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Case discussion #20: 76 year old gentleman with chronic rupture of the achilles tendon

Mr C is a delightful 76 year old gentleman who sustained an achilles tendon rupture on a background of chronic achilles tendinopathy. He underwent a successful total hip replacement and during his rehabilitation developed pain in his achilles tendon and the sudden weakness without history of trauma.


He was referred to Dr Touzell for an opinion after his astute General Practitioner was concerned about the potential for achilles tendon pathology despite the unusual clinical presentation. Clinically, there was a clear divot at the achilles tendon and squeeze test was positive. A subsequent MRI scan demonstrated a complete rupture of a tendinopathic achilles tendon with 5cm of separation (see below).

Initially, a course of non-operative management was trialled using a CAM boot and heel raise, but Mr C had ongoing pain after several months of treatment so the option of surgical intervention was discussed.


A direct repair was not possible due to the 5cm tendon defect as well as pre-existing tendinopathy and poor tendon integrity. We therefore proceeded with a flexor hallucis longus tendon transfer, where the tendon to the great toe is divided at the inferior ankle and transferred to the achilles tendon insertion at the calcaneum (see diagram below).

Mr C was non weight bearing for two weeks to allow for wound healing, then partially weight bearing in a CAM boot with heel wedge for a further eight weeks. He commenced weight bearing as tolerated in normal shoe three months after surgery and started a strengthening program at that stage.


Two years after surgery, his pain has resolved and he is mobilising independently without gait aids or orthotics. He complained of some moderate swelling in his lower limb, particularly after a long day on his feet, but this was not associated with pain or reduced mobility.


DISCUSSION

Acute ruptures of the achilles tendon can be successfully treated non-operatively after careful discussion with the patient about risks and benefits of both operative and non-operative management. However, in this case a spontaneous rupture occurred on a background of chronic achilles tendinopathy. A trial of non-operative management was not successful so surgery was required to restore quality of life and mobility. A flexor hallucis longus (FHL) tendon transfer provides strength to push-off in the absence of a functioning achilles tendon, as well as a vascular bed to allow tendinopathy to resolve through improved vascularity. Whilst patients' strength, range of motion and exercise tolerance is not at levels prior to the original injury, an FHL tendon transfer in an option that can provide a satisfactory outcome for patients with chronic achilles tendon disorders.

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