V-Y Lengthening: Chronic ATR Treatment

Below is an explanation and link about the procedure used on my acute ATR injury back in October 2012. MY injury went untreated for approximately 4.5 months, and I’m providing this for anyone who’s doctor may recommend this procedure, or others like the FHL graft. So you’ve come to a decent  place for some explanations for treatment of acute chronic ATRs. My surgery didn’t include the FHL tendon graft, but only the V-Y Lengthening.

This information came from the Orthopaediczone.com

Approach11,14

An extensile posterior incision over the calf is required for the procedure. The initial longitudinal incision is made distally at the rupture level, placed immediately medial to the Achilles tendon to avoid potential sural nerve injury. Once the diagnosis and rupture gap is confirmed, the incision is extended proximally along the posterior midline of the calf and extended to the myotendinous junction (Figure 3). Care should be taken to identify and protect the sural nerve as it crosses from lateral to central in the midcalf area. The nerve is usually found with the lesser saphenous vein, which aids in its identification, and should also be preserved if possible (Figure 4).


Figure 3. The incision is medial distally and curves to the midline proximally. 


Figure 4. The sural nerve and lesser saphenous vein are identified and retracted laterally.


At the distal rupture level, a full-thickness incision is sharply made down to and through the paratenon, which is then reflected full thickness together with the skin flap and preserved for later repair. After identifying the ruptured region, the gap is measured (Figure 5). A scar pseudotendon is usually found between the retracted tendon ends and should be resected along with all nonviable ends of the tendon. The true gap can then be measured with the knee flexed to 30 degrees and the ankle held in a resting position matching that of the contralateral side (Figure 6).


Figure 5. The rupture site is identified with the interposed pseudotendon. This should not be used as the gap measurement as it is misleading. 


Figure 6. The true gap is measured after debridement of the pseudotendon.

V-Y Lengthening

An inverted V incision is made within the myotendenous portion of the gastrocsoleus-Achilles mechanism, with the apex of the V placed midline at the most proximal portion of the myotendinous junction. The limbs of the V diverge to exit through the medial and lateral borders of the tendon (Figure 7). The limbs should be at twice the length of the measured true gap. The V is then incised through the tendinous portion (superficial) only, leaving the underlying muscle fibers intact (Figure 8). A heavy braided non-absorbable suture (No. 2 Fiberwire, Arthrex Inc, Naples, FL, or No. 5 Ethibond, Ethicon-J&J, Piscataway, NJ) is then sutured into the ends of the ruptured tendon using a locking Krakow technique with five locked loops on each of the medial and lateral sides, with the suture ends exiting out of the ends of the rupture stump.


Figure 7. The V is drawn with the apex at the musculotendinous junction and the limbs divergent to exit the medial and lateral borders of the tendon. The length of the limbs should be twice the length of the measured gap.

Login to view presentation on V-Y Advancement and FHL Transfer-Video 8 Incise the V

Figure 8. The V is incised through the tendinous portion (superficial) only, leaving the underlying muscle fibers intact.


The suture is then used to apply longitudinal traction to the  proximal tendon stump, while gently teasing the muscle fibers longitudinally, allowing the myotendinous junction to slide distally. It should be done with great patience and care not to detach the tendon from the underlying muscle, which would devascularize the tendon (Figure 9).  This is continued until the tendon ends are approximated.

Figure 9. A suture is used to apply longitudinal traction to the proximal tendon stump, while gently teasing the muscle fibers longitudinally, allowing the myotendinous junction to slide distally.


The tendon ends are repaired using the sutures that were previously placed. The V-shaped incision is now repaired creating an inverted Y, with the long arm of the Y being the length that the tendon was elongated, which is also the length of the measured gap (Figure 10).


Figure 10. The V-shaped incision is then repaired creating an inverted Y, with the long arm of the Y being the length that the tendon was lengthened and the true gap.

Other Sources

V-Y Myotendious Lengthening

Surgical Treatment of Neglected Achilles Tendon Rupture

Overview of ATR treatment Methods

Acute and Chronic ATR in Athletes

2 responses so far

2 Responses to “V-Y Lengthening: Chronic ATR Treatment”

  1. superjewgrlon 05 Aug 2013 at 8:59 PM 1

    WOW! So when I was healing non-op and I would flex my calf, I felt it. Late last week I started flexing again and I felt it, so I was really happy. Now I’m thinking I have a tingle (a good tingle) when I flex my calf because of all this explained on this page. So am I correct that there are a lot of sutures underneath holding everything together?

    I thought there were probably just a few sutures keeping the tendon together. I’m wondering how I made it adulthood after reading all this.

    This is nothing like the video I saw on you tube.

    Thank you!!!!!! I am now very intrigued. Take Care. xx

  2. wheelchair24on 27 May 2019 at 4:26 AM 2

    Nice article. I think it is useful and unique article. I really love this kind of article and this kind of blog. I liked it and enjoyed reading it. Keep sharing such important posts.

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