Achilles Lengthening: Master's Surgical Technique
Achilles Lengthening: Master's Surgical Technique
Achilles Lengthening: Master's Surgical Technique
Achilles Lengthening
Sean A. Tabaie, MD1 and Anthony J. Videckis, BS2
Children’s National Hospital, George Washington University School of Medicine, Washington, DC; 2Georgetown
1
Abstract:
An equinus or plantarflexed positioning of the calcaneus relative to the tibia often results in shortening of the Achilles
tendon, gastrocsoleus complex, or both. This may result in a number of patient symptoms including abnormal gait,
pain with weight-bearing, toe walking, plantar forefoot callosities, and inability to properly fit into orthoses. When
properly indicated, operative Achilles lengthening corrects fixed ankle equinus that exists with the knee flexed as well
as extended. The ultimate goal is to improve ankle dorsiflexion, ideally to 10 degrees of ankle dorsiflexion past neutral
with the knee flexed and 5 degrees with the knee fully extended. In this article, we discuss the clinical decision-mak-
ing, various surgical techniques, and postoperative protocol of Achilles lengthening.
Key Concepts:
• Before proceeding with an Achilles lengthening, determine whether fixed ankle equinus exists with both the knee
flexed as well as extended (negative Silfverskiold test).
• All associated joint contractures should be addressed in conjunction with an Achilles lengthening to achieve opti-
mal results.
• It is important to prevent overlengthening of the Achilles tendon by repairing the tendon in adequate tension or
with the ankle in neutral dorsiflexion.
• To prevent wound healing complications, the paratenon should not be dissected free from the overlying subcuta-
neous tissues posteriorly.
Introduction
An equinus deformity can be either congenital or ac- Operative Achilles lengthening is to address fixed ankle
quired and can be dynamic or fixed. Unlike a dynamic equinus that exists with the knee flexed as well as ex-
deformity, a fixed deformity does not correct with pas- tended which also interferes with normal gait. It is im-
sive manipulation.1 The shortening of the Achilles ten- portant to understand that surgical management of fixed
don and/or gastrocsoleus complex arises from an equi- ankle equinus in only knee extension that resolves with
nus or plantarflexed positioning of the calcaneus relative knee flexion (positive Silfverskiold test) should consist
to the tibia.2 Clinical conditions that often necessitate the of surgery to the gastrocnemius fascia alone.3 The ulti-
need for Achilles lengthening include pain with weight- mate goal is to improve ankle dorsiflexion, ideally to 10
bearing, toe walking, plantar forefoot callosities, inabil- degrees of ankle dorsiflexion past neutral with the knee
ity to properly fit into orthoses, and/or midfoot pain. flexed and 5 degrees with the knee fully extended.4
Positioning
The patient can be positioned with a non-sterile thigh
tourniquet either supine or prone, and this should be
based primarily on the surgeon’s preference. The supine
positioning is ideal if an isolated Achilles lengthening or
gastrocnemius recession is performed. The prone posi-
tion does offer better direct exposure to the Achilles ten-
don and adjacent capsular structures; however, careful
padding of the bony prominences is required.
Operative Technique
Figure 2. Ankle Joint–Lateral view: (A) grade 0 normal, (B)
Achilles lengthening can be performed using an open grade 1 anterior tibial osteophyte, (C) grade 3 anterior tibial
or percutaneous approach.9,10 When an Achilles length- osteophyte, (D) grade 3 anterior tibial osteophyte.8
ening is indicated for severe equinus, we recommend approximately 6 centimeters in length. Begin just proxi-
an open approach. In these cases, a percutaneous tech- mal to the calcaneal insertion and continue proximally to
nique often doesn’t result in adequate correction and the proximal extent of the tendon. Continue the dissection
can lead to scar formation making a subsequent proce- through the subcutaneous tissue in line with the incision
dure more challenging. After the tendon is exposed, ei- until the paratenon is identified. Incise the paratenon and
ther an open sliding lengthening or z-lengthening tech- expose the Achilles tendon. A longitudinal incision along
nique can be performed.9,10 For patients with mild to the anteromedial border of the Achilles tendon is recom-
moderate Achilles contractures, a sliding lengthening is mended to decrease postoperative complications.11,12
appropriate.9,10 In Achilles contractures with greater
than 20 degrees plantarflexion deformity, it is preferred With the tendon tensioned by passive dorsiflexion of the
to utilize a z-lengthening technique to adequately ad- ankle, complete two cuts exposing the distal, anterior
dress the deformity.11,12 two-thirds of the tendon fibers and preserving the poste-
rior third of the tendon fibers. This is performed by com-
The following steps are carried out for the open sliding pleting a 4- to 6-centimeter longitudinal cut proximally
technique. First, perform a posteromedial skin incision and then turning the scissors laterally and performing a
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Volume 3, Number 3, August 2021
lateral ½ cut of the tendon.6 At the proximal portion of Figure 4. Posterior view of the Achilles
the exposure, progressively divide the medial half of the tendon demonstrating the open z-lengthen-
ing. The medial half of the tendon fibers
tendon and maintain pressure until a definite yield point are released from the calcaneus and the
is reached. The medial fibers will slide laterally, and a free end is elevated. The lateral half of the
lengthening in continuity will be affected. There should tendon is divided approximately 5 to 6 cen-
timeters proximal to the distal cut.
