Tag Archives: Achilles tendon

Aberrant Tendo-Achilles Tendon in Club Foot: A case report

by J. Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho)1, Mathew Varghese, M.S. (Ortho)2, Balu Sankaran, FRCS, FAMS3, Rajendra Kumar Gupta4, Simon Thomas, MBBS, DNB (Ortho), MNAMS (Ortho)5, Amit Mittal6

The Foot & Ankle Journal 2 (2): 2

This case report discusses the presentation and treatment of a baby boy with club foot deformity. He was initially treated by Ponseti’s method of weekly plaster of paris casting. The club foot did not reduce after 6 weeks of serial casting. The boy then underwent percutaneous Achilles tendon lengthening and placed in a Steinbek Splint. After 12 weeks, the equinus persisted and we decided to perform an open Achilles lengthening. An aberrant tendo-achilles tendon was discovered during open tenotomy and this was released. Once the aberrant tendon was released, the club foot reduced and at 9 months, the baby could walk with good heel strike and the foot was supple with no residual deformity.

Key words: Aberrant tendo-Achilles tendon, club foot, talipes equinus, Ponseti’s casting method

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: January, 2009
Published: February, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0202.0002

Congenital club foot is a complex deformity that is difficult to correct. It has a tendency to recur until the age of six or seven years. While there may be a so-called recurrence in an adolescent, this is usually associated with incomplete initial correction rather than being secondary to growth alone. We present a case report of a 15 day-old boy with aberrant tendo-Achilles tendon of the right side which caused an incomplete correction of club foot.

Case Report

A 15 day- old baby was referred by a pediatrician for the management of right clubfoot. The baby was a full-term, normal delivery in a governmental hospital. On examination the baby was found to have a 3-dimensional deformity (CAVE) with four components in the right foot (Figs. 1)


Figures  1   A 15 day- old baby presents with right club foot deformity.  The deformity is 3-dimensional with 4 components including cavus, forefoot adduction, heel varus and equinus (CAVE).

C-Cavus-increased longitudinal arch of foot.
A-Adduction-tarsal bones are directed towards the median plane
V-Varus-inversion and adduction of calcaneum
E-Equinus-increased plantar flexion of foot

The spine and pelvis were clinically normal. The baby was treated by Ponseti’s method of weekly POP (plaster of paris) cast. Simultaneous correction of the three components of deformity (Cavus, Forefoot, Adduction and heel varus) was achieved in 6 weeks. (Fig. 2)

Figure 2   The baby is treated with serial casting  by Ponseti’s method of weekly plaster of paris cast.

The baby had persistent equinus (Fig. 3A) after 6 weeks of serial POP casting. The foot could be abducted and externally rotated to 60 degrees.A percutaneous tenotomy of the tendo-Achilles was done under local anesthesia. Postoperatively, toe to groin cast with knee in 90 degrees of flexion to maintain the corrected position and to allow tendon healing was applied for 3 weeks. Then the foot was maintained in 60-70 degrees of abduction, external rotation and 15-20 degrees of dorsiflexion by Steinbek Splint (open toe high top straight shoes attached to bar of length equal to shoulder width). This splint is usually worn 23 hours/day for the first 3 months and 14-16 hours/day up to 3-4 years of age.

Twelve weeks later, the parents were complaining that their baby touches the floor only with tip of the right toe. On examination, the heel cord was found tight. (Fig. 3B)


Figures 3A and 3B  The boy presents with persistent equines following 6 weeks of serial casting. (3A)  After 12 weeks, the heel cord was still found to be tight and open Achilles tendon lengthening was planned. (3B)

Equinus was found to be persistent. We decided to do an open tendo-Achilles lengthening. Intra-operatively, we found an aberrant tendo-Achilles tendon (Fig. 4) attaching just posterior to the tendo-Achilles tendon and the calcaneal tuberosity. This was released from the calcaneum and the foot could be dorsiflexed to 20 degrees on the operating table. The baby was given an above- knee POP cast for 3 weeks and followed with Steinbek Splint in 70 degrees of abduction, external rotation on affected side and 45 degrees on normal side with 15 degrees of dorsiflexion.

Figure 4  An aberrent tendo-Achilles tendon was discovered during open tenotomy.  The aberrent tendon was located just posterior to the Achilles tendon and calcaneal tuberosity.

