Treatment of Achilles Tendon Rupture in Older, Less Active Adults
Older adults who rupture the Achilles (heel) tendon may end up with a case of Achilles tendinosis that requires a special kind of surgery. Tendinosis refers to replacement of normal collagen fibers in the tendon with scar tissue or fibrous material. The substandard replacement tissue is weak resulting in pain, decreased strength, and loss of function.
When conservative (nonoperative) care is not enough and traditional surgical repair is not possible, then an alternate two-part procedure may be necessary. Older adults who are inactive and overweight are the main candidates for this type of treatment.
The first step is debridement and involves removing the diseased tissue from the damaged and poorly repaired Achilles tendon. Any bone spurs that may have developed around the heel where the Achilles tendon attaches are also shaved away.
The second half of the surgery is a tendon transfer of the flexor hallucis longus (FHL). This tendon/muscle helps the big toe flex or bend. A portion of the FHL tendon was removed and threaded through a tunnel in the calcaneus (heel bone) made by the surgeon. The flexor hallucis longus (FHL) was then attached to the calcaneus where the Achilles tendon normally inserts.
In this study of 48 adults between the ages of 44 and 64 who had this procedure done, all were in the obese category (Body Mass Index of 30 or more). Everyone was followed for two years. Results were reported based on improvements in pain intensity, physical function, and disability. Ability to rise on one foot (called a single-leg heel rise) and balance were also evaluated for any changes.
The authors reported significant improvement in all areas except the single-leg heel rise. But even though the heel-rise was not normal (due to loss of toe motion and weakness), no one seemed to be having any trouble walking normally. No one seemed to be having any problems with balance. Both of these functions do depend on the flexor hallucis's ability to flex or bend the big toe. And almost everyone (97 per cent of the group) had no difficulty walking in sandals (keeping them on the feet).
Keeping track of when patients experienced improvements, there were significant benefits from the surgery in the first three months. Improvements continued to be seen at the end of six months, 12 months, and even after 24 months. Most of the changes took place in the first year after surgery.
There were a few minor problems and complications associated with the surgery. A couple patients developed wound infections or blood clots. Pain in the scar was reported by four people. Unfortunately, one person fell and tore the reconstructed tissue.
The most surprising finding was the development of peroneal tendinitis (muscle in the lower leg). The authors were unsure how to explain that particular result. Perhaps there was more general tendinopathy (affecting more than just the Achilles tendon) present before surgery than they realized. Or maybe this was a new problem developing as a result of the surgery. They suggest further study to sort this out in an effort to prevent it from happening.
Lew C. Schon, MD, et al. Flexor Hallucis Longus Tendon Transfer in Treatment of Achilles Tendinosis. In The Journal of Bone and Joint Surgery. January 2, 2013. Vol. 94A. Vol. 1. Pp. 54-60.