|Year : 2015 | Volume
| Issue : 2 | Page : 203-205
Chronic tendoachilles rupture
Rahul R Bagul, Tushar Agarwal, Mahendra Bendale, Tarun Kukreja
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||13-Mar-2015|
Rahul R Bagul
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
We report two cases of chronic tendoachilles (TA) rupture, which was treated with V-Y plasty and turned down flap from the proximal segment to cover the defect. Chronic TA ruptures can be challenging to treat. A number of operations have been described for the repair and augmentation of the chronic TA rupture.
Keywords: Chronic tendoachilles rupture, fascial turn down flap, V-Y plasty
|How to cite this article:|
Bagul RR, Agarwal T, Bendale M, Kukreja T. Chronic tendoachilles rupture. Med J DY Patil Univ 2015;8:203-5
| Introduction|| |
The tendoachilles (TA) is among the most commonly ruptured tendons.  About 20% of all TA ruptures are initially misdiagnosed, and these make up about 40% of all surgically repaired TA. ,, TA ruptures may be misdiagnosed because patients maintains plantar flexion with the deep flexor muscles, or by fibrous in-growth and the gap defect fills with fibrous tissue.  Chronic TA ruptures are defined as those of >4 weeks duration without treatment. 
| Case Reports|| |
A 55-year-old female came with the complaints of weakness with prolonged walking, sense of unsteadiness in her gait and difficulty climbing stairs and walking uphill since 3 months. Patients gave a history of slip and fall in bathroom 3 months back where she was hit on the left ankle against the side of a door. She took initial treatment in the form of analgesic and crepe bandaging. On examination, there was calf wasting, loss of normal push-off, plantar flexion weakness and a gap was palpated along the course of the TA [Figure 1]. She was unable to perform a single leg heel raise. Ultrasonography was done which showed complete tear of TA with proximal retraction of the tendon fibers, which appeared thickened and hypoechoic. During operation, we found a gap of 8 cm after freshening the ends of the tendon [Figure 2]. We did a V-Y plasty first to gain length and then a 2 cm × 6 cm flap was raised from the proximal tendon fragment and turned down to cover the defect [Figure 3]. Postoperatively, an above knee cast with 30° knee flexion and 20° planter flexion was applied and a window was made posteriorly for dressing. After 4 weeks, the cast was removed and physiotherapy started. The patient had a good functional result at 1-year follow-up.
A 30-year-old male came with the complaints of inability to walk, pain, and difficulty climbing stairs since 6 months. He gave a history of a slip and fall 6 months back from staircase where he hit his right ankle and had an open wound. He took initial treatment in the form of suturing of the open wound, antibiotics and analgesic. On examination, there was calf wasting, loss of normal push-off, plantar flexion weakness and a gap was palpated along the course of the TA. The patient was unable to perform a single leg heel raise. Ultrasonograghy was done, which showed complete tear of TA with proximal retraction of the tendon fibers, which appeared thickened and hypoechoic. During operation we found that there was a gap of 10 cm after freshening the ends of the tendon. We did V-Y plasty first to gain length and then a 2 cm × 8 cm flap was raised from the proximal tendon fragment and turned down to cover the defect [Figure 4]. Postoperatively, an above knee cast with 30° knee flexion and 20° planter flexion was applied and a window was made posteriorly for dressing. After 4 weeks, cast was removed and physiotherapy was started. The patient had a good functional result at 1-year follow-up.
| Discussion|| |
Chronic TA ruptures are difficult to treat. Most of these are a result of failure to diagnose an acute rupture. Although pain is not the main symptom, these patients have significant functional deficits that can interfere with activities of daily living. Loss of TA function causes a significant loss in plantar flexion strength, which can result in an inability to run, stand on tip toes, and difficulty climbing stairs. A number of operations have been described for the repair and augmentation of the ruptured tendon, the use of tendon and fasciocutaneous flaps, , tendon transfers that involve flexor halluces longus and or peroneus brevis, ,, free autogenous muscle and fascia lata flaps and grafts, , tendon and fascia lata allografts, allogeneic tissues , and synthetic materials to reconstruct the tendon.  Christensen described the use of a 2 cm × 10 cm flap that was raised from the proximal tendon fragment and turned down to cover the defect in both acute and chronic ruptures.  He reported 75% of outcomes as being satisfactory. Bosworth reported on six patients with chronic ruptures treated with a strip of tendon from the proximal tendon stump, which is woven through the proximal stump transversely and then through the distal stump of the rupture and finally back again through the proximal stump.  Bosworth reported good results in his six patients treated with this technique. Rush raised an inverted "U" from the proximal fascia and then sutured the ends together to create a tube.  All five patients were happy and could return to activities but they noted some weakness compared with the other side. Arner and Lindholm evaluated three different turndown flaps in their series of patients and found no significant functional difference among the various techniques.  Abraham and Pankovich described V-Y tendinous flap for the end to end repair of chronic TA ruptures.  They reported results in four patients with chronic TA rupture, with a gap of 5-6 cm between ends, with three of four patients regaining full strength. Parker and Repinecz in their case report noted that a tendon advancement technique had the advantage of allowing healthy tendon-to-tendon apposition, minimizing tension at the repair site and avoiding foreign materials at the site of healing.  We did two cases of chronic TA rupture in which the defect was 8 cm and 10 cm. It is difficult to treat when the defect is >5 cm. In both cases, we did V-Y plasty first to gain length so that less length of the flap is taken down from proximal tendon fragment. After which we made flap from the proximal tendon fragment and turned down to cover the defect. Technically, this surgical technique is easier. Both patients had good functional result at 1-year follow-up and was able to walk, climb staircase and had no unsteadiness in there gait. Both patients were able to perform single-leg heel rise and single affected-side leg hopping. Postoperative ankle range of movement was equal to that of the opposite side. The functional results were good at 1-year follow-up, but we need to do a longer follow-up to assist the functional results. We have done only two cases and we need to have a larger series to assist the functional results.
| References|| |
Pérez Teuffer A. Traumatic rupture of the Achilles tendon. Reconstruction by transplant and graft using the lateral peroneus brevis. Orthop Clin North Am 1974;5:89-93.
Józsa L, Kvist M, Bálint BJ, Reffy A, Järvinen M, Lehto M, et al
. The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases. Am J Sports Med 1989;17:338-43.
Maffulli N. Clinical tests in sports medicine: More on Achilles tendon. Br J Sports Med 1996;30:250.
Carden DG, Noble J, Chalmers J, Lunn P, Ellis J. Rupture of the calcaneal tendon. The early and late management. J Bone Joint Surg Br 1987;69:416-20.
Mendicino SS, Reed TS. Repair of neglected Achilles tendon ruptures with a triceps surae muscle tendon advancement. J Foot Ankle Surg 1996;35:13-8.
Pintore E, Barra V, Pintore R, Maