Occasionally debridement will leave a large gap which must be bridged to restore function. A similar problem may arise in the treatment of chronic ruptures.
The options include:
- primary repair, possibly reinforced with plantaris
- turn-down flap (Christensen or Lindholm technique)
- V-Y lengthening
- transfer of another tendon (usually FHL or peroneus longus)
- interposition of artificial material such as a Leeds-Keio ACL graft
Small gaps can generally be closed either by primary suture or a turn-down flap. Gaps from 3-6cm can usually be closed by a turn-down flap or a V-Y advancement of the tendon (larger gaps may be closed with these techniques depending on the quality and amount of gastrocnemius aponeurosis available - our record is 15cm - but this cannot necessarily be relied on and we always ask patients for consent to FHL transfer).
Larger gaps usually require a tendon transfer or the use of artificial implants (Jennings and Sefton 2002). The main donor options are the plantaris, peroneus longus or flexor hallucis longus. FHL has the advantage of being in phase with the Achilles tendon, is stronger than peroneus brevis and readily harvested. The donor site deficit is not functionally significant (Sammarco 2002, Coull 2003, Hahn 2008, Will 2009)). Plantaris is readily available but small; weave techniques have been described but enough tendon is not always available.
The results of late repair are not much, if at all, inferior to those of primary repair (Boyden et al 1995), although Boyden found that no repair restores the full strength of the Achilles tendon.