis strength and to cover this portion of the tendon that lost a portion of the tendon sheath (B).

The extracellular jacket is then pulled down to cover and encase the tendon where there is no tendon sheath coverage.  The incision is then closed (Figure 4A, 4B).

figure-4a figure-4b

Figure 4A and 4B  The tendon is encased in the extracellular matrix after reconstruction of the Allograft tendon both proximal and distally.  Prior to closure of the subcutaneous layer, the entire construct is infused with additional platelets enriched in potential growth factors (A). The incision is then closed with horizontal mattress sutures and buttressed with skin strips (B).  The patient is then placed in a posterior fiberglass splint and kept non-weightbearing.


Biomaterial supplementation of tendon repairs gained prominence in the past 10 years in an effort to strengthen repairs. The extracellular matrix (ECM) of tendons is composed of collagen and a smaller fraction of elastin embedded in a hydrated proteoglycan matrix. The principal role of the collagen fibers is to resist tension, whereas proteoglycans are primarily responsible for the viscoelastic properties of the tendon [3].

In one small report, Park and Sung report two cases using frozen allograft for neglected Achilles tendon rupture.  They recommended removal of the distal bone from the allograft if there was sufficient tendon attachment along the posterior heel [1].

In this case report, I found it easier to remove the bone graft and plicate the graft tendon into the bone using a simple Arthrex SpeedBridge™ technique that is often done in reattachment procedures of Achilles tendon repair.  

In a series of 12 patients with chronic Achilles ruptures, Park and Sung concluded that “Chronic Achilles tendon ruptures can be successfully treated by careful selection of the reconstruction method according to the length of defect gap and state of the remaining tissue.  With an extensive defect, use of an Achilles tendon allograft can be a good option” [1].

The use of allograft tendon repair is rare in neglected Achilles ruptures.  It has been successfully used to repair patellar tendon ruptures and ACL and cruciate repairs of the knee [4].  In fact, the failure rate in one study of 158 patients undergoing ACL repair with Achilles tendon allograft was less than 5.6% [4].  

The rarity of repair using a cadaver allograft may be partly due to various other techniques used such as a autografting using free fascia lata and even V-Y advancement flaps and the use of tendon augmentation using the Flexor Hallucis tendon and even Xenografts.  There is also suggestion of a risk of failure in the use of allograft tendon and ‘rejection’ or potential for disease transmission in an allograft tendon.  

Host Rejection and Allograft Strength

Bio-sterilization techniques are also thought to impair the mechanical properties of graft tissue. There is a potential concern of the loss of tensile strength in tendons and tissue undergoing sterilization.  Does irradiation, when done properly retain the normal tensile strength of human tissue tendon grafts?

In an article published through the Arthrex website, Dr. Liisa M. Eisenlohr describes the use of controlled-dose, low-temperature gamma irradiation for complete sterilization of tissue [5].

Dr. Eisenlohr writes, “ . . . excessively high dose(s) of uncontrolled radiation has been shown to have a deleterious effect on the material properties of most allograft tissue, particularly of structural allografts, and is therefore generally not recommended for processing of allogeneic tissue.  The temperature at which radiation is administered appears to play a critical role  . . . Studies have shown that uncontrolled gamma irradiation of freeze-dried or hydrated samples at room temperature negatively affects biomechanical tissue properties.  In contrast, irradiated deep-frozen bone allografts seem to be less brittle than similar grafts irradiated at room temperature. “ [5].

She also describes a technique using Allowash XG, described as non-irradiation technique of sterilization that retrains tissue and bone tensile strengths and structure.  

Most studies now conclude that present day sterilization techniques using both gamma irradiation and non-irradiation does not adversely affect the biomechanical or biochemical properties of tissue needed for their intended clinical applications.

Graft Incorporation and Platelet Enriched Plasma

To understand how a tendon allograft is incorporated as normal tissue, we must understand the proper healing cascade in normal tendon injury.  This cascade can be discussed in terms of both allograft tendon and acellular extracellular matrix (ECM) incorporation, since the tendon dry mass is basically composed of 60% Type 1 collagen and 95% of the total collagen base [6].

In tendon healing, the repair process passes through three main phases containing distinctive cellular and molecular cascades.  The initial inflammatory phase forms a clot or hematoma, which is propagated by platelets.  In additional to inflammatory cells such as neutrophils, monocytes and macrophages  attracted to the site of injury by pro-inflammatory cytokines, platelets also release potentially hundreds of healing proteins called growth factors.  The angiogenic process with formation of new blood vessels is also important in the initial cascade, to set up the vascular network for tendon repair and incorporation into the host tissue.

There has also been suggestion that tendons often repaired without the use of extracellular supplementation and cellular proteins are prone to re-rupture or failure [3].  In this case, rehydration of the allograft was performed with platelet enriched plasma (PRP) in an effort to facilitate the healing cascade, improve graft incorporation into surrounding tissues and decrease the overall acute inflammatory responses.  The benefits of extracellular grafting and the use of platelet enriched plasma allows for rapid cellular repopulation and revascularization of the graft.  

