Tendon Flap Research Articles

The current status and challenges of surgical treatment for chronic Achilles tendon rupture

With the growing demand for physical activity, an increasing number of individuals with chronic Achilles tendon ruptures are opting for surgical intervention. Surgical approaches encompass end-to end anastomosis, tendon flap techniques, tendon transfer procedures, and free tendon grafting, among others. When selecting the appropriate surgical method and determining the surgical indications, it is imperative to consider factors like the length of the Achilles tendon defect, patient age, aesthetic preferences, functional requirements, and local tissue conditions. As medical devices evolve and surgical techniques advance, the criteria for surgical intervention are also evolving. Drawing from existing literature evidence, it becomes crucial to define reasonable parameters for addressing Achilles tendon defects with each surgical technique, aligning more closely with clinical needs. Additionally, auxiliary technologies such as biologic therapy and innovative biomaterials have demonstrated promising results in laboratory or animal models. The focal point of advancing these auxiliary technologies lies in facilitating the translation of pertinent clinical outcomes in the future.

"Coronal Split/Overlap Repair" Patellar Tendon Shortening in Skeletally Immature Patients.

"Coronal split/overlap repair" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy. The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks. Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap1-3. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication4, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened2,5-7, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened8,9. The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises. Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase1,3,8. Reported complications with this technique were mainly superficial infection. Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximally and distally with use of 2 mosquito clips.To avoid difficulties with crossing of the patellar sutures, always keep the straight needle inside the 1st tunnel until the 2nd tunnel is created and its respective suture is passed.To distalize the patella, the patellar/tibial sutures are tied in a simple knot and held by a mosquito clip in order to allow retensioning until the desired patellar height is reached.The 2 patellar/tibial suture knots are slid to the proximal and distal ends of the surgical field. 3DGA = 3-dimensional gait analysisADL = activities of daily livingCP = cerebral palsyCPM = continuous passive motionDFEO = distal femoral extension osteotomyFAQ = Functional Assessment QuestionnaireFMS = Functional Mobility ScaleGMFCS = Gross Motor Function Classification SystemGMFM = Gross Motor Function MeasureGPS = Gait Profile ScoreGVS = Gait Variable ScoreK-wires = Kirschner wiresPTA = patellar tendon advancementPTS = patellar tendon shorteningSEMLS = single event multi-level surgery.

Less invasive turn-down flap tendinoplasty in chronic Achilles tendon rupture

Bridging the defect in chronic ruptures of the Achilles tendon via aturn-down flap of the aponeurosis sparing the skin of the rupture zone. Chronic Achilles tendon rupture with adefect distance ≤ 6 cm. Extended Achilles tendon defect interval ≥ 7 cm, chronic wounds or infections near the surgical approach, higher degrees of arterial or venous malperfusion, complex regional pain syndrome. Dorsomedial surgical approach proximal to the rupture zone, splitting of the crural fascia, loading of the distal Achilles tendon stump with anonresorbable augmentation suture using the Dresden instrument, preparation of the turn-down flap of the aponeurosis securing the turning point with acatching suture. Transfer of the turn-down tendon flap under the skin bridge and suture to the distal tendon stump tying the augmentation suture under adequate pretension simultaneously closing the gap in the aponeurosis. Alternative technique: free advancement of the autologous tendon graft. Anterior splint in 20°of plantar flexion, consecutive mobilization and rehabilitation similar to the percutaneous technique in acute Achilles tendon rupture with the Dresden instrument. Lower leg orthosis with 20°of plantarflexion for 8weeks, then stepwise reduction of the heel height. Physiotherapy beginning from the 2ndpostoperative week, active full-range of ankle motion from 6weeks after surgery. In general, worse results than in percutaneous reconstruction of acute Achilles tendon injuries. Despite this, high degrees of patient satisfaction with alow rate of postsurgical complications and good functional outcome with admittedly poor data availability. Relevant increase of plantar flexion strength depending on the amount of degeneration of the triceps surae muscle.

