Tag Archives: Achilles tendon repair

Management of Open Chronic Tendo Achilles Injuries: A case report

by Anil Thomas Oommen MS Orth1 , Pradeep Mathew Poonnoose MS Orth2 ,
Debabrata Padhy MS Orth3 , Ravi Jacob Korula MS Orth4

The Foot and Ankle Online Journal 3 (1): 2

Delayed presentation of an open Tendo Achilles injury with segmental loss of tendon and soft tissue is a challenging problem for the Orthopaedic surgeon. We present a patient who presented with a 4 x 5 cm open wound and a 4cm segmental loss of the tendon 6 months after the injury. To bridge the defect in the tendon, lengthening of the proximal tendon was done using a tongue in groove sliding technique, and a reverse sural artery flap was used to cover the soft tissue defect. At 9 months follow up, the patient was able to perform a single limb toe stance. The technique and the relative merits of this simple procedure are discussed.

Key words: Achilles tendon, Sural artery flap, Bakers slide, Tendo Achilles, tendon rupture.

Accepted: December, 2009
Published: January, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0301.0002

Open Tendo Achilles injuries commonly occur following cycle spoke injuries or after a fall into ‘Indian style’ closets. [1] If patients present within 6 to 12 hours of the injury a thorough wash followed by primary or delayed repair of the tendon can be done. Management of delayed presentation of open Tendo Achilles injuries is more complex, as there is a loss of soft tissue cover in addition to the tendon defect.

An effective surgical procedure is required to bridge the defect in the Tendo Achilles, as well as to achieve adequate soft tissue cover. [1,2] A number of procedures have been described for reconstruction of the Tendo Achilles. These include lengthening the aponeurotic tendon either in a ‘tongue in groove’ fashion as described by Baker, or the V-Y technique popularized by Abraham and Pankovich. [1,2] The other methods described for repair of neglected rupture include augmentation with the peronei (Teuffer’s modification of White and Kraynick technique), or with a strip from the median raphe of the proximal tendon (Bosworth’s technique). [2] Management of the defect in an open injury is more complex because of the associated loss of soft tissue cover. The use of vascularised extensor digitorum brevis and various composite free flaps have been described for such defects. [2] These require the expertise of a micro vascular surgeon.

We present the case of a patient who presented with a 4 x 5 cm open wound and a 4 cm segmental loss of the tendon six months following a fall. Following a thorough debridement, we opted to bridge the defect by lengthening the tendon with a Baker’s procedure, and cover the skin defect with a reverse sural artery flap. The technique and relative merits of this simple procedure are discussed.

Surgical Procedure

With the patient in prone position, the wound was debrided and the residual skin defect measured. Swabs taken from the wound confirmed the absence of active infection.

The reverse sural artery flap was elevated before the tendon was lengthened. (Fig 1) The flap was marked proximally on the calf, with the edges 0.5 cm more than the measured recipient area.

Figure 1  Presentation of injury. Elevation of the reverse sural artery flap, with insert (A) showing the skin defect over the ruptured Tendo Achilles. The flap has been cut back to a bleeding edge.

The small saphenous vein, sural artery and nerve were cut at the proximal edge of the flap and raised along with the fascio-cutaneous flap. The deep fascia was anchored to the epidermis prior to elevating the flap, in order to prevent shearing between the deep fascia and the skin. Distally, the incision was extended up to the medial border of the wound. Laterally, the flap was raised to 7.5 cm short of the lateral malleolus, in order to preserve the perforators from the peroneal artery that supply the elevated flap. At this stage, the tourniquet was released, and bleeding from the flap edge was noted. As the bleeding from the leading edge of the flap was inadequate, the flap had to be cut back until a bleeding edge was obtained. (Fig. 1) The flap was then turned over its pedicle, and laid over the defect.