In the second phase of tendon healing, often called the reparative or proliferative phase, there is proliferation of Type III collagen and proteoglycans, another major component in the tendon ECM providing more structural integrity to the tendon.  This phase is highlighted by increased collagen, hydration and vascular proliferation.

The final or remodeling phase is subdivided into two distinct phases called the consolidation and then maturation phase.  Consolidation occurs 6-8 weeks after injury and may take 1-2 years to complete depending on the age of the patient.  During this time, collagen fibers organize in a longitudinal axis restoring tendon tensile strength.  After 10 weeks, the maturation phase includes collagen fibril cross-linking and formation of mature tendon.   Maturation can also take up to a year to complete.  

All three phases do overlap and vary.  However, in the first 48 hours after injury, the introduction of hematoma and the release of growth factors seem to be the most crucial phase in overall progression of this cascade.  This is why a concentration of these factors are thought to help incorporate and increase the likelihood of graft success [3].

A sterilized allograft is incorporated into the body in a similar fashion as autografts.  Again, graft incorporation has been shown to go through a series of histological changes including graft necrosis, cellular repopulation, revascularization, and collagen remodeling [7].  

In a histologic presentation of Achilles autograft 11 years after its use in posterior cruciate ligament reconstruction, Miyamoto concluded that allograft can remain successfully incorporated for extended periods and histologically appeared as “indistinguishable from those of normal, native cruciate ligament.” [7].

In these terms, it appears that graft incorporation will propagate within its normal tissue environment.  


To date, the patient had very little pain or swelling post surgically.  He is presently undergoing strengthening exercises and is wearing a walking boot prior to transition back to his shoes.  The present case report does support similar findings as reported in the literature.  Deese, et al. reported in 2015 a retrospective study of 78 patients with chronic Achilles tendon ruptures.  Of that study, they only identified 8 patients who underwent repair by tendon allograft.  All 8 patients had over a 5 cm gap and did well after follow-up.  They suggest that “patients undergoing Achilles allograft reconstruction technique demonstrated promising results and suggests that allograft reconstruction is a reasonable solution” [8].


  1. Park Y-S, Sung K-S. Surgical Reconstruction of Chronic Achilles Tendon Ruptures Using Various Methods. Orthopedics. 2012. doi:10.3928/01477447-20120123-13.
  2. Grove DJR. Autograft, Allograft and Xenograft Options in the Treatment of Neglected Achilles Tendon Ruptures: A Historical Review with Illustration of Surgical Repair. The Foot & Ankle Journal. 2008;1(5). doi:10.3827/faoj.2008.0105.0001.
  3. Docheva D, Müller SA, Majewski M, Evans CH. Biologics for tendon repair. Advanced Drug Delivery Reviews. 2015;84:222-239. doi:10.1016/j.addr.2014.11.015.
  4. Crossett LS, Sinha RK, Sechriest VF, Rubash HE. Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty. J Bone Joint Surg Am. 2002;84-A(8):1354-61.
  5. Eisenlohr LM. Allograft Tissue Sterilization using Irradiation – What are the implications for clinical performance?, LifeNet Health, Bio-Implants Division. June 2007.
  6. Riley G. The pathogenesis of tendinopathy. A molecular perspective. Rheumatology. 2003;43(2):131-142. doi:10.1093/rheumatology/keg448.
  7. Miyamoto RG, Taylor S, Desai P, Bosco J. Histologic presentation of achilles allograft 11 years after its use in posterior cruciate ligament reconstruction. Am J Orthop. 2009;38(1):E25-7.
  8. Deese JM, Gratto-cox G, Clements FD, Brown K. Achilles allograft reconstruction for chronic achilles tendinopathy. J Surg Orthop Adv. 2015;24(1):75-8.

Repair of Nelgected Achilles Tendon Rupture with Monofilament Polypropylene Mesh: A Case Study of 12 Patients

by Robert Fridman, DPM, AACFAS1, Fred Rahimi, DPM, FACFAS2, Paul Lucas, DPM, FACFAS3, Rob Daugherty, DPM, AACFAS4, Heidi Hoffmann, DPM5

The Foot & Ankle Journal 1 (5): 2

The purpose of this study is to evaluate the effectiveness of polypropylene mesh as an alternative to autogenous grafts and/or tendon transfers for neglected Achilles tendon rupture. Twelve patients with neglected Achilles tendon rupture underwent surgical repair using monofilament polypropylene mesh graft from 1999-2003. The average follow-up was 1.5 years. All patients were placed in a non-weight bearing, below-knee cast for 3 weeks, followed by 3 weeks of partial weight bearing in walking boot. All patients healed uneventfully, with three patients complaining of mild pain, one of moderate pain, and five with stiffness that resolved with physical therapy. The adjunctive use of monofilament polypropylene mesh is an appropriate method for the treatment of neglected Achilles tendon ruptures.