Trapeziectomy and Ligament Reconstruction Tendon Interposition Technique Experience for the First Carpometacarpal Joint Arthrosis

Osteoarthritis of the hand is rare; however, the most retained joint after the distal interphalangeal joint is the first carpometacarpal (1. CMC) joint. Pain in the rest and increased pain with opposition is the most serious symptom, which significantly decreases the quality of life. The aim of these patients is to obtain a painless and stable thumb. Experience of trapeziectomy and ligament reconstruction tendon interposition technique for a Stage III patient was shared and diagnosis and treatment were discussed through the relevant literature. A 53-year-old female patient was admitted with complaints of pain in the right hand thumb root and unable to open the jar lid. In direct radiography, narrowing in the 1. CMC joint space and osteophytes were detected. After the trapeziectomy, 1st and 2nd metacarpals were fixed with K wire. Flexor carpi radialis tendon was passed from the first metacarpal base to the second metacarpal base in the form of a distal-based tendon flap to mimic the beak ligament. There was no pain at the postoperative 6th month, and the Kapandji opposition score was 10. When diagnosing 1. CMC osteoarthritis, pain during opposition and circumduction movements that is not relieved with analgesics and rest is the most important symptom for a clinician to look for. Many treatment principles have been defined according to the staging for the postdiagnosis period, despite the diagnosis is a challenging process.

A Reconstructive Extensor Tendon Centralization Technique for Sagittal Band Disruption.

Sagittal band injuries may result in extensor digitorum communis (EDC) tendon instability and may require operative treatment for symptomatic loss of extension, pain, and snapping at the metacarpophalangeal joint (MCPJ). Operative methods vary according to the source of donor tissue, as well as the anchor point of attachment. We present a surgical technique that diminishes tension of the repair with MCPJ flexion. Twenty-two EDC tendon stabilization procedures were performed between 2006 and 2017 using a tendon flap method. The selection criteria for this group of patients included completely dislocating extensor tendons with persistent complaints of pain and decrease in finger extension despite at least a 6-week conservative treatment attempt. All subjects underwent surgical treatment for tendon centralization using a distally based tendinous flap from the EDC sutured to the adjacent finger volar plate. A mathematical model was developed to analyze repair tension at 30, 60, and 90 degrees of MCPJ flexion calculating the flap length difference of 2 attachment points: deep transverse metacarpal ligament versus adjacent volar plate. Centralization was maintained in all digits with no evidence of subluxation at final postoperative evaluation. Clinical symptoms of pain and weakness resolved in all patients. Mathematical modeling provided evidence that translation of the anchor point of reconstructed flap to the volar plate of the adjacent finger resulted in lower tensile forces when compared with attachment at the intermetacarpal ligament. This optimized forces on reconstructed tendon flap experienced during MCPJ flexion.Level of Evidence: Level IV-therapeutic, case series.

Peroneus Brevis flap in Achilles tendon reconstruction. Clinical, radiological and functional analysis

BackgroundWe would like to describe our experience with Peroneus Brevis flap in complicated Achilles tendon re-ruptures with fringed stumps. MethodsEight patients with monolateral re-rupture of Achilles tendon were selected as eligible for surgical repair with Peroneus Brevis flap. Patients’ outcome was evaluated clinically (ATRS and ROM), functionally (Gait analysis) and MRI was performed before and after surgery. ResultsEffective coverage of tissue defect was reached in all patients. Functional assessment evaluation results were registered in a follow-up time that ranged from 12 to 18 months. ATRS and ROM tests’ results showed good functional recovery without functional limitations or subjective reports pain. Post-operative MRI showed no signs of inflammation or tissue gaps. Gait analysis showed a partial reduction of performance in the affected side that did not affect patients’ quality of life. ConclusionsIn the presence of fringed stumps in Achilles tendon re-rupture, tendon flaps have the benefits of autologous tissues transfers and present less risks of failure than free flaps. Among them, Peroneus Brevis flap is easy to perform and leads to donor site’s low morbidity. Our preliminary experience provides support for this technique to be potentially validated in larger more controlled trial.

