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Definition & Objective
Achilles tendon lengthening is a surgical procedure that is directed at stretching the Achilles tendon, that are overly tight due to spasticity, to bring relief to chronic pain and allow a person to walk flat-footed without a bend in the knee. By making small incisions on the Achilles tendon at the back of the ankle, the contracted tendon is elongated. As the wounds heal, the tendons elongate naturally.
The goal of this procedure is to put an end to tiptoe walking and allowing increased motion at the ankle joint. If left untreated, the problem would get worse as the child grows. The aims of Achilles tendon lengthening surgery can be summarized as follows:
- Improve Ankle Movement when it is limited by both calf muscles (gastrocnemius and soleus)
- Improve Walking Pattern, i.e. decrease toe walking
- Improve Positioning in a brace
Compensatory Measures Adopted In Achilles Tendon Contracture
People with contracted Achilles tendon develop ways and means to compensate for their limited ankle motion, listed as follows:
- Compensation often leads to other foot, leg or back problems.
- The most common method of compensation is the flattening of the arch.
- Compensation is done by picking up the heel early when walking, placing increased pressure on the ball of the foot.
- Other compensation mode is toe walking.
- A few patients take steps by bending abnormally at the hip or knee.
Causes Of Achilles Tendon Contracture
There can be attributed several conditions that can cause Achilles contracture. These conditions that cause issues with mobility of the ankle include:
- Tightness In The Achilles Tendon
- Being In A Cast Or On Crutches
- Frequently Wearing High-Heeled Shoes
- Cerebral Palsy
- Tethered Cord
- Spina Bifida
- Chronic Tendinitis
- Spinal Cord Injury
- Viral Myositis
- Congenital Muscular Dystrophy
- Birth Defects
- Foot Deformity Caused By Diabetes Or Clubfoot
- Limb-Length Discrepancy
The Symptoms Of Achilles Tendon Contracture
A variety of foot conditions can develop, each presenting an indication of a contracted tendon including:
- Calf Cramping
- Extensive Pain In The Achilles Tendon
- Shin Splints
- Discomfort At The Back Of The Feet
- Bent Foot Causing Flatfoot, Forcing The Knees To Bend
- Arthritis Of The Midfoot
- Pressure Sores On The Ball Of The Foot Or The Arch
- Bunions And Hammertoes
- Abnormal Toes Position
- Poor Posture
- Muscle Spasticity (Stiffened Muscle)
The Diagnostic Procedure Of Achilles Contracture
To diagnose Achilles tendon contracture, the foot and ankle surgeon will evaluate the condition in the following ways:
- A Thorough Medical History for careful decision-making
- A Detailed Physical Examination for general assessment and gauging the ankle’s range of motion when the knee is flexed as well as extended, to identify whether the tendon or muscle is tight and whether bone is interfering with ankle motion.
- Imaging Techniques developed to serve the very purpose of acquiring precision, accuracy and reliability that include:
- MRI Scan
- Laboratory Studies using blood sample
The Treatment Approach Considerations
Observation is appropriate for a toddler with idiopathic toe walking who should be monitored at 6-month intervals. If progressive Achilles tendon contractures are detected or if the gait does not resolve spontaneously by age 3 years, treatment has to be considered. Non-operative management is always considered before operative management.
The Non-operative Treatment Approach
The noninvasive treatment methodology may comprise of one or several of the following modalities:
- Night Splint is used to placethe foot in a splint at night to maintain it in a position that helps reduce tightness of the calf muscle.
- Heel liftsplaced inside the shoes or wearing shoes with a moderate heel takes stress off the Achilles tendon when walking and may help reduce symptoms.
- Arch Supports, Bracing Or Custom Orthotic Devicesthat fit into the shoe are often prescribed to keep weight distributed properly and to help control muscle/tendon imbalance.
- Serial Casting comprises of short leg casts that can be applied for one- to two-week intervals to progressively work on stretching the tight muscles and improving the position of the foot and ankle.
- Injectable consisting of Botox injections may be administered to help stretch the tight muscles in casts in some children.
- Physiotherapyis usually advised to help cure muscle tightness and exercises that stretch the calf muscle(s) are recommended.
The Invasive Treatment Approach
If nonsurgical measures fail to correct and relieve symptoms after about 12 months, surgery may be necessary to correct the cause of Achilles tendon contracture, related to a tight tendon that limits the ankle motion, in order to achieve a flat foot position with walking. The foot and ankle surgeon would determine the type of procedure that is best suited to the individual patient.
There are 3 primary procedures used in the tendon lengthening surgery, outlined below. Before surgery, the patient is placed under anesthesia with the back facing up.
The Percutaneous Method
- Small incisions are made in the tendon through the skin using stab wounds.
- The cut areas move apart elongating the tendon.
The Gastrocnemius Recession
- This procedure targets only the gastrocnemius muscle in the calf.
- It helps to loosen the muscle fibers attached to the cord and is used for mild cases only.
The Z-plasty Method
- In Z-plasty lengthening, being the most common one, the surgeon makes an incision in the skin behind the ankle to expose the Achilles tendon.
- Then a Z-shaped incision is cut in the tendon.
- When the tendon is stretched, the Z-shaped incision stretches and grows longer naturally.
- The surgeon then uses sutures to sew the tendon in place.
- This surgical method is the most controlled way to lengthen the whole tendon and muscle.
Postoperative Care & Recovery
- The patient may be placed under observation depending on the intensity of their initial condition.
- The patient is generally immobilized in a below-the-knee cast for approximately 4-6 weeks.
- There is limited aggressive physical activity and movement to allow for healing of the tendon at a rapid pace.
- The limb(s) should be elevated for 2-3 days until acute swelling subsides.
- Weightbearing on the operated limb is routinely permitted in case of a percutaneous or open sliding tendon lengthening.
- For open Z-lengthening, weightbearing is preferably deferred until tendon healing is sufficient in around 6 weeks’ interval.
The Potential Complications
The potential complications of Achilles lengthening surgery include:
- Bacterial Infection In The Wound
- Damage To Nerves & Blood Vessels
- Excessive Bleeding
- Blood Clot Formation
- A Bad Reaction To The Anesthesia
- Stiffness In The Achilles Tendon
- Delayed Wound Healing
- Complete Tendon Rupture During Surgery Or Recovery