Key words: Achilles Tendon Rupture, Achilles Tendon Repair, Marlex ® Mesh

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org

Accepted: April 1, 2008
Published: May 1, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0105.0002

Degeneration, tendon contracture, and a high re-rupture rate are frequent sources of failure in non-operative treatment of neglected Achilles tendon ruptures. [1] Bosworth previously noted that retraction of the gastrocnemius-soleus complex may occur within three days of injury, making re-approximation of the tendon ends difficult. [2] Current clinical practice supports surgical repair of the tendon in this condition. End-to-end [3], percutaneous [4] and limited-open repairs [5] may not be as effective in neglected ruptures due to excessive tendon contracture and degeneration of the tendon ends.

Therefore, tendon augmentation is routinely employed in cases of neglected rupture. The flexor hallucis longus tendon is most commonly used to augment reconstruction. [6,7,8] Mann and others described using the tendon of the flexor digitorum longus as a graft. [9] Fascia lata, [10] peroneus brevis, [11] gracilis, [12] and plantaris [13] tendon grafts have also been described in the literature.
Synthetic grafts may also be used to augment the surgical repair in situations where surrounding autogenous tissues are weak or unable to span the defect. The advantages of synthetic grafts over autogenous grafts include absent donor site morbidity and unlimited material available for sizable defects.

A distinct disadvantage of synthetic grafts is possible foreign body reaction after implantation. Dacron® vascular graft, [14] carbon fiber composites, [15] collagen tendon prosthesis, [16] and GraftJacket® [17] have all been described as alternatives to autogenous grafts. Ozaki, et al, reported that polypropylene mesh had little to no tissue reaction when implanted during rotator cuff repair [18] and subsequently used this material for repair of Achilles tendon with satisfactory results. [19] This case study reports on a series of neglected Achilles ruptures repaired with Marlex ® polypropylene mesh.

Materials and Methods

Twelve patients with neglected Achilles tendon rupture were treated surgically by the same surgeon using Marlex ® polypropylene mesh (Davol Inc., Rhode Island, USA) as described by Ozaki, et al. The diagnosis of neglected Achilles tendon rupture was based on history, clinical and MRI findings.

Neglected tears were defined as a closed rupture of 10 or more days duration without previous surgical treatment for the affected tendon. MRI findings were all indicitive for complete rupture of the Achilles tendon with fatty degeneration. (Fig.1)

Figure 1  MRI of neglected rupture of Achilles tendon shows significant gapping and degeneration of tendon ends.

The average patient age was 52.5 years (range = 31 to 70 years). There were 8 males and 4 females included in the study, with an average follow-up period of 1.5 years (range = 0.5 – 4 years). Table 1 summarizes the demographic data.

TABLE 1  Demographics of 12 patients with neglected Achilles tendon rupture.

Patients were either contacted by telephone or interviewed in the clinic. A modified VISA-A Questionnaire was used for clinical evaluation.20 (Table 2)

TABLE 2  The modified VISA-A (Victorian Institute of Sport Assessment-Achilles) Questionnaire.

Surgical Procedure

The procedure is performed under general anesthesia with a pneumatic thigh tourniquet. Both lower extremities are prepped and draped, so as to have an appropriate reference point when tensioning the repaired tendon. Prophylactic antibiotics are given prior to inflating the tourniquet. The patient is positioned prone and local anesthetic is infiltrated into the surgical site. A posteromedial incision is made along the Achilles tendon extending proximally and distally past the defect (Fig. 2).

Figure 2   A posteromedial incision is made along the Achilles tendon extending proximally and distally past the defect.

The sural nerve is retracted laterally, and the paratenon is incised and tagged for later closure. The ruptured ends of the tendon are identified, and fibrotic and/or degenerated tendon is excised (Fig. 3).

Figure 3   The ruptured ends of the tendon are identified and degenerated tendon is removed.

The tendon ends are prepared for insertion into the mesh graft by incising the tendon 2-3 cm in the frontal plane. The mesh is prepared by tri-folding it to a slightly smaller width than the tendon itself. The folds are secured with 3-0 non-absorbable suture (Fig. 4).

Figure 4  The mesh is prepared by folding it 3 times to a slightly smaller width than the tendon itself.  The folds are secured with 3-0 non-absorbable suture.

To assess the length of graft, the gastrocnemius-soleus complex is pulled distally and then compared to the resting tension of the contralateral limb. The mesh is then measured and cut to fit the defect. The mesh is held in place with heavy non-absorbable suture, securing all knots anteriorly to prevent scarring and stenosis with the underlying superficial fascia and skin. The proximal portion is secured first (Fig.5), which allows for easier tensioning adjustments prior to securing the distal end.

Figure 5  The proximal portion of the mesh-tendon interface is first secured. 