Therapie frischer und veralteter Quadrizeps- und Patellarsehnenrupturen

Ruptures of the extensor mechanism of the knee joint are rare but disabling injuries. Injuries occur on the basis of degeneration or acute trauma. The understanding of anatomy and biomechanical function plays an essential role for choosing the right diagnostic methods and initiating successful treatment. Besides clinical examination ultrasound is a cost efficient primary diagnostic measure. Additional MRI can be beneficial for partial tears or chronic ruptures. Non-operative treatment is suitable for minor partial ruptures with sustained function. The most common methods for reattachment of the quadriceps and patellar tendon are either sutures placed through transpatellar drill holes or the use of suture anchors. For chronic ruptures various methods have been shown to be well accomplished. Most commonly local tendon flaps or harvested tendon transplants have shown good clinical outcomes. Early primary repair leads to mainly good functional outcomes. The results of chronic disruptions of the extensor mechanism of the knee vary widely.

Functional Recovery Following an L-Lengthening Local Tendon Flap for Extensor Pollicis Longus Chronic Ruptures

Extensor indicis proprius tendon transfer has been considered the reference standard technique for extensor pollicis longus (EPL) chronic ruptures, but relevant complications have been reported. We describe a new reconstructive technique for chronic EPL ruptures and assess functional recovery after this procedure. We observed 31 patients who fulfilled inclusion criteria an average of 6.8 months after treatment. An L-shaped local tendon flap was prepared by making a transverse incision to the middle of the tendon and then longitudinally toward the end of one of the tendon stumps. Absorbable suture was used to coapt the free ends and as a reinforcement suture. We used the total active motion scale to classify results. Total active motion in patients who completed the follow-up period was 89% of the normal side; 97% of patients returned to their previous employment. Surgical complications were infrequent and only one patient (3%) required surgery for extensor tendon adhesions. This technique permits reconstruction of the EPL tendon without the need for a tendon graft or tendon transfer. Therapeutic IV.

Gravity Equinus Position to Control the Tendon Length of Reversed Free Tendon Flap Reconstruction for Chronic Achilles Tendon Rupture

Repair of chronic Achilles tendon rupture is a surgical challenge. We describe the use of a free turndown tendon flap augmentation raised from the proximal gastrocnemius aponeurosis. To control optimal tension or the reconstructed Achilles tendon length, we used an original method by referring to the gravity planter flexion ankle angle of the contralateral limb. Key aspects of the technique are described. A retrospective analysis of the short-term outcomes achieved in a case series (n = 56) is presented. The postoperative anthropometric findings are also presented to indicate the successful outcomes achieved with this technique.

Combined arthroscopic resection with repair of joint capsule using tendon flap of medical head of gastrocnemius for treating popliteal cyst

Combined arthroscopic resection with repair of joint capsule using tendon flap of medical head of gastrocnemius for treating popliteal cyst

Achilles Tendon Open Repair Augmented With Distal Turndown Tendon Flap and Posterior Crural Fasciotomy.

The aim of the present study was to investigate the outcomes after open repair of Achilles tendon rupture augmented with a distal turndown gastrocnemius flap and deep posterior crural fasciotomy based on the modified Lindholm technique. Twenty-three patients with acute Achilles tendon injury underwent open end-to-end tendon repair augmented with a distal turndown gastrocnemius flap and deep posterior compartment fasciotomy. The concentric and eccentric muscle strength was measured using a functional squat system, and dynamic balance was assessed using the Y-balance test with anterior, posteromedial, and posterolateral reach distances. Jump performance was assessed using the vertical jump and 1-leg hop tests. All patients returned to their preinjury activity level, and their mean American Orthopaedic Foot and Ankle Society hindfoot scale score was 98.2±2.3 after surgery. No significant difference was found between the involved and uninvolved extremities in terms of concentric and eccentric muscle strength (p=.82 and p=.53, respectively). In addition, no significant differences were seen between legs in the vertical jump (p=.16), one-leg hop (p=.15), and balance (p>.05) tests. Open end-to-end repair of the Achilles tendon rupture with augmentation and fasciotomy of the deep posterior compartment healed without any major complications. Functional performance of the involved leg after recovery was similar to that of the uninvolved leg. The modified Lindholm surgical technique described in our report appears to be a useful intervention for acute Achilles tendon rupture.

