Percutaneous TendoAchilles Lengthening

Indications

A Percutaneous TendoAchilles lengthening (PTAL) is a procedure that lengthens the Achilles tendon and thereby increase the ability for the ankle to move upwards (dorsiflexion).  This may be indicated in children with an equinus contracture (inability to fully bring the foot upwards) such as may occur in clubfoot deformity.  It also may be indicated in adults who have a flatfoot deformity or have diabetic foot issue which has caused an ankle equinus contracture.

Procedure

A tendoAchilles procedure itself is done thorough a series of small incisions over the Achilles.  Typically, the three-incision technique described by Hoke in the 1930’s is used.  In this procedure, the Achilles is identified and one half of the tendon is cut through a small tab incision over the back of the Achilles.  The first incision is made close to where the tendon inserts into the heel bone (Calcaneus).  The cut is done in such a way the scalpel is taken through the skin and half of the tendon is cut -usually the inside (medial) half.  The second incision is then made one-half to one inch (1-2cm) further up the leg.  Again, half of the Achilles is cut but in this case the opposite half to what was previously cut usually the outside (lateral) half.  A third incision is then made still further up the leg usually one-half to one inch (1-2cm) from the second incision.  This third incision releases the inner half of the tendon.  After half of the tendon has been cut in each of these three spots gentle pressure is applied to the foot.  This allows the fibers of the cut tendon to slide over each other and the Achilles tendon is gently lengthened.  At this point, the incisions are closed and the patient s immobilized with the ankle joint in a neutral angle (right angle) position.

Recovery

The cut Achilles tendon does need to heal.  In adults this typically requires six weeks of relative immobilization in a cast, boot, or splint.  This is often followed by another six weeks of gradual increasing activity.  The actual recovery may be dictated more by the other procedures that are often done in addition to the Achilles lengthening.

Potential Complications

General Complications

Like other operative procedures there are general complications that may occur when a percutaneous tendoAchilles lengthening is performed.  Fortunately, because of the small incisions these complications are relatively uncommon but may include:

Infection

Wound healing problems

Deep Vein Thrombosis (DVT)

Pulmonary Embolism (PE)

Specific Complications

Complications that are specific to this procedure include:

Rupture to the Achilles tendon. 

When performing a percutaneous tendoAchilles lengthening it is quite possible to over-lengthen or rupture the Achilles which may require more a definitive open surgical repair of the Achilles tendon.

Sural Nerve

A sural nerve injury may also occur.  This nerve runs on the outer side of the lower leg and can be accidently injured during one of the incisions.  If this nerve is cut or injured there may be numbness on the outside of the foot and/or some burning-type pain at the site of the nerve injury.

Edited September 3rd, 2013