Following the elevation of the flap, the aponeurosis and tendinous portion of the Tendo Achilles was exposed. The proximal edge of the defect was freshened, and a no. 5 ethibond (ETHICON, Inc.) Bunnel suture was passed through the distal end of the tendon. Care was taken not to disturb the mesotenon near the defect. A ‘tongue in groove’ lengthening of the tendon was done at the musculotendinous junction. For the defect of 4 cm, a 9 cm cut was made in the aponeurosis, to ensure adequate overlap after the lengthening. Traction was applied to the tendon with the ethibond suture to lengthen the tendon, and the defect was closed with the ankle in 10 degrees of plantarflexion. (Fig. 2)

Figure 2 Repair of the tendon using a ‘tongue in grove lengthening’ of the aponeurosis.

There was no distal remnant of the Tendo Achilles, and hence the tendon was anchored on to the calcaneum directly. The insertion site on the calcaneum was freshened, and the ethibond suture was threaded through the calcaneum using a Beath pin, and anchored tightly onto the sole of the foot over a button. (Fig. 2) Additional bony sutures were placed between the tendon and the calcaneum.

After anchoring the tendon, the flap was rotated and sutured over the defect. Multiple corrugated drains were used under the flap to ensure good drainage. The donor site was covered with split thickness skin graft. An anterior plaster splint was applied to keep the ankle in plantarflexion. Once the sutures were removed after 2 weeks, the leg was casted in 20 degrees of flexion at the ankle for 2 months, followed by another 2 months in neutral position. The button used to anchor the ETHIBOND suture was removed at 4 months. He was then allowed to bear weight, though the repair had to be protected with a cast for another 2 months. At 9 months, he was able to perform a single limb toe stance. (Fig. 3)

Figure 3 Nine months following surgery, the patient was able to stand on one leg without support.


Delayed presentation of open Tendo Achilles injuries require careful repair of the tendon defect, and adequate soft tissue cover. [1,2] Reconstruction of the defect can be challenging, as the blood supply of the Tendo Achilles at its insertion is extremely poor. [3] The reconstruction of Tendo Achilles injuries require meticulous handling of the remnant segments. The mesotenon of the tendon segment near the defect should be preserved in order to maintain vascularity and achieve healing at the site of reconstruction. [3] Bosworth advocated elevation of a full thickness central strip of the proximal tendon, which is turned over and sutured to the distal end of the defect. The ‘turned over’ section of the graft has poor vascularity, and the healing at the repair site could potentially be compromised.

If the defect is bridged by lengthening the tendon proximally, the dissection of the mesotenon near the defect is less extensive, and hence the vascularity at the repair site is relatively well preserved. The repair is more biological and is more appropriate for reconstruction of the Tendo Achilles. The repair is also less bulky near the insertion site.

For protection of the reconstructed tendon, a full thickness soft tissue cover is necessary, as split thickness skin graft is unlikely to heal over the repair site.

The options for soft tissue cover include free vascularised composite tensor fascia lata flap, medial plantar flap with plantar aponeurosis or a free flap. [1,4] These free flaps often require micro vascular expertise.

The reverse sural artery flap is a neuro-cutaneous flap that has the advantages of having a fairly constant blood supply with associated ease of elevation and preservation of major vascular trunks in the lower extremity. [2,3] This flap is based on the distribution of the sural nerve and the retrograde perfusion is maintained by the anastomoses of the cutaneous perforating branches of the peroneal artery and the median superficial sural artery. [2,3]

This flap remains the workhorse for soft tissue cover over the posterior distal third of the leg and heel. [2,3] It is a relatively simple flap that can be performed by most orthopaedic surgeons. [2,4] The Tendo Achilles slide can be done through the same incision used for elevation of the flap. The resultant flap is however, often quite bulky. Where expertise is available, an adipo-fascial flap can be used to make the repair more aesthetic. [1]


The sliding technique for bridging defects in the Tendo Achilles followed by a reverse sural artery flap is an excellent option for management of delayed presentation of open Tendo Achilles injuries.


No benefits in any form have been received or will be received from any commercial party related directly or indirectly to the subject of this article.