Open Achilles tendon defects: reconstructive surgeries and long term follow-up

Objective To explore the reconstructive surgeries for open Achilles tendon defects and their long term outcomes. Methods A retrospective review was performed on 31 patients with open Achilles tendon defects treated at our center. There were 19 males and 12 females with an average age of 23.1 years (range, 4-55 years). There were 7 cases on left side and 24 on right. The injury causes included spoke injuries (18 cases), crash injuries (6 cases), machine injuries (6 cases), and cut injuries (1 case). The defect lengths of the Achilles tendons in the study ranged from 1 to 11cm and the soft tissue defects ranged from 3 cm×3 cm to 12 cm×10 cm. There were 10 cases with calcaneus fractures. Surgeries for Achilles tendon defects included sliding the Achilles tendon stump down with the sliding gastrocnemius musculocutaneous flap (15 cases), suture at the plantar flexion (10 cases), tendon flap turndown (1 case), hamstring tendon autograft (1 case), fascia lata muscle reconstruction (1 case) and tendon allograft (3 cases). Free flaps (7 cases) and non-free flaps (24 cases) were used for the coverage of concomitant skin defects. The calcaneus fractures were fixed with screws (6 cases) or K-wires (4 cases). The treatment protocols were based on the defect length of the Achilles tendon. Results The follow up period was 1-6 years (average, 1.8 years). There was no total flap failure or tendon re-rupture, while 7 cases who had partial flap loss 2-4 days after the surgeries. In the latest follow-up, all the cases had regained full walking abilities: 19 cases (61.3%, 19/31) even had regained the heel raising by the reconstructed foot while 12 cases (38.7%) cannot. Compared with the contralateral side, 31 cases' (100.0%) reconstructed ankles had the maximum plantar flexion, while 21 cases (67.7%) had the maximum dorsal extention. Ten cases (32.2%) lost their maximum dorsal extension ranging from 5° to 25°. Conclusion There are many reconstructive surgeries available for open Achilles tendon defects, however, the optimal choice should be based on the defect length of the Achilles tendon: those within 4 cm could be reconstructed with tendon reattachment and local flaps; those between 4 cm and 11 cm could be best treated with sliding gastrocnemius flap; and those over 11 cm should be reconstructed with free anterolateral thigh perforator flap with tendon autograft. The long term follow-up showed the strength and elasticity of the reconstructive Achilles tendon was satisfactory. Key words: Achilles tendon; Wounds and injuries; Surgical flaps

One-stage reconstruction of isolated and combined tendon defects with the vascularized adductor magnus tendon graft: Surgical technique and preliminary results

Secondary reconstructions of isolated and combined tendon defects are still a challenge for plastic surgeons. Due to its reliable anatomy, reconstructive potential and low donor-site morbidity, the medial femoral condyle is an ideal area for harvesting isolated and combined tendon flaps. This study evaluates our preliminary results with the vascularized adductor magnus tendon flap. The study included six patients who received a vascularized tendon flap (upper extremity: three patients; lower extremity: three patients) from 2011 to 2015. For three patients, the adductor magnus tendon was used as a single flap; for the other three patients, the tendon was included in a composite flap. A retrospective chart review provided the patients' demographic data, surgical details and the post-operative course. The further objective and patient-reported outcome was evaluated with a long-term follow-up. All of the free vascularized flaps healed without complications and with good vascularization upon duplex ultrasonography. One patient did, however, require revision surgery in the late post-operative course. At the end point, all patients showed good functional results without any donor-site morbidity. For carefully selected isolated and combined tendon defects on the upper and lower extremities, the vascularized adductor magnus tendon flap provides a reliable and versatile method for microsurgical reconstruction.

Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap

BackgroundAchilles tendon ruptures are becoming more common. Complications after open or minimally invasive surgery are: recurrent rupture (2–8%), wound breakdown, deep infections, granuloma, and fistulas. The authors expose their experience with a personal technique. MaterialsIn 8 patients with acute rupture of Achilles tendon the surgery was performed at least 25 days after trauma. Clinical exam and MR demonstrated in all case a total lesion of tendon. After a posterolateral skin incision the tendon stumps were debrided and suture in end-to-end fashion. A tendon flap was harvested from the proximal part of the tendon, in order to protect and reinforce the suture itself. A plaster cast was applied for 3 weeks and the patients started the rehabilitation protocol. ResultsAfter 4 months all patients returned to pre-injury daily activities. The mean follow up was 13 months (ranged between 6 and 24 months). No major complications occurred. ConclusionThe posterolateral skin incision, not above the tendon, preserves the vascularity of the soft tissues, allows identifying and not accidentally injuring the sural nerve, and prevents the cutaneous scar is overlapped the tendon. In this way is favoured physiological tendon sliding.The preparation of the flap tendon does not weaken the overall strength of the tendon and protects the tendon suture. The tension on sutured stumps is less than being spread over a larger area.In our sample of 8 patients the absence of short-and long-term complications and the rapid functional recovery after surgery suggest that the technique used is safe and effective.

Achilles Tendon Open Repair Augmented with Volar Turndown Tendon Flap and Deep Posterior Crural Fasciotomy

Objectives:The aim of the study was to investigate the outcomes after open repair of Achilles tendon rupture with augmented volar turndown gastrocnemius flap and deep posterior crural fasciotomy.Methods:Twenty-three (22male/1female) patients with acute Achilles tendon injury were operated. Open end to end repair and augmentation with a volar turndown gastrocnemius flap and fasciotomy of the deep posterior compartment was performed in each patient. Home physiotherapy program was instructed for each patient. Muscle strength, balance and jump performance were assessed.Results:All patients returned to their preinjury activity level and repairs healed without any major complication. One patient had serous drainage who did not require surgical intervention (4,3%). There was no significant difference between involved and uninvolved leg in terms of concentric and eccentric muscle strength (p=0.82 and p=0.53, respectively). In Y balance test, there was no significant difference between involved and uninvolved legs in anterior (p=0.06), posteromedial (p=0.97) and posterolateral (p=1.00). In addition, there were no significant differences between leg in vertical jump (p=0.16) and one leg hop (p=0.15) tests. AOFAS Hindfoot score was 98.6±2.3 (93-100).Conclusion:Open end to end repair of the Achilles tendon rupture with augmentation and fasciotomy of the deep posterior compartment healed without any major complication. Fasciotomy of the deep posterior compartment decreased the tension at the skin repair site while decompressing the supeficial compartment anteriorly. Additionally, the augmented bulky repair construct of the Achilles tendon cambered volarly through the deep posterior compartment and decreased irritation sense during and after tendon healing.

Total Lip Reconstruction with Tendinofasciocutaneous Radial Forearm Flap

Introduction. Squamous cell carcinoma is a common tumour of lower lip. Small defects created by surgical resection may be readily reconstructed by linear closure or with local flaps. However, large tumours resection often results with microstomia and oral incompetence, drooling, and speech incomprehension. The goal of this study is to describe our experience with composite free radial forearm-palmaris longus tendon flap for total or near total lower lip reconstruction. Patients and Methods. This procedure was used in 5 patients with 80–100% lip defect resulting from Squamous cell carcinoma. Patients' age ranged from 46 to 82 years. They are three male patients and two female. In 3 cases chin skin was reconstructed as well and in one case a 5 cm segment of mandible was reconstructed using radius bone. In one case where palmaris longus was missing hemi-flexor carpi radialis tendon was used instead. All patients tolerated the procedure well. Results. All flaps totally survived. No patient suffered from drooling. All patients regained normal diet and normal speech. Cosmetic result was fair to good in all patients accept one. Conclusion. We conclude that tendino-fasciocutaneous radial forearm flap for total lower lip reconstruction is safe. Functional and aesthetic result approaches reconstructive goals.