A portion of the plantaris tendon is resected and fanned out to cover the anterior and posterior portion of the graft, and is secured using 3-0 non-absorbable suture (Fig. 6).

Figure 6  A portion of the plantaris tendon is resected and fanned out to cover the anterior and posterior portion of the graft and is secured.

The tendon and graft are reinforced with calcaneal bone anchors inserted medially and laterally (Fig. 7).

Figure 7  Bone anchors secure the repaired tendon to the calcaneus.

The anchor sutures are then braided along the sides of the tendon creating a finger-trap stitch. The paratenon is repaired with an interlocking baseball stitch and the skin is reapproximated using 5.0 absorbable suture. (Figs. 8,9)

Figure 8 The paratenon is reapproximated.

Figure 9  Absorbable suture is used for closure and surgical strips are placed across the surgery site.

All patients were placed in a non-weight bearing, short leg cast in gravity equinus for 3 weeks, and then advanced to a non-weight bearing walking boot with passive range of motion exercises for an additional 3 weeks. Progressive weight bearing with active physical therapy was initiated post-operatively at 6 weeks.


The average time for follow-up was 1.5 years (range 0.5 – 4 years; mean = 2 years; standard deviation 1.515; median 1.5 years; 25th percentile = 0.75 years; 75th percentile = 4 years). There were no cases of foreign body reaction following implantation of the mesh graft. All patients were able to return to work or to their level of activity before the injury. Of the twelve patients involved in the study, eight related no pain at the time of the interview.

Three patients related mild pain. One patient presented to the surgeon five months after surgery complaining of moderate pain at the operative site, and stated that he heard a “pop” when ambulating and began to experience pain at the surgical site. This patient was immobilized in a non-weightbearing walking boot with crutches and follow-up MRI showed evidence of diffuse thickening at the site of the repair with no evidence of a recurrent tear. He then returned to pre-operative activities of daily living without incident. Five patients related mild ankle joint stiffness upon waking in the morning. Two patients complained of mild weakness to the calf muscle.

Four patients stated that they were limited in their shoe gear, with one patient stating that she was no longer able to wear high heel shoes. All patients were satisfied with the overall results of the procedure. (Table 3)

TABLE 3 Data Results.


A number of surgical techniques have been described for the repair of neglected Achilles tendon ruptures. Autogenous grafts in the form of local tendons or free fascia may be used when the donor tissue is healthy and where the gaps are manageable. Synthetics grafts are useful when autogenous grafts cannot be used.

Lieberman, et al, [14] described repair of Achilles tendon ruptures with Dacron® vascular graft in 7 patients, with a follow-up of ten to 38 months. The graft was woven from distal to proximal and across the rupture in a Bunnell-type fashion, and the patients were immobilized in a short-leg cast for two weeks and then fitted with a posterior fiberglass splint.

Patients were allowed to return to their normal level of activity approximately five months after surgery. There was no incidence of re-rupture, wound infection, or skin adhesion. All of the patients had normal gait, normal range of motion of the ankle, and had returned to their pre-injury level of activity. Two patients noted weakness in the injured leg and two years after the repair; however, their activity levels had not been altered. Another patient complained of tightness in the tendon area and discomfort after a significant amount of exercise.

Parsons, et al, [15] described repair of Achilles tendon using a composite carbon implant in 48 patients/51 procedures with an average follow-up of 2.1 years. Three cohort groups were observed on a temporal basis and quantitatively evaluated at 1 year (N = 29), 18 months (N = 22), and 2 years (N = 20), respectively. These three groups demonstrated continuous improvement during the first postoperative year, with 86% having a good to excellent result. A high level of function was maintained throughout the second year.

Lee [17] described a case-report using GraftJacket ® for augmentation of a gastrocnemius recession repair in a chronic Achilles rupture. The augmentation obviated the need for tendon transfer or free tendon graft, and early return to activity and good plantarflexion strength was noted postoperatively.

This series reports on 12 patients who were repaired using Marlex ® polypropylene mesh. This material has been extensively used in general and cardiovascular surgery with predictable results. Hosey, et al, studied the Marlex ® -tendon complex in rabbits and reported that it had similar physical properties to a normal tendo Achilles. [20] There was no reported incidence of foreign body reaction. The potential risk of donor site morbidity was eliminated through use of a synthetic graft. All patients were satisfied or very satisfied with their surgical outcome. Ozaki [19] and Choskey [22] reported findings that were similar to those in our set.

There are a number of limitations in this study. The sample size is small, and our results are compared to historical controls, which inherently introduces bias between the two groups. Additionally, we did not consider any independent variables, such as weight or length of the tendon defect, which may have added confounders or bias to the overall outcome of the study.

