Foot and Ankle cases 21
A 29-year-old male presents with the chief complaint of weakness in his right leg.
He reports that 6 months ago he was playing basketball and when jumping felt that he was kicked in the back of the leg. He never sought medical care, and since that point he has been unable to recover strength in his leg. He takes no steroids, never had an injection into his Achilles, was not on antibiotics, and there was no family history of inflammatory arthropathy.
On physical examination, he is a fit male in no distress. He is unable to perform a single leg heel rise on the right and there is marked atrophy of his gastrocnemius on this side. In the prone position with his knees flexed there is no plantar flexion with calf squeeze, and the resting position of his right foot is in 5 degrees of plantar flexion compared with 25 degrees of plantar flexion of his left foot.
His radiographs are unremarkable. An MRI is reviewed (Fig. 5–45), which shows a gap of 4 cm between the proximal and distal ends of the Achilles tendon. Treatment options were discussed with him and you recommend surgery.
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Figure 5–45 Sagittal T2 MRI of Achilles tendon demonstrating rupture with a gap of 4 cm.
Which of the following is unlikely to be utilized in the upcoming surgery?
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Gore tex graft
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Flexor hallucis longus (FHL) tendon transfer
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V to Y advancement of the Achilles
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Gastrocnemius turndown flap
Discussion
The correct answer is (A). Synthetic graft has not been proven to be successful nor should it be utilized as a first-line of treatment for chronic Achilles tendon ruptures. There is some degree of evidence to support the use of allograft in a patient who has undergone multiple revisions or has a very large gap between the proximal and distal segments (>6 cm). The flexor hallucis longus can be easily harvested through the same incision and placed into the calcaneus. Another option is to harvest the FHL more distally and double it on itself to provide more collagen to the repair. Utilizing a Strayer, V to Y advancement, or gastrocnemius turndown can also address a gap in the Achilles. Usually a gap of up to 6 cm can be addressed with some form of a lengthening procedure of the Achilles. Beyond this distance, utilization of allograft may be considered.
The patient undergoes an FHL transfer in addition to a V to Y advancement secondary to a residual gap following mobilization of the proximal tendon (Fig. 5–46). The FHL tendon was harvested through the posterior approach, placed into the calcaneus, and secured with an interference screw. You considered the need for increased length of the FHL tendon and thought of harvesting the tendon at the hallux interphalangeal (IP) joint of the great toe.
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Figure 5–46 Clinical photograph demonstrating residual gap present after initial mobilization of the proximal gastrocsoleus complex.
When the FHL is harvested at the IP joint, one must perform a release of the FHL tendon where?
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Release of the FHL from adhesions of the plantar fascia
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Nothing more needs to be released
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The FHL must be freed from the fibroosseus tunnel below the sustentaculum
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Release at the master knot of Henry
Discussion
The correct answer is (D). The FHL and FDL are connected at the knot of Henry. This is located dorsal and lateral to the abductor hallucis musculature. Significant adhesions at the sustentaculum are rarely encountered. There is no connection between the FHL and the plantar fascia.
The patient asks when he will be able to return to playing basketball. You inform him that it will likely be no earlier than:
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4 weeks
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8 weeks
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12 weeks
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6 months
Discussion
The correct answer is (D). Even among the most aggressive rehabilitation protocols for a primary repair of an Achilles tendon, it would be extremely aggressive to return a player to basketball in less than 3 months. Willits et al. demonstrated good success with an early rehabilitation program, however even in this protocol the patient was weaning from the boot in the 8- to 12-week period. A few studies have demonstrated return to jogging at 3 months, but the earliest successful return to sports reported has been 4 months. Many studies have demonstrated a return to sports between 6 to 12 months postoperatively.
Objectives: Did you learn...?
Identify physical examination findings of a chronic Achilles rupture? Describe various treatment options of chronic Achilles tendon ruptures?
Describe the anatomy flexor hallucis longus in relation to the master knot of Henry?