From the Guidelines
For a chronically contracted lower extremity, an Achilles tendon lengthening procedure would provide improved range of motion, as supported by the most recent guidelines 1. This surgical intervention involves making partial cuts in the Achilles tendon to allow it to stretch and lengthen, effectively reducing the contracture. The procedure can be performed as a percutaneous triple hemisection or as an open Z-lengthening, depending on the severity of the contracture. Some key points to consider when deciding on a procedure include:
- The specific joint affected by the contracture
- The severity of the contracture
- Whether the limitation is primarily due to soft tissue or bony restrictions Other potential procedures include:
- Gastrocnemius recession (Strayer procedure) for less severe contractures that primarily affect ankle dorsiflexion with the knee extended
- Hamstring release for knee flexion contractures
- Digital flexor tenotomy for flexible toe deformities, as recommended in the guidelines for persons with diabetes and a neuropathic plantar or apex ulcer on digits 2–5 1 Post-operatively, the patient typically requires 4-6 weeks in a cast or walking boot, followed by physical therapy for 2-3 months to maintain the new range of motion and strengthen the surrounding muscles. Proper patient selection and post-operative rehabilitation are essential for optimal outcomes and to prevent recurrence of the contracture. It is also important to consider the use of offloading devices, such as non-removable knee-high offloading devices, to promote healing of any ulcers present, as recommended in the guidelines 1.
From the Research
Tendon Release Procedures for Improving Range of Motion
- Achilles tendon lengthening is a surgical procedure that can improve range of motion in a chronically contracted lower extremity, as seen in a case report where a patient's ankle function was restored to near normal after a two-incision, wire-assisted Achilles tendon Z-lengthening procedure 2.
- Open fasciotomy is a surgical treatment for chronic exertional compartment syndrome, which can also improve range of motion by releasing the fascial compartment and preventing compression of local vasculature 3.
- Tendon lengthening surgery has been shown to have long-term benefits in reducing chronic Achilles tendon pain and improving range of motion, with a mean increase in dorsiflexion of 5 degrees 4.
Non-Surgical Alternatives
- Dynamic splinting with prolonged, passive stretching can be an effective treatment for lower extremity joint contractures, with a significant direct, linear correlation between the total number of hours in stretching and restored active range of motion 5.
Considerations for Tendon Release Procedures
- The percutaneous triple hemisection technique for Achilles tendon lengthening may have a higher failure rate than previously reported, with 21 out of 60 hemisections failing in a cadaver-based study 6.
- Open procedures may be preferred over percutaneous techniques, especially in cases where the boundaries of the tendon are less easily palpable, to minimize the risk of technical failures 6.