NEGLECTED AND CHRONIC ACHILLES TENDON RUPTURE RECONSTRUCTION WITH FLEXOR HALLUCIS LONGUS TRANSFER

Abstract

Introduction: Achilles tendon (AT) rupture is a common sports injury. However, about 10% to 25% of the complete AT ruptures are not diagnosed. The management of neglected or chronic AT ruptures is usually different from that of acute rupture as the tendon ends were retracted and atrophied with short fibrous distal stumps. In the current series, we reported the mid- to long-term outcome of 10 patients with neglected or chronic AT rupture managed by a modified Flexor Hallucis Longus (FHL) transfer.

Materials and Methods: Between April 2002 and December 2003, 10 patients (6 males, 4 females) were operated on for a neglected or chronic AT rupture with a FHL transfer. The age at surgery averaged 44.1 years (range, 27–70). Five patients presented with a neglected AT rupture, 3 with a chronic AT rupture associated with Achilles tendinosis and 2 with an AT re-rupture. The AT defect after fibrosis debridement averaged 7.4 cm (range, 2.5–10). Beside FHL transfer, we performed a transfer augmentation with the 2 remaining Achilles fibrosis flaps. If no residual fibrosis after debridement was found, a Bosworth augmentation was performed to strengthen the transfer.

Functional assessment was performed using Kitaoka score. Postoperative complications were analyzed. Delay of work and sports recovery was noticed. Isokinetic evaluation was performed using Con-Trex^® dynamometer.

Statistical analysis was performed using Student’s t-test and Wilcoxon test (level of significance, p < 0.05).

Results: The mean follow-up was 61 months (range, 40–73). Functional outcome was excellent with a significant improvement of the average Kitaoka score at latest follow-up (98/100 (range, 90–100)). Average delay of work and sports recovery was 5 months (range, 2–12) and 10 months (range, 6–18) respectively. All patients returned to a sports activity within minor limitations. No re-rupture has been described. No major complication was observed particularly on wound healing. All patients presented with a loss of active range of motion of the hallux interphallangeal joint without subsequent hyperextension. However, no patient presented with functional weakness of the hallux during athletic or daily life activities. Isokinetic testing at 30 deg/sec and 120 deg/sec revealed a significant average decrease of 28±11% and 36±4.1% respectively, in the plantar flexion peak torque of the involved ankle compared with the non-involved ankle.

Discussion: Although strength deficit persisted at latest follow-up, functional improvement was significant. Morbidity due to FHL harvesting was clinically in significant at latest follow-up. For patients with neglected or chronic Achilles tendon rupture with a rupture gap of at least 5 centimeters, surgical repair using FHL transfer with fibrous AT stumps reinforcement achieved excellent outcome at our latest follow-up.