Bankart Augmentation for Capsulolabral Deficiency Using a Split Subscapularis Tendon Flap

Traumatic anterior shoulder instability is a frequent problem and often requires surgical management. In the absence of significant bone deficiency, arthroscopic capsulolabral repair is associated with low recurrence rates and good functional outcome. However, capsulolabral deficiency, particularly after multiple previous attempts at repair, may preclude traditional arthroscopic Bankart techniques. Previous reports have described the use of autograft or allograft augmentation or coracoid transfer in the treatment of this difficult problem. The purpose of this report is to describe a novel technique of arthroscopic Bankart augmentation of capsulolabral deficiency using a split subscapularis tendon flap to reinforce a damaged capsule. In the absence of bone deficiency, this technique can restore anterior shoulder restraint without excessively constraining the glenohumeral joint.

Quadrizeps- und Patellasehnenrupturen

Ruptures of the quadriceps or patellar tendon are uncommon but extremely relevant injuries. Early diagnosis and surgical treatment with a stable suture construction are mandatory for a good postoperative clinical outcome. The standard methods of repair for quadriceps and patellar tendon injuries include the placement of suture loops through transpatellar tunnels. Reinforcement with either a wire cerclage or a PDS cord is used in patellar tendon repair. The PDS cord can also be applied as augmentation in quadriceps tendon repair. In secondary patellar tendon repair an autologous semitendinosus graft can be used. For chronic quadriceps tendon defects a V-shaped tendon flap with a distal footing is recommended. The different methods of repair should lead to early functional postoperative treatment. The clinical outcome after surgical treatment of patellar and quadriceps tendon ruptures is mainly good.

Chronic Achilles Tendon Rupture Treated with Two Turndown Flaps and Flexor Hallucis Longus Augmentation – Two-year Clinical Outcome

Both conservative and operative management have been described in the literature for the management of chronic Achilles tendon ruptures with surgical management generally having more favourable results. In our institution, the favoured reconstructive technique was the use of 2 turndown tendon fl aps fashioned from the proximal Achilles tendon augmented by a tenomyodesis of the flexor hallucis longus. The purpose of this study was to assess the clinical outcome of all patients who underwent this procedure. From the records, a total of 9 patients underwent the above-mentioned procedure of whom 6 patients had complete data collection sets [including SF-36, Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores, ankle range of motion (ROM), presence of residual symptoms and complications] at 2 years of follow-up. Our results showed an average AOFAS Ankle-Hindfoot score of 94.2, VAS of 0 in all but 1 patient, and generally high scores (75-96) in all 8 domains of the SF-36 questionnaire. Patient satisfaction was also rated to be high from the surgical procedure. We submit that the procedure adopted at our institution is able to reproduce satisfactory results with low morbidity in patients with this challenging condition.

Anatomic Reconstruction of Neglected Achilles Tendon Rupture With Autogenous Peroneal Longus Tendon by EndoButton Fixation

Neglected or chronic rupture of the Achilles tendon usually needs a reconstruction procedure. Many graft sources have been reported for this procedure, such as a proximal V-Y gastrocnemius tendon flap, flexor hallucis longus tendon, fascia lata, plantaris tendon, synthetic materials, and peroneus brevis. However, how to fix the graft at the calcaneal site remains controversial. An alternative technique to anatomically reconstruct the Achilles tendon using an autogenous peroneal longus tendon with EndoButton-CL fixation at the calcaneal site for treatment of a patient who had a chronic neglected rupture of the Achilles tendon is described. The patient was allowed to begin gentle exercise, such as swimming and cycling 12 weeks after surgery, and encouraged to augment rehabilitation of hindfoot eversion and ankle plantar flexion. The ankle plantar flexion and hindfoot eversion strength was not reduced after active rehabilitation in 2.5 years of follow-up. Our technique reuses two small central incisions, thus, preserving skin integrity as much as possible to reduce wound breakdown or infection. The management of chronic or neglected Achilles tendon rupture by autogenous peroneal longus tendon with EndoButton-CL fixation at the calcaneal site is an anatomic and safe, but technically demanding technique.