The VISA-A (Victorian Institute of Sport Assessment-Achilles) questionnaire provides a valid and reliable index of severity of Achilles tendinopathy. [20] It was modified in this study to include questions about return to work and footwear restrictions. Additionally, it qualifies VISA-A pain, stiffness, and weakness score of 0 as none, 1-3 as mild, 4-6 as moderate, and 7-10 as severe. This modification may alter the operating characteristics of the questionnaire, however, it is quite unlikely.

In conclusion, the results demonstrated above suggest that polypropylene mesh graft is an effective alternative to autogenous grafts and/or tendon transfers in the treatment of neglected Achilles tendon rupture.

This investigation was not funded by any commercial or other outside agency or corporation. The investigators do not have any potential conflicts of interest, actual or perceived, to this investigation.


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Address correspondence to: Robert Fridman, DPM, AACFAS, Department of Orthopaedics, New York-Presbyterian Hospital, University Hospitals of Columbia and Cornell, New York, NY.

1Private Practice, Foot Associates of New York, New York, NY.
2Fahey Medical Center, Des Plaines, IL.
3Alexian Brothers Medical Center, Hoffman Estates, IL.
4Private Practice, Daugherty Foot and Ankle Clinic, Cape Girardeau, MI.
5Private Practice, Northwest Suburban Podiatry, Arlington Heights, IL.

© The Foot & Ankle Journal, 2008

Autograft, Allograft and Xenograft Options in the Treatment of Neglected Achilles Tendon Ruptures: A Historical Review with Illustration of Surgical Repair

by Jason R. Grove, DPM1, Mark A. Hardy, DPM, FACFAS2

The Foot & Ankle Journal 1 (5): 1

Achilles tendon ruptures are injuries that are becoming more common as the participation of recreational activities continue to increase. Fortunately, most acute ruptures are identified and treated within the first month of the injury, whether by immobilization or by primary surgical repair. Ruptures are sometimes missed by physicians or ignored by patients and the consequences of the so-called neglected Achilles rupture can be devastating. Surgical repair of neglected Achilles ruptures is less controversial than that of acute ruptures; however, selection of the most appropriate procedure often proves difficult. There have been a number of surgical approaches described to treat the neglected rupture. We present a review of the surgical approaches described in the literature as well as an illustration of our preferred methods.

Key words: Neglected Achilles tendon rupture, Surgical Achilles tendon repair

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: April 2008
Published: May 1st, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0105.0001

Achilles tendon ruptures were first described in 1575 by Ambrose Paré. [1,2] Historically, Achilles tendon ruptures were considered rare with an incidence of less than 0.2%. [3-6] Over the past decade the rate of ruptures has increased. [7-9] The Achilles accounted for 40% of operated tendon ruptures in one study. [10] Today, the Achilles tendon is the most common tendon ruptured in the lower extremity. [4] This recent increase in Achilles tendon ruptures is believed to be a consequence of increased participation in recreational acivities. [9,11-14]

Inglis and Sculco noted that 75% of the patients in their study related that the injury occurred during a recreational activity. [15] Endurance sports such as running and jogging can lead to chronic overuse and subsequent rupture of the tendon. [16,17]

Common symptoms include the feeling of being kicked from behind, [8] difficulty walking, weakened plantarflexion power, [18] swelling, and bruising about the ankle. On examination, there may be a palpable gap, [8,19,20] diminished plantarflexion strength, or a positive Thompson test. [21] Ma and Griffith stated that a palpable gap at the rupture site and diminished plantar flexion strength are pathognomonic of an Achilles tendon rupture. [22] Ecchymosis, edema, and pain on palpation may be present on exam.

In some patients, the symptoms may diminish quickly, or are minimal enough that they do not seek immediate treatment. [23] In Christensen’s analysis of 57 patients who suffered Achilles tendon ruptures, [19] were said to be painless. [24] Another concern is a missed diagnosis in the acute setting. It has been noted that up to 20% of Achilles ruptures are missed on initial exam. [25] The sequelae of disrupted Achilles tendon function is loss of ankle stability, calcaneal limp, and abnormal gait. [26,27]

There is still confusion in the literature at regarding the point at which an acute rupture is considered neglected. Bosworth noted contraction of the triceps surae complex occurs within 3-4 days after the rupture. [28] Four weeks is the most often cited interval describing a neglected Achilles tendon rupture. [9,29-31] The neglected Achilles rupture consists of a large gap with secondary contracture of the gastro-soleus complex [32] resulting in over-lengthening and weakness. Healing may not be directly related to return of functional activity. [29] Neglected ruptures often pose a more difficult task to the treating physician than do acute ruptures. [32-34] Barnes and Hardy showed that untreated Achilles ruptures heal with scar tissue filling the resultant gap. [35] The main factor in the success or failure of healing is the functional length of the muscle-tendon unit. Interposed scarring can impair the functional end result by weakening the plantar flexion power and cause instability about the ankle. [23,27,29] The ability to produce tension in an over-lengthened musculotendinous unit is poor. [29,35]