At 9 months, the baby could walk with a good heel strike and the foot was supple with no residual deformity. (Fig. 5) At 18 months follow up the baby was found to have a pain-free, plantigrade foot, with good mobility. (Fig. 6) The parents were advised to continuously use the brace for the baby, 14 to 16 hours a day until 3 to 4 years of age.

Figure 5  At 9 months, the boy could walk with good heel strike and the foot was supple with no deformity.

Figure 6  At 18 months follow-up, the baby was found to have a pain-free, plantigrade foot, with good mobility.


Club foot deformity has four components [3-5,6,14,15]: equinus, varus, adductus, and cavus. The goal of treatment is to reduce or eliminate these four deformities so that the patient has a functional, pain-free, plantigrade foot, with good mobility and without calluses, and does not need to wear modified shoes. The most severe deformities in a club foot occur in the hind part of the foot. The talus and calcaneus are generally deformed and in severe equinus, the calcaneus is in varus angulation and medially rotated, and the navicular is severely displaced medially. [2,11,12,17,18,20,21] These components of the deformity are inextricably inter-related. The ligaments of the posterior aspect of the ankle and of the medial and plantar aspects of the foot are shortened and thickened. The muscles and tendons of the gastrocnemius tibialis posterior, and toe flexors are shortened. [4,14,15,20]

Most orthopedists have agreed that the initial treatment of a club foot should be non-operative. [4,5,8,11,12,14,15] The preferred method is manipulation and application of a plaster cast at weekly intervals. Less favored methods of initial treatment are use of a Denis Browne splint, stretching and adhesive strapping, and physiotherapy. Manipulation and serial application of casts, supported by limited operative intervention, yielded satisfactory functional results in 89 percent of the feet. [8,14,15] However, at other institutions, manipulative treatment has resulted in increased cavus deformity, rocker-bottom deformity, a longitudinal breach, flattening of the proximal surface of the talus, lateral rotation of the ankle, and increased stiffness of the ligaments and joints. [1,2,3,4] To avoid these distressing outcomes, early and even primary operative treatment of club foot is practiced in some centers [5,7,9,10,12,15,19,23], often with equally disturbing failures and complications, such as wound infection, necrosis of the skin, severe scarring, stiff joints, overcorrection and under correction, dislocation of the navicular, flattening and beaking of the talar head, talar necrosis, and weakness of the plantar flexors of the ankle with major disturbances of gait.

The reported results of operations in newborns have been either short term and not encouraging. Early operative treatment often results in reduced motion of the ankle and foot, whereas manipulation and the application of plaster casts with proper technique lead to greater mobility and less disability. [7,9,10,13,15]

Most orthopedists have agreed that an operation [3,4,5,11,12,15,21] should be considered only after manipulation and serial application of casts have failed to obtain correction in a specified period of time, preferably not more than three months. The poor results of manipulative treatment of most club feet in many clinics suggest that the attempts at correction have been inadequate or that the technique has been faulty. [8,14,15] Books and papers on pediatric orthopedics have devoted scant space to manipulative technique in the treatment of this deformity, and often the descriptions have been incorrect. The correction of the cavus component of the deformity is usually not addressed. [14,15] The equinus is corrected by dorsiflexion of the foot with the heel in valgus after the adduction of the foot and the varus deformity of the heel has been corrected. The correction entails stretching of the tight posterior capsules and ligaments of the ankle and subtalar joints and the tendo-Achilles. [4,5,8,12,14,15] Two or three plaster casts that carefully mold the heel, applied after manipulation, are usually needed to correct the equinus deformity. Care should be taken not to cause a rocker-bottom deformity, which can occur when dorsiflexion of the foot is attempted with pressure under the metatarsals rather than under the mid-part of the foot, particularly when the varus deformity of the heel has not been corrected. [1,8]

A simple subcutaneous tenotomy of the tendo-Achilles, performed with the patient under local anesthesia, facilitates correction of the equines. [8,14,15] This tenotomy is done in about 70 percent of patients, when 15 degrees of dorsiflexion has not been obtained with the use of the casts. Dorsiflexion of the ankle to more than 10 to 15 degrees is rarely possible because of the talar and calcaneal malformations and tight ligaments. A posterior capsulotomy of the ankle and subtalar joint is rarely done, because the few additional degrees of correction that are obtained may be completely lost later due to retraction of the scar tissue. [4,5,13,14,15]