1. Mohanty A, Jain P: Reconstructing and resurfacing open neglected Achilles tendon injury by distal posterior tibial artery based adipofascial flap. Eur J Plastic Surgery 27: 196 – 199, 2004.
2. Bullocks JM, Hickey RM, Basu CB, Hollier LH, Kim JY: Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap. J Plast Reconstr Aesthet Surg 61(5): 566 – 572 , 2008.
3. Carr AJ, Norris SH: The blood supply of the calcaneal tendon. J Bone Joint Surg 71B (1):100 – 101, 1989.
4. Jeng SF, Wei, FC: Distally based sural island flap for foot and ankle reconstruction. Plastic and Reconstructive Surgery 99 (3): 744 – 750,1997.

Address Correspondence to : Anil Thomas Oommen, Assistant Professor, Unit 2,Department of Orthopaedics,Christian Medical College and Hospital, Vellore, India, 632004 Email : lillyanil@cmcvellore.ac.in

Assistant Professor,Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282172.
Associate Professor, Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282173.
Assistant Professor,Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282081.
Professor and Head, Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282167.

© The Foot and Ankle Online Journal, 2010

The Achilles Musculotendinous Junction: A Survey of Orthopaedic Surgeons

by Richard Cove1 , David Weller2, Mark Westwood3

The Foot and Ankle Online Journal 2 (12): 4

Background: Achilles tendon rupture is a common injury, which can frequently affect young, active people. Consequently, there are important socio-economic implications in choosing the correct treatment. There is considerable debate in the literature concerning surgical versus non-surgical treatment and most surgeons would elect not to repair a rupture within the muscle belly above the musculotendinous junction. There is a wide anatomical variation in the exact location of the Achilles musculotendinous junction, which can lead to confusion among surgeons when trying to identify the location of a rupture and treatment plan.
Materials and Methods: Delegates at a regional orthopaedic meeting were asked to fill in a questionnaire, which showed a photograph of a lower limb. They were asked to draw two transverse lines, the first identifying the musculotendinous junction, and the second marking the highest level at which they would consider a surgical repair. They were asked about their understanding of the term “musculotendinous junction”.
Results: Twenty two delegates (n =22) of various degrees of seniority responded. There was a wide variety of answers, with the average level of the musculotendinous junction identified as being 10.1cm above the insertion into the calcaneum. The average highest level for considering surgical intervention was 8.71cm above the insertion into the calcaneum. Cadaveric measurements have shown that in fact the Achilles musculotendinous junction lies on average 5.51cm above the tendons attachment to the calcaneum.
Conclusion: There is confusion regarding the exact location and nature of the Achilles musculotendinous junction among the orthopaedic surgeons in our survey. Although most surgeons stated that they would not operate on a rupture above the musculotendinous junction, almost all identified a point higher than this region as their highest point for repair. Particular care is advised if an ultrasound reports the location of any rupture relative to the musculotendinous junction.

Key Words: Achilles tendon, rupture, surgical repair, conservative treatment, musculotendinous zone.

Accepted: November, 2009
Published: December, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0212.0004

The most common site for Achilles tendon rupture is 2-6cm from the calcaneal insertion, [1,2] although avulsion fractures of the os calcis have been described. [3] The Achilles tendon rupture is a common injury, affecting approximately 18 in 100,000 people [4,5], typically males between 30 and 50 years of age.

There is considerable debate in the orthopaedic literature about the benefits of surgical versus conservative treatment. However, it is generally accepted that surgical repair offers a lower rate of re-rupture, and conservative treatment avoids wound complications. [4,6,7] Many surgeons would elect to treat a rupture proximal to the musculotendinous junction (i.e. within the muscle belly) conservatively. The aim of this study was to investigate the confusion among surgeons of the exact nature and location of the musculotendinous junction.

Subjects and Methods

Delegates at the 2008 British South West Orthopaedic Club (SWOC) were asked to fill in an anonymous questionnaire, which showed a photograph of an exposed lower leg (male, 177cm tall – age and weight of the subject?). They were firstly asked their level of seniority, and then asked to draw two lines on the photograph; the first (labeled “line 1”) at the level of musculotendinous junction, and the second (labeled “line 2”) at the upper limit of where they thought surgical repair of an Achilles tendon rupture could be beneficial. They were also asked what they understood by the term “musculotendinous junction” for the Achilles tendon, and what they considered as the clinical significance of this junction.