be a thinned-out portion of the tendon distally and a Absorbable sutures are used for the repair.
square medial gap at the proximal extent of the tendon.
Dorsiflex the ankle to 5–10 degrees past neutral with the
knee extended/hindfoot inverted, and the tendon will
slide over one another yet remain intact (Figure 3).
Once the tendon has been divided, dorsiflex the ankle to 3) Ensure proper patient positioning prior to draping the
neutral with the knee extended. Under moderate tension, patient. In the supine position, a contralateral small
reapproximate the tendon with braided non-absorbable hip bump can improve exposure to the anteromedial
suture via a side-to-side or end-to-end repair (Figure 5). border of the Achilles tendon.
4) Maintain the integrity of the paratenon to facilitate correction and can lead to scar formation making a sub-
repair. sequent procedure more challenging.
5) Maintain attachments of the paratenon to the subcuta- Postoperatively, reoccurrence of the contracture is com-
neous fat to preserve blood supply of the surrounding mon. Multiple randomized controlled trials show Achil-
tissues. les tendon contracture reoccurrence ranging between
9.1% and 21.2% in spastic hemiplegic and diplegic chil-
6) Use a new surgical blade when starting the cuts
dren with cerebral palsy.13,14,15 In order to reduce risk of
within the tendon. A dull blade can make things diffi-
recurrence, one should consider nonoperative methods of
cult.
treatment (PT, serial casting, ankle-foot orthotic (AFO)
7) In the sliding technique, slowly dorsiflex the ankle to use, and occasional botulinum toxin injection) for
the desired correction and maintain that position younger children (less than 7–8 years of age). After sur-
while closing the wound to allow for even distribu- gery, recurrence can be minimized by casting for the ini-
tion of the tension to the surrounding soft tissues. tial postoperative period then transitioning to an AFO for
at least a year and often until a child is done growing and
8) In the z-lengthening technique, repair the tendon with
dependent on etiology.
the ankle in neutral dorsiflexion and under moderate
tension to avoid overlengthening. Postoperative Care
9) Apply a short leg cast with the ankle in neutral dorsi- Prior to reversal of anesthesia, apply a short leg cast in-
flexion. This can be made easier by flexing the knee traoperatively by placing the ankle in neutral dorsiflex-
and having an assistant hold the ankle and subtalar ion with the foot plantigrade. If a large equinus deform-
joints in neutral. ity is corrected and the skin blanches, then the initial cast
should place the ankle in slight plantarflexion to mini-
What to Avoid
mize wound healing issues.
In a patient with the appropriate indications, an Achilles
lengthening can greatly improve gait and overall func- Six weeks of casting postoperatively is recommended
tion; however, if incorrectly utilized, it can lead to a cal- with a cast change completed between 10 to 14 days for
caneal gait pattern and subsequent development of those legs casted short of full dorsiflexion. If residual con-
crouched gait. It is important to understand the underly- tracture remains, then weekly cast changes may be per-
ing etiology of the Achilles contracture. Treatment can formed. The patient may weight bear as tolerated, and the
vastly differ in an idiopathic toe walker versus a patient cast can be reinforced, or a cast shoe may be provided.
with cerebral palsy who may have tight hamstrings that During the cast process, the patient should be molded for
if not also treated can lead to iatrogenic couch gait. an AFO. A transition to the AFO should be completed at
Before operating, identify all other proximal and distal the end of the 6 weeks. Additionally, the patient should
soft tissue contractures or skeletal malalignments and be start a course of physical therapy to assist with strength-
able to distinguish between true equinus versus apparent ening and gait training.
equinus. Properly perform the Silfverskiold test both
preoperatively and intraoperatively when the patient is Complications
asleep to ensure an Achilles lengthening is needed so Overlengthening of the tendon is the most common com-
overlengthening of the tendon is prevented. When an plication. This is often due to inappropriately performing
Achilles lengthening is needed, use an open approach as an Achilles lengthening before exhausting nonoperative
percutaneous techniques often don’t give enough modalities and not choosing a less aggressive method of