Endoscopic-assisted percutaneous reconstruction of chronic Achilles tendon ruptures with allograft Achilles tendon: a report of two cases with novel surgical technique

Chronic Achilles tendon ruptures with large defects are difficult to reconstruct because of tendon retraction, poor tissue quality, and the risk of wound complications associated with open surgery. This report describes a novel endoscopic-assisted percutaneous technique for Achilles tendon reconstruction using an Achilles tendon allograft and illustrates its application in two patients. Two male patients with chronic Achilles tendon defects (12 centimeters after a neglected rupture; 5 centimeters after traumatic amputation with replantation and multiple soft-tissue procedures) underwent reconstruction with an Achilles tendon allograft. A 4.0-millimeter, 30-degree endoscope was introduced within the paratenon to debride fibrotic tissue and to create a soft-tissue tunnel between the paratenon and tendon, with endooscopic confirmation of the tissue plane and tunnel adequacy. The allograft was passed through a small proximal transverse incision and retrieved distally under endoscopic guidance. Distal fixation to the calcaneus was achieved with two suture anchors. Proximal and distal integration with native tendon stumps was reinforced using nonabsorbable sutures and percutaneous Bunnell-type sutures through small portals. At 6 months, both patients demonstrated marked functional improvement without wound complications or re-rupture. Plantarflexion strength improved to grade 4/5 on the Medical Research Council (MRC) muscle strength scale in both cases. Case 1 regained active plantarflexion to 45 degrees and improved the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score from 45 to 90; magnetic resonance imaging at 7 months confirmed graft integration without recurrent gap formation. Case 2 regained plantarflexion to 40 degrees, returned to single heel raise, hopping, and sports activities, and improved the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score from 40 to 92; magnetic resonance imaging at 20 months showed durable healing and integration. This descriptive two-case series demonstrates the technical feasibility of endoscopic-assisted percutaneous reconstruction using an Achilles tendon allograft for chronic Achilles tendon defects. Larger studies with longer follow-up are needed to define indications, safety, and durability. Not applicable.