Management

Management of chronic tendon rupture is a demanding task due to the presence of tendon retraction, muscle atrophy, and skin contracture that is frequently present around the tendon (1)

Conservative management

• can be attempted in patients who refuse surgery or are contraindicated
• brace or ankle-foot orthosis can be used
• in a series of fifty-one patients with fifty seven ruptures (out of which nearly two-thirds were chronic ruptures) eighteen were treated conservatively
  • satisfactory results were seen in ten of these eighteen patients e.g. - the gait was normal, the patient returned to his or her previous occupation, and there was slight or no discomfort)
  • recovery time of these patients were long sometimes over several years
  • however the results were poor when compared to patients who were managed surgically (1,2)

Surgical management

• optimal technique for treating chronic Achilles tendon rupture is controversial. Operative procedures for treatment of chronic rupture include:
  • end to end anastamosis
  • flap tissue turn down using one and two flaps
    • V-Y advancement flap - anastomosis of the tendon ends is achieved by making an inverted V-shaped incision in the proximal part of the tendon and repairing it in a Y-shaped fashion
    • gastrocnemius fascial turndown flap
  • local tendon transfer
    • peroneus Brevis tendon transfer
    • flexor halluces longus tendon (FHLT) transfer
  • autologous free tendon grafts
    • gracilis tendon
  • allografts (1,2)
• according to the length of the defect, two classification systems have been proposed for the surgical management of the condition
  • Myerson’s classification
    • type-1 defect is no more than 1 to 2 cm long - managed with end-to-end repair and a posterior compartment fasciotomy
    • type-2 defect ranges between 2 and 5 cm - managed with V-Y lengthening, with or without a tendon transfer
    • type-3 defect is >5 cm - bridged with use of a tendon transfer, alone or in combination with a V-Y advancement (1,2)

Reference:

• (1) Maffulli N, Ajis A. Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am. 2008;90(6):1348-60.
• (2) Maffulli N, Via AG, Oliva F. Chronic Achilles Tendon Disorders: Tendinopathy and Chronic Rupture. Clin Sports Med. 2015;34(4):607-24.