Surgical treatment of acute ruptures is still under debate. [12,20,36-38] Surgical treatment of neglected Achilles ruptures has been well documented to be more effective than conservative treatment in providing the patient better function. [17,29,31,33,34,39,40-47] Cetti, et al, found 75% of those treated with surgery had acceptable results, whereas only 56% of those treated with casting had return of normal function. [3] Nonetheless, surgical treatment of Achilles ruptures pose many challenges to the surgeon. [15,33,47]

There are complications that can occur with these surgeries, in particular, a high rate of wound complications such as dehiscence and infection. [15,16,49]

Christensen in 1931 was the first to report surgical treatment of neglected Achilles tendon ruptures. [50] Since that time, a number of reconstruction techniques have been described to treat neglected Achilles ruptures. Unfortunately, none of these techniques have shown evidence of superiority through comparative studies. [7,8,51] The surgical techniques have been categorized into two main groups: autologous and synthetic or allograft repair. The autologous techniques include augmentation with free fascia or tendon graft, fascia advancement or turn-down flaps, and local tendon transfers. [52]

Surgical Techniques


The free fascia lata graft was first described by Bugg and Boyd in 1968. [44] Maffulli described the use of a free gracilis graft for augmentation. [53] The fascia advancement technique was popularized by Abraham and Pankvich in 1974 with the V-Y plasty. [44] The gastrocnemius-soleus turn-down flap was described by Arner and Lindholm in 1959. [2,15,54] Disadvantages of using free grafts include the technical difficulty of some repairs as well as some requiring a separate incision.

Local tendon transfers have become more popular for repair of neglected Achilles rupture. The most commonly used tendons are the peroneus brevis, flexor hallucis longus (FHL), and flexor digitorum longus (FDL) tendons. [29] The peroneus brevis tendon transfer was first described by White and Kraynick. [55] Teuffer studied 30 patients with peroneus brevis transfer for neglected Achilles ruptures and at a mean follow up of 5 years, 28 of the 30 patients had excellent results, however he did not distinguish between early and late repairs. [56]

Although no evidence suggests abnormal gait after a peroneal brevis transfer, it may be disconcerting since it provides lateral ankle stability and eversion motion. The peroneus brevis is responsible for 28% of the eversion capacity of the hindfoot. [57]

Mann, et al, described using the FDL tendon transfer with a turn-down flap and had excellent or good results in 6 out of 7 patients studied. [38]

Hansen described the FHL tendon transfer. [45] Hansen, and more recently Den Hartog [58] harvested the tendon through the posterior incision, whereas Wapner [32,47] described the use of a second incision medially to allow for increased tendon length for transfer. A cadaveric study by Tashjian found that the average length of FHL tendon through a single incision was 5.16cm compared to 8.09cm when a double incision approach was used. [59] The 5.16cm tendon length was found to be more than adequate for transfer and solid fixation into the calcaneus. The technique described by Wapner involves passing the tendon through a transverse tunnel in the calcaneus and weaving the tendon into the Achilles. Pearsall et al described the use of interference screw fixation for FHL transfer which allows the tendon to be fixated directly into the calcaneus requiring less tendon length. [60]

There are a number of advantages to using the FHL tendon transfer. The FHL is stronger than the peroneus brevis [8] and Leppilahti [9] stated that the FHL tendon is twice as strong as FDL. The FHL tendon also maintains normal muscular balance that may be sacrificed with other transfers. Another advantage is the location of the muscle belly in relation to the Achilles tendon. It extends distally into the relatively avascular area of the Achilles tendon, offering a rich supply of blood. [14,45,47,61-63] As with any tendon transfer, subsequent weakness is a concern. Hansen noted that most patients over 30 years old did not have altered function after the loss of FHL strength. [45] Coull, et al, [64] discovered residual weakness of FHL function, but found no mechanical differences in forefoot loading patterns between the operated foot and the normal, non-operative foot.

Synthetic Materials

Synthetic materials include Dacron vascular grafts, [65] carbon fiber composites, [66] polyglycol threads, [67] or Marlex mesh. [68] Early studies showed success with these products. Unfortunately, they do not function as biologic grafts and are incapable of remodeling. [40,69,70] Furthermore, they may be biologically intolerant and prone to failure as a result of premature loading. [40,44,71] Amis, et al, observed a significant foreign body response with carbon fiber composites. [72]


Tendon allografts have become popular for ligament and tendon repair in orthopedic and podiatric surgery. In orthopedic surgery, this is particularly true for knee and shoulder reconstruction. In a 5 year follow up comparing autograft and Achilles tendon allograft for anterior cruciate ligament repair, Poehling, et al, found that functional outcomes were similar with fewer activity limitations in the allograft group compared to autograft group. [73] Nellas in 1996, Yuen in 2000, and more recently Lepow, et al, in 2006 have described the use of Achilles allograft for treatment of neglected Achilles ruptures with favorable outcomes. [74-76] Lepow utilized the allograft alone to repair a 10cm gap and at one year follow up the patient was back to pre-injury activity level. [76] The mechanical strength of rehydrated freeze-dried allografts were found to be similar to autografts in an animal study. [77] Most studies have now shown that the incorporation and remodeling phases of allografts are longer compared to autografts. [77] Unfortunately, the use of allografts can carry a small risk of disease transmission, especially HIV and hepatitis C. The most recently published report of the American Association of Tissue Banks states that more than 2 million musculoskeletal allografts have been distributed during the past 5 years with no documented incident of a viral disease transmission caused by an allograft. [77]


The OrthADAPT™ Bioimplant by Pegasus Biologics, Inc. is a xenograft tissue scaffold derived from equine pericardium. It provides an acellular highly organized collagen scaffold allowing for ingrowth and remodeling of normal tendon or ligamentous tissue. It functions to provide augmentation to healing and is not a substitute for tendon. The implant is less bulky than other grafts, with a thickness of 0.5mm. Because the graft is not of human origin, the usual risk of viral infection as seen in allografts is insignificant. The graft has a shelf-life of two years. It can easily be folded, cut to size, and fenestrated to cover an area of 9cm x 9cm. Its use in Achilles tendon ruptures can be useful not only to act as a tendon scaffold, but also to act as a barrier to the underlying tendon in cases when the paratenon is absent or adhered to the skin and must be sacrificed. A major disadvantage to its use is that it adds an avascular substance to an already poorly perfused area. [30,78]

Operative Techniques

The procedure is performed with the patient prone. General anesthesia is used and a thigh tourniquet used for hemostasis. A ten-centimeter linear posterior skin incision is made just medial to the Achilles tendon. (Fig. 1)

Figure 1   A linear incision is made just medial to the Achilles tendon. This incision allows for adequate exposure while decreasing rate of adhesion formation. The offset incision of the skin and underlying paratenon allows the presence of 2 barriers to the outside environment.

This technique is utilized to offset the incisions of the skin and paratenon to decrease risk of adhesion formation postoperatively. The paratenon is then incised; however it is often noted to be adhered to the underlying post-rupture, tissue fibrosis and this portion is usually sacrificed. Upon reflection of the paratenon at the rupture site, an area of fibrotic tissue is often interposed between the ruptured ends of the Achilles tendon. This is completely resected until normal tendon is noted at the distal and proximal ends.

FHL Tendon Transfer

First the fascia overlying the FHL muscle belly is incised to allow increased perfusion to the remaining Achilles tendon. The FHL tendon is then harvested as described by Hansen. [45] (Fig. 2)

Figure 2    Dissection deep and just medial to the Achilles tendon allows exposure of the flexor hallucis longus tendon.  The neurovascular structures lie just deep and medial to the tendon, necessitating the use of blunt dissection in this area. The blue arrow is pointing to the FHL tendon and the yellow arrow to the FHL muscle belly.

The tendon of the FHL is freed as distal as possible through the posterior incision. With care taken to protect the adjacent neurovascular structures, the tendon is cut and harvested. For fixation of the transferred tendon, we utilize the Bio-Tenodesis™ screw. (Arthrex, Naples, FL). The first step is to insert the drill guide. It is inserted from the superior calcaneal tuber through the plantar cortex in a posterior to anterior orientation. The angle of the drill must be such that the drill passes the plantar calcaneal cortex distal to the plantar calcaneal tubercles. (Fig. 3)

Figure 3   The drill is driven from the superior calcaneal tuber through the plantar cortex. Note the free FHL tendon, highlighted by the yellow arrow, which is ready for transfer.

After the FHL tendon width is measured, the reamer is then placed over the guide drill and inserted to a depth of the length of the screw. (Figs. 4,5)

Figure 4    The width of the tendon is measured to determine proper screw and tunnel diameter.

Figure 5    Insertion of the reamer over the guide drill. Only the near cortex is drilled creating the “open” tunnel for interference screw placement. The far (plantar) cortex is often spared during reaming as this helps prevent formation of painful bone callus or creation of a stress fracture.

Only the superior calcaneal cortex is reamed. This creates the open tunnel and the calcaneus is now ready for insertion of screw and tendon. First, the distal end of the free FHL tendon is secured with the modified Krackow stitch utilizing 2-0 Fiberwire™. A tendon passer is then inserted from the plantar heel superiorly through the drilled hole. The suture is harvested and the passer is pulled plantarly. This results in the Fiberwire™ being passed through the plantar heel. (Fig. 6)

Figure 6    The free FHL tendon is secured with 2-0 Fiberwire™ and then harvested and passed through the tunnel and the suture is pulled out the plantar aspect of the heel. This may be performed with a tendon passer (yellow arrow) or looped through the slot in the drill (blue arrow).

The last step is to secure the tendon with the screw utilizing the interference technique as described by Pearsall et al. First the Fiberwire™ exiting the plantar heel is pulled with the foot slightly plantarflexed. Care must be taken to ensure that the FHL tendon freely enters the open tunnel.

While maintaining tension on the Fiberwire™ with the foot in a slightly plantarflexed position, the FHL tendon is then secured into the superior calcaneus with the Bio-Tenodesis™ screw. (Fig. 7) The screw must be inserted completely into the calcaneus. The remaining Achilles tendon is then attached to the FHL tendon with 2-0 Fiberwire™, once again maintaining physiologic tension.

Figure 7    Insertion of interference screw:  Notice that there is firm tension on the suture coming out the plantar heel.  This will allow proper tension on the suture coming out the plantar heel. This will allow proper tension on the FHL tendon as the screw is inserted. The foot is kept in slight plantarflexion during this maneuver.

Allograft Achilles Tendon

The freeze-dried graft (Fig. 8) is allowed to warm and rehydrate in normal sterile saline for at least 30 minutes prior to implantation. The graft is then cut to the length needed to fill the gap left after debridement of scar tissue. #2 Fiberwire™ is utilized for its maximal strength to make a running Krackow stitch. (Fig. 9) The graft is then inserted and the free suture ends are tied with the foot in slight plantarflexion. (Fig. 10)


Figures 8,9,10    The cadaveric Achilles tendon allograft: The rehydration process should be performed for at least 30 minutes prior to use. (Fig. 8) The graft is cut to the proper length required to fill the gap and is then prepared for insertion with #2 Fiberwire™. (Fig. 9) Insertion of the graft: The suture ends are then tied with the foot slightly in plantarflexion for physiologic tension. (Fig. 10)


For further augmentation and due to inadequate paratenon coverage, the OrthADAPT™ (Pegasus Biologics, Inc, Irvine, CA) (Fig. 11) may be utilized. It is cut to size and wrapped circumferentially around the repair; alternatively, strips of graft may be sutured along the repair. The graft was secured to the Achilles tendon with 2-0 Fiberwire™. (Fig. 12)


Figures 11,12    OthADAPT™ graft prior to trimming and application to the Achilles repair. (Fig. 11) The OrthADAPT™ has been secured with #2 Fiberwire™ and acts as a sheath over the repair. (Fig. 12)

Postoperative Course

After wound closure, the patient is placed into non-weightbearing posterior splint with the ankle plantarflexed to gravity equinus. The patient is typically kept non-weightbearing for four to six weeks followed by four weeks in walking cast with gradual increase in weightbearing and propulsion. After suture removal (typically at 2 weeks) the patient is then instructed to begin gently range-of-motion exercises at the ankle joint to begin applying mild tension on the healing Achilles tendon, transferred tendon, or graft.


Neglected Achilles tendon ruptures have become a more common condition than in past decades and represent a difficult challenge for even the most experienced surgeon. Contrary to acute Achilles tendon ruptures, the evidence undoubtedly supports surgical treatment. However, the surgeon has the task of repairing a residual gap, restoring function, and preventing the many complications that commonly occur with Achilles tendon surgeries.

Furthermore, a number of surgical and grafting techniques have been described, none of which has become the gold standard. We believe there are distinct advantages of the FHL tendon transfer compared to the alternative techniques. These advantages include 1) tendon harvesting through a single posterior incision , 2) the FHL provides plantarflexory power greater than that of the FDL, 3) it offers a rich vascular supply form its muscle belly, 4) it is less technically demanding than other procedures, 5) and has no significant deleterious effect on the normal biomechanics of the foot.

In cases that have severe gaps and may require something more substantial than a tendon transfer, we believe the Achilles tendon allograft is a viable option either by itself or with FHL tendon transfer. It has similar strength to autografts and obviates the need for a donor site. It can, however, carry the risk of infectious transmission and takes longer to incorporate than autografts.

Lastly, we also believe the OrthADAPT™ xenograft allows for an acellular matrix that is useful in reinforcing the FHL or allograft augmentation. We have found that many of the neglected Achilles tendon ruptures have absent or diseased paratenon at the site of injury. Therefore, after the repair, the OrthADAPT™ provides not only a matrix for the augmented repair to incorporate into, but also a temporary barrier, preventing adhesions postoperatively. We believe these techniques are an effective and practical method for surgical repair of neglected Achilles tendon ruptures.


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Address correspondence to: Mark A. Hardy, DPM, FACFAS, Kaiser Permanente Foundation Department of Podiatric Surgery
12301 Snow Road Parma, OH 44130
Email: markhardy@sbcglobal.net

1Senior Resident, Kaiser Permanente/Cleveland Clinic Foundation Residency Program, Cleveland, Ohio.
2Director, Cleveland Clinic/Kaiser Permanente. Foot & Ankle Residency Program. Director, Foot and Ankle Trauma Service. Kaiser Permanente – Ohio Region

© The Foot & Ankle Journal, 2008