Minimally Invasive Revision Surgery Combining Endoscopic Double-Row Reinsertion and Flexor Hallucis Longus Transfer for Insertional Achilles Tendon Re-Rupture in a Semi-Professional Rugby Player: A Case Report.

Abstract

Background/Objectives: Acute insertional Achilles tendon rupture (A-IATR) is a rare, often season-ending injury in athletes. Revision after a failed repair is particularly challenging, and return to sport (RTS) after such surgery is rarely documented. We report one such case. Methods: A 32-year-old semi-professional rugby prop forward sustained an insertional re-rupture eighteen months after open transosseous reinsertion without suture anchors. MRI showed complete detachment with 15 mm of retraction and no residual tendon on the footprint. A single-stage procedure combining endoscopic double-row (SpeedBridge™) reinsertion and flexor hallucis longus (FHL) transfer was performed, followed by six weeks of non-weight-bearing cast immobilization and criteria-based rehabilitation, with Ankle-GO™-guided return to play. Results: At three months, MRI showed tendon continuity without re-rupture. Return to play was authorized at 8.2 months (Ankle-GO™ 16/25); the patient returned to official competition at 9.4 months and was still competing approximately 17 months after surgery. At 15 months, the Achilles Tendon Total Rupture Score was 84 and the AOFAS score 90. No complication occurred. Conclusions: To our knowledge, this is the first report of RTS after this combined endoscopic revision technique. This single case suggests that this approach may be a feasible revision option in high-demand athletes; comparative studies are needed.