The original photograph included a tape measure which was cropped out of the image shown to the delegates. The exact location of the Achilles tendon insertion was established using ultrasound and a mark on the subjects’ skin, which was digitally removed on the image shown to the delegates. A scaled ruler was used to directly measure the delegates’ markings on the photograph.


Twenty-two (out of 35) surgeons returned a completed form- 7 Consultants (2 with an interest in foot and ankle surgery), thirteen Specialist registrars (SpR), 1 Associate Specialist, 1 ST1 trainee, and 1 respondent not specifying their grade.

The average level at which the musculotendinous junction was identified was 10.1cm (Standard Deviation [SD] 3.9cm) above the calcaneal attachment, with the average for consultants slightly higher than SpRs, at 11.5cm and 8.8cm respectively. The average highest level at which people thought surgery would be beneficial was 8.7cm (SD 2.7cm), with little difference between consultants and SpRs (8.8cm compared to 8.6cm). This meant that overall, those that responded thought that the highest level at which a patient might benefit from surgery was on average 1.4cm (SD 1.4cm) below the level of the musculotendinous junction.

There was a wide disparity in answers, with levels identified for the musculotendinous junction varying between 5.5cm and 24.5cm, with the level identified for considering surgery varying between 5.5cm and 17.5cm. The variation in differences between the two levels was also large, from people identifying the highest level for surgery at 3.5cm below the musculotendinous junction through to 2.5cm above it.

When asked what their understanding of the term “musculotendinous junction” was, virtually all respondents stated that it was where the muscle fibres were replaced by tendon, with a few people identifying it as a zone of transition rather than a discrete “junction”. When asked what they felt its clinical significance was, comments varied from “the muscle enhances healing/vascularity”, “the suture in the muscle belly is less likely to hold”, to “nil”, and “arbitrary”. However, most comments (thirteen out of twenty two) suggested that tears above the musculotendinous junction should be treated non-operatively, with comments such as “ruptures proximal to this don’t benefit from surgery”, and “repair at or above will be difficult due to suture cut out”. The results are summarized in figures 1 and 2.

Figure 1 Survey Results.

Figure 2 Results Key.


In 2007 Pichler, et al. [8], directly measured the distance from the soleus musculotendinous junction to the attachment of the tendon to the posterior surface of the calcaneal tuberosity in series of cadavers.

Although they reported a wide anatomical variation, ranging from 0 to 11.75cm, they showed that the overall average distance was 5.51cm, with 70% of their subjects having a musculotendinous junction between 2.54cm and 7.62cm from the attachment to the calcaneus. [8] This is considerably lower than the level identified by the surgeons in our survey (where the average was 10.1cm). This suggests that orthopaedic surgeons consistently overestimate the level of the musculotendinous junction. This disparity is of concern as it may lead to misinterpretation of ultrasound reports that make reference to the musculotendinous junction.

It is interesting to note that the surgeons surveyed are prepared to consider operative repair more proximal than the anatomical musculotendinous junction. It would suggest that there is adequate quality tendon to repair proximally. This is despite the fact that the majority of respondents defined the musculotendinous junction as a level beyond which sutures would not hold.

We would suggest that the term musculotendinous junction should continue to define the point at which the last fibres of soleus attach to the Achilles tendon. Proximal to this there is a ‘musculotendinous zone’. This study has identified an ‘Achilles surgical zone’ which is approximately 0-10cm from the calcaneal insertion. Further research is required to discover the true value of surgery for high Achilles ruptures.

In the light of our findings, and bearing in mind the considerable anatomical variation identified by Pichler, et al., [8] we suggest that, to avoid confusion, any ultrasound scan on a suspected Achilles tendon rupture should identify the level of a rupture relative to the calcaneal insertion.


1. Carr AJ, Norris SH: The blood supply of the calcaneal tendon. J Bone Joint Surg 71B:100 – 101, 1989.
2. Lagergren C, Lindholm A: Vascular distribution in the Achilles tendon. Acta Chir Scand 116: 491 – 495, 1958/59.
3. Arner O, Lindholm A: Avulsion fracture of the os calcaneus. Acta Chir Scand 117: 258 – 260, 1959.
4. Khan RJK, Fick D, Keogh A, Crawford J, Brammar T, Parker M: Treatment of acute Achilles tendon ruptures. J Bone Joint Surg 87A (10) 2202 – 2209, 2005.
5. Bhandar M, Guyatt GH, Siddiqui F, Morrow F, Busse J, Leighton RK, Sprague S, Schemitsch EH: Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res. 400:190-200, 2002.
6. Lea RB, Smith L: Non-Surgical Treatment of Tendo Achilles Rupture. J Bone Joint Surg 54A (7): 1398 – 1407, 1972.
7. Strauss EJ, Ishak C, Jazzrawi L, Sherman O, Rosen J: Operative treatment of acute Achilles tendon ruptures: An institutional review of clinical outcomes. Injury 38: 832 – 838, 2007.
8. Pichler W, Tesch NP, Grechenig W, Leithgoeb O, Windisch, G: Anatomical variations of the musculotendinous junction of the soleus muscle and its clinical implications. Clin Anat 20: 444 – 447, 2007.

Address Correspondence to: Richard Cove FRCS(orth)
Email: richard_cove@yahoo.com

Orthopaedic Registrar, Royal Cornwall Hospital, Truro, UK.
Orthopaedic SHO, Derriford Hospital, Plymouth. UK.
Othopaedic Consultant, Plymouth. UK.

© The Foot and Ankle Online Journal, 2009

An Unusual Second Rupture of the Achilles Tendon: A case report

by Oladejo A. Olaleye, MRCS Ed., DOHNS, MBBS1 , Helmut Zahn, FRCS (Tr&Ortho)2

The Foot & Ankle Journal 1 (12): 3

This case report describes an unusual second rupture sustained after conservative treatment of an initial Achilles tendon rupture at the musculotendinous junction. The initial injury was successfully managed conservatively with an equinus cast for 6 weeks. The patient developed a tendonitis 10cm below the initial rupture and subsequently sustained a second traumatic rupture of the Achilles tendon at a new site after tripping on a curb. The patient had no known systemic diseases and was not on steroid or fluoroquinolone therapy. The site of this second rupture was repaired surgically using an open technique without any long term complications.

Key words: Achilles tendon, rupture, traumatic

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: November, 2008
Published: December, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0112.0003

Case report

A 37 year-old male, dog-handler from the police force was chasing a suspect when he experienced acute pain to the right posterior leg in the Achilles region. He was unable to ambulate after the initial injury. No previous leg injuries or tendinitis were reported. The patient did not report any history of taking corticosteroids or fluoroquinolone antibiotics. Clinically, the patient had a positive Simmond’s test and rupture of the Achilles tendon was isolated to the musculo-tendinous junction.

A clinical diagnosis of Achilles rupture was rendered. No magnetic resonance imaging (MRI) was initially performed and the patient was managed conservatively in an equinus cast for 6 weeks and then in an adjustable boot to bring the foot to ankle range of motion to 90 degrees over the following 6 weeks. The adjustable boot was initially put in 20 degrees of dorsiflexion for 3 weeks then adjusted to 90 degrees over the following course of treatment.

The adjustable boot was removed and he managed to walk without crutches. The patient had regained total range of motion of the ankle with no gap or tenderness along the Achilles tendon and good plantarflexion power.


He subsequently developed a painful lump in his Achilles tendon 10cm inferior to the initial rupture location. Clinically, he had a fusiform swelling of the tendon which was slightly fluctuant and tender to palpation. He was placed on a course of anti-inflammatory medication and referred to physiotherapy for ultrasound. To confirm the diagnosis, an MRI scan was scheduled. During this period, the patient sustained a second injury to the same tendon while waiting for the MRI scan. The patient had been walking on the road with a group of friends when he tripped on a curb and felt a sharp pain along his right Achilles tendon. MRI confirmed a second injury more inferior to the original site of injury. (Fig. 1)

Figure 1 Region of second rupture as identified on MRI (arrow).  More proximally, the initial injury can be seen at the musculo-tendinous junction. 

MRI of the site of injury revealed an abnormally high signal change and thickening within a somewhat retracted Achilles tendon 3 cm above its insertion as well as at the musculo-tendinous junction of the gastrocnemius muscle.

This was consistent with a full-thickness, high-grade tear or rupture of the Achilles tendon at the musculo-tendinous junction. Intra-tendinous edema associated with the presence of fluid was located within and about the Achilles tendon suggesting the presence of intra-tendinous hematoma. There was also swelling of the posterior surrounding subcutaneous soft tissues.

There was little fluid noted within the retrocalcaneal bursa or along the lower aspect of the Achilles tendon about 2.5cm from its insertion.

A small region of marrow edema was noted in the posterior aspect of the talus. The tibia and fibula were intact and no fracture of ankle was reported.

On his second presentation to the hospital, there was a palpable gap to the Achilles tendon with a positive Simmond’s test. At this time, he was scheduled for primary surgical repair of the tendon.

Intraoperatively, the patient had a general anaesthetic, positioned in a prone position with tourniquet applied. The incision was limited to the second rupture site and the initial injury was not visualised as it was at the musculotendinous junction. The tendon was exposed demonstrating the second rupture with obvious complete rupture 3 cm above the calcaneus with high attenuation. (Figs. 2A and B)


Figure 2A and B  Intra-operatively, substantial attenuation of reinjury is identified with a forcep holding distal end of achilles tendon rupture, 3cm above its calcaneal insertion (A)  The proximal end of the ruptured tendon is also identified with a forcep. (B)

The ruptured edges were identified and re-apposed by a modified Kessler locking core stitch using No.5 Ethibond and a running suture using No.1 Vicryl. (Fig. 3) Postoperatively, he was placed in an equinus cast with DVT (deep vein thrombosis) prophylaxis and gradual rehabilitation with good recovery.

Figure 3 Repair after closure of the Achilles paratenon.


Achilles tendon rupture is a complete disruption of the Achilles tendon most commonly affecting 30-50 year old males with the rupture about 4-5cm above the calcaneus (a zone of poor blood flow in the tendon). [7] There is a male:female predisposition of 6:1. Predisposing factors include chronic tendonitis or tendinopathy and prior cortisone injection treatments. The majority of these injuries occur during some athletic event requiring forceful push-off of the foot. Other associating risk factors include gout, patient with blood type O, systemic lupus erythematosus, rheumatoid arthritis, patients on steroid medication and fluoroquinolone-type antibiotics. [7]

Achilles tendon rupture is often characterized by an acute onset of pain in the distal posterior portion of the lower leg. Patients often think they have been kicked, cut or hit in the back of the leg with subsequent difficulties ambulating or putting weight down on the affected foot.

Pathophysiological theories include chronic degeneration of the tendon and failure of the inhibitory mechanism of the musculotendinous unit. [5] Some believe that it may be due to the whipping action or bowstring effect caused by ankle pronation, or by the Achilles tendon’s relatively weak blood supply. Others consider the cause to be the combination and frequency of eccentric shortening when the heel hits the ground followed rapidly by concentric contraction when the toes push off. [9]

There is obvious leg swelling with a palpable defect in the Achilles tendon and a positive Thompson’s test. The Thompson’s test usually reveals absence of plantar flexion on squeezing the calf with the patient lying in the prone position.

The diagnosis is often made clinically. Plain radiographs, ultrasonography, and MRI can also be useful to confirm the diagnosis. The MRI is the gold-standard for diagnosing acute Achilles tendon ruptures and can also confirm the diagnosis of a partial rupture which may not be clinically apparent.

Achilles tendon injuries can occur in different locations along the Achilles tendon. Tennis leg is a rupture between the Achilles tendon and the gastrocnemius. Achilles tendinosis, Achilles tendonitis, Achilles tenosynovitis, Achilles tendon rupture and medicine side effects are most often felt an inch or two above the heel. Insertional Achilles tendinosis, tendonitis, and tenosynovitis occur where the Achilles tendon and heel connect. Achilles tendon laceration or crushing could occur anywhere along the Achilles tendon. [9]

Achilles tendon ruptures can be managed conservatively or operatively and several methods have been employed with varying results. Lower re-rupture rates and slightly improved strength and functional ability may be expected with surgical repair. The rate of minor surgical complications is higher than that of non-operative treatment. [5] With careful attention to the surgical wound and patient compliance to post-operative rehabilitation protocols, operative repair of acute Achilles tendon ruptures is a reliable treatment for active patients. [8] Three partial Achilles tendon re-ruptures and one complete rupture were documented in a series of 74 patients that had operative repair. [8] A known benefit of surgical repair is the decreased re-rupture rate. One study showed a 4% re-rupture rate for operative repair compared to an 8% re-rupture rate for conservative management. [6] Re-rupture rates of 1.4% and 13.4% for surgical and conservative management respectively have been reported. [1] A meta-analysis found re-rupture rates of 1% and 18% for surgical and conservative repair. [3] There were no re-ruptures for 44 patients treated surgically as opposed to 9 of the 44 for those treated conservatively. [2]

Recent studies have suggested better outcomes with early postoperative functional rehabilitation. An unusual type rupture, where the Achilles tendon was ruptured in two places requiring several innovative techniques to repair has been described. [4]

In our institution, we prefer operative approach with early mobilisation in an adjustable air cast boot. The usual regime is to apply a dorsal slab until the wound has healed. An adjustable air cast boot is then applied starting at 45 degrees of equinus aiming to reach 90 degrees by 6 weeks, at which point, weight bearing is allowed. Passive dorsiflexion is continued until range of movement equals contralateral side. The air cast is discarded 3 months after surgical repair.


This case report highlights an unusual second rupture of the Achilles tendon at a different site on the same tendon following an initial traumatic rupture at the musculotendinous junction. This is a rarely reported injury in the literature. This previously fit and healthy patient had a traumatic rupture of his right Achilles tendon at the musculotendinous junction which was treated conservatively in an equinus cast. He subsequently developed a tendonitis and then traumatic rupture at a site 10cm below the initial rupture on the same tendon. This was treated with open surgical repair and rehabilitation.

In conclusion, the presentation of this case study has highlighted the potential role for routine MRI scanning to assess Achilles tendon ruptures and identification of risk for a second rupture.


1. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus non-operative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 21 (6): 791 – 799, 1993.
2. Inglis AE, Scott WN, Sculco TP, Patterson AH. Ruptures of the tendo Achilles: an objective assessment of surgical and non-surgical treatment. J Bone Joint Surg 58A (7): 990 – 993, 1976.
3. Kellam JF, Hunter GA, McElwain JP. Review of the operative treatment of Achilles tendon rupture. Clin Orthop 201: 80 – 83, 1985.
4. Kuwada GT. A severe acute Achilles rupture and repair. J Foot Ankle Surg 34 (3): 262 – 5, 1995.
5. Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med 25(2): 79 – 100, 1998.
6. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture: a prospective randomized study. J Bone Joint Surg 63A (3): 394 – 399, 1981.
7. Saglimbeni AJ & Fulmer CJ. Achilles tendon injuries and tendonitis. Emedicine, 2008.
8. Strauss EJ, Ishak C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes. Injury 38(7): 832 -838, 2007.
9. Everything about Achilles tendons (2004-2006). Online, accessed 24th November 2008.

Address correspondence to: Olaleye MRCS Ed., DOHNS, MBBS
Trauma and Orthopaedic Surgery Department
William Harvey Hospital, Ashford
Kent, United Kingdom. TN24-OLZ
Email: dejolaleye@yahoo.com

1 CT1 Trauma and Orthopaedic Surgery, William Harvey Hospital. Ashford, Kent. UK.
2 Consultant, Trauma and Orthopaedic Surgery, William Harvey Hospital, Ashford, Kent. UK.

© 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

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