Regardless of treatment, a club-foot deformity tends to relapse until the child is about seven years old. [3,4,5,8,12,14,15] To prevent relapse, some orthopedists hold the foot in maximum correction with a series of plaster casts or with splints. Denis Browne splints and high-top shoes with well-molded heels that hold the feet in lateral rotation are the most effective means for maintenance of the correction. The splints are worn full time for two to three months and thereafter at night for two to four years. The splint should maintain the foot in 60 to 70 degrees of external rotation, to prevent recurrence of varus deformity of the heel, adduction of the foot, and in-toeing. [8,14,15] With careful supervision and with cooperative and responsible parents who follow instructions faithfully; relapse can be prevented in about 50 percent of patients. In the other 50 percent, a relapse will occur between the ages of ten months and seven years (average age, two and one-half years). A relapse is detected when slight equinus and varus deformity of the heel is observed, usually without increased cavus and adduction deformity of the fore foot. [16,18,22,23]

The original correction may be recovered in four to eight weeks with manipulations followed by application of a toe-to-groin plaster cast, with the foot held in marked lateral rotation, every ten to fourteen days. This treatment is often followed by lengthening of the tendo-Achilles, if the tendon prevents dorsiflexion of the ankle to at least 15 degrees, and by use of the Denis Browne splint at night. [3,4,5,8,12,14,15] A large proportion of club feet that are treated with this procedure found the correction of the equinus, varus deformity of the heel, was obtained with manipulation and application of casts. If this can be maintained, the anteroposterior talocalcaneal angle will become normal. Cavus component of the club-foot deformity rarely recurs. [8,14,15] When this deformity is resistant to manipulation, it should be treated with plantar fasciotomy and recession of the extensor hallucis longus tendon to the neck of the first metatarsal. The adductus component of the club-foot deformity does not recur in patients who have received good treatment and follow-up care. When proper treatment with manipulation and casting has been started shortly after birth, operative release of the tarsal joints is seldom needed. [19]

An early operation (not later than the second month of life) is indicated only in the small percentage of patients who have short, rigid feet, with very severe equino varus deformity, that do not respond to proper manipulations. Many orthopedists also favor release of the tarsal joints in less rigid feet when manipulations have failed to completely correct the displacement of the navicular and the talocalcaneal alignment to a normal talocalcaneal index. Extensive posteromedial release, with or without internal fixation of the tarsal bones, is the preferred procedure, but there has been much disagreement about the timing of the operation. Recently, more radical [19,22,23] techniques have been tried in younger patients. The objective of all of these operations is release of the tight capsules and ligaments of the ankle and tarsal joints, and lengthening of the shortened tendons of the foot to facilitate placement of the tarsal bones in normal alignment.

The baby in this case report had a persistent eqinus deformity even after percutaneous tenotomy. Intra-operatively an aberrant tendo-Achilles was noted and was released from its calcaneal attachment. This could be the reason for the resistant equinus deformity. The literature rarely describes the aberrant tendo-Achilles tendon and the management.


The initial treatment of club foot should be non-operative. Corrective manipulation and serial application of casts, followed by calcaneal tenotomy and release of an aberrant tendo-Achilles tendon if found, should be successful in at least 85 percent of patients who are initially treated a few days after birth. High index of suspicion for an aberrant tendon should be there, if there is a resistant equinus deformity alone, especially after manipulation, POP cast correction and percutaneous tendo-Achilles tenotomy.

The orthopedist and podiatrist must have a thorough understanding of the deformity and be highly skilled with regard to manipulation and the application of plaster casts. Most relapses can be treated successfully with additional manipulations and applications of casts for four to eight weeks. Operative correction of a club foot is indicated when the deformity has not been treated successfully with proper manipulation and serial application of casts, supported by limited operative intervention. Most of these resistant club feet can be corrected with the use of an extensive posteromedial release and release of aberrant tendo-Achilles tendon with satisfactory functional results.


1. Altar D, Lehman WB, Grant AD.: Complications in clubfoot surgery. Orthop Rev 20: 233 – 239, 1991.
2. Beatson TR, Pearson JR. A method of assessing correction in club feet. J Bone Joint Surg 44B( 1): 40 – 50, 1966.
3. Brockman EP. Congenital Club-Foot (Talipes Equinovarus). Bristol, John Wright. 1930.
4. Carroll NC. Congenital clubfoot: patho anatomy and treatment. In Instructional Course Lectures, in American Academy of Orthopedic Surgeons. Vol. 36. pp. 117 – 121. Park Ridge, Illinois. The American Academy of Orthopaedic Surgeons, 1987.
5. Cummings RJ, Lovell WW. Current concepts review. Operative treatment of congenital idiopathic club foot. J Bone Joint Surg 70A: 1108 – I112, 1988.
6. Evans D. Relapsed club foot. J Bone Joint Surg 43B(4): 722 – 733, 1961.
7. Green ADL, Lloyd-Roberts C. The results of early posterior release in resistant club feet. A long-term review. J Bone Joint Surg 67B (4): 588 – 593, 1985.
8. Laaveg SJ, Ponseti IV.: Long-term results of treatment of congenital club foot. J Bone Joint Surg 62A: 23-31, 1980.
9. Lau JHK, Meyer LC, Lau HC. Results of surgical treatment of talipes equinovarus congenita. Clin Orthop. 248:219 – 226. 1989.
10. Levin MN, Kuo KN, Harris CF, Matesi DV. Posteromedial release for idiopathic talipes equinovarus. A long-term follow-up study. Int Orthop 242: 265 – 268, 1989.
11. Lovell WW. Bailey T, Price CT, Purvis JM. The non-operative management of the congenital clubfoot. Orthop. Rev 8: 1l3 – 115, 1979.
12. McKay DW. New concept of and approach to clubfoot treatment: section I principles and morbid anatomy. J. Pediat Orthop. 2: 347 – 356, 1982.
13. Main BJ, Cnder RJ. An analysis of residual deformity in club feet submitted to early operation. J Bone Joint Surg 60B (4): 536 – 543, 1978.
14. Ponseti IV, Campos J. Observations on pathogenesis and treatment of congenital clubfoot. Clin Orthop. 84: 50 -60, 1972.
15. Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. J Bone Joint Surg 45A (344): 261 – 275, 1963.
16. Porter RW. Congenital talipes equinovarus: Resolving and resistant deformities. J Bone Joint Surg 69B (S): 822- 825, 1987.
17. Porter RW, Roy A, Rippstein J. Assessment in congenital talipes equinovarus. Foot and Ankle Int 1: 16 – 21, 1990.
18. Scott WA, Hosking SW, Catterall A. Club foot. Observations on the surgical anatomy of dorsiflexion. J Bone Joint Surg 66B (1): 71-76. 1984.
19. Simons CW. Complete subtalar release in clubfeet. Part I- a preliminary report. J Bone Joint Surg 67A: 1144 – 1055, 1985.
20. Swann M, Lloyd-Roberts G, Catterall A. The anatomy of uncorrected club feet. A study of rotation deformity. J Bone Joint Surg 51B (2): 263 – 269, 1969.
21. Tachdjian MO. The Child’s Foot. Philadelphia, W. B. Saunders, 1985.
22. Thompson GH., Richardson AB, Westin GW. Surgical management of resistant congenital talipes equinovarus deformities. J Bone Joint Surg 64A 652 – 665, 1982.
23. Turco VJ. Resistant congenital club foot – one-stage postero medial release with internal fixation. A follow-up report of a fifteen-year experience. J Bone Joint Surg 61A: 805 – 814, 1979.

Address correspondence to: Dr. J. Terrence Jose Jerome, MBBS.,DNB (Ortho), MNAMS (Ortho)
Registrar in Orthopedics, Dept. of Orthopedics
St. Stephen’s Hospital, Tiz Hazari, Delhi 54, India

Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
Head Professor, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
Professor Emeritus, Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. E-mail: pasle@bol.net.in
Consultant in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. Phone: 991-23966021-27.
5-6  Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. Phone: 991-23966021-27.

© The Foot & Ankle 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

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.


1. Lo, IK; Kirkley, A; Nonweiler, B; Kumbhare, DA. Operative versus non-operative treatment of acute Achilles tendon ruptures: a quantitative review. Clin J Sport Med. Jul;7(3):207-11, 1997.
2. Bosworth DM. Repair of Defects in the Tendo Achilles. J Bone Joint Surg Am. Jan;38-A(1):111-4, 1956.
3. Porter DA, Mannarino FP, Snead D, Gabel SJ, Ostrowski M.Primary repair without augmentation for early neglected Achilles tendon ruptures in the recreational athlete. Foot Ankle Int. Sep;18(9):557-64, 1997.
4. Ma GW, Griffith TG. Percutaneous repair of acute closed ruptured achilles tendon: a new technique. Clin Orthop Relat Res. Oct;(128):247-55, 1977.
5. Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P. Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study.
J Bone Joint Surg Am. Feb;84-A(2):161-70, 2002.
6. Wapner, KL; Pavlock, GS; Hecht, PJ; Naselli, F; Walther, R. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle. Oct; 14(8):443-9, 1993.
7. Hansen, ST: Transfer of the flexor hallucis longus to the heel cord. In: ST Hansen, ed, Functional Reconstruction of the Foot and Ankle, Philadelphia, Lippincott, pp. 425–429, 2000.
8. Tashjian RZ, Hur J, Sullivan RJ, Campbell JT, DiGiovanni CW. Flexor hallucis longus transfer for repair of chronic achilles tendinopathy. Foot Ankle Int. Sep;24(9):673-6, 2003.
9. Mann RA, Holmes GB Jr, Seale KS, Collins DN. Chronic rupture of the Achilles tendon: a new technique of repair. J Bone Joint Surg Am. Feb;73(2):214-9, 1991.
10. Dabernig J, Shilov B, Schumacher O, Lenz C, Dabernig W, Schaff J. Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap.J Plast Reconstr Aesthet Surg. 59(2):142-7, 2006.
11. Miskulin M, Miskulin A, Klobucar H, Kuvalja S. Neglected rupture of the Achilles tendon treated with peroneus brevis transfer: a functional assessment of 5 cases.J Foot Ankle Surg. Jan-Feb;44(1):49-56, 2005.
12. Maffulli N, Leadbetter WB. Free gracilis tendon graft in neglected tears of the Achilles tendon. Clin J Sport Med. Mar;15(2):56-61, 2005.
13. Schedl R, Fasol P. Achilles tendon repair with the plantaris tendon compared with repair using polyglycol threads. J Trauma. Mar;19(3):189-94, 1979.
14. Lieberman JR, Lozman J, Czajka J, Dougherty J. Repair of Achilles tendon ruptures with Dacron vascular graft. Clin Orthop Relat Res.Sep;(234):204-8, 1988.
15. Parsons JR, Weiss AB, Schenk RS, Alexander H, Pavlisko F. Long-term follow-up of Achilles tendon repair with an absorbable polymer carbon fiber composite. Foot Ankle. Feb;9(4):179-84, 1989.
16. Kato YP, Dunn MG, Zawadsky JP, Tria AJ, Silver FH. Regeneration of Achilles tendon with a collagen tendon prosthesis. Results of a one-year implantation study. J Bone Joint Surg Am. Apr;73(4):561-74, 1991.
17. Lee MS. GraftJacket augmentation of chronic Achilles tendon ruptures. Orthopedics. Jan;27(1 Suppl):s151-3, 2004.
18. Ozaki J, Fujimoto S, Masuhara K, Tamai S, Yoshimoto S. Reconstruction of chronic massive rotator cuff tears with synthetic materials. Clin Orthop Relat Res. Jan;(202):173-83, 1986.
19. Ozaki J, Fujiki J, Sugimoto K, Tamai S, Masuhara K. Reconstruction of neglected Achilles tendon rupture with Marlex ® mesh. Clin Orthop Relat Res. Jan;(238):204-8, 1989.
20. Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, Taunton JE, Khan KM; Victorian Institute Of Sport Tendon Study Group. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med. Oct;35(5):335-41, 2001.
21. Hosey G, Kowalchick E, Tesoro D, Balazsy J, Klocek J, Pederson B, Wertheimer SJ. Comparison of the mechanical and histologic properties of Achilles tendons in New Zealand white rabbits secondarily repaired with Marlex ® mesh. J Foot Surg. May-Jun;30(3):214-33, 1991.
22. Choksey A, Soonawalla D, Murray J. Repair of neglected Achilles tendon ruptures with Marlex ® mesh. Injury. Apr;27(3):215-7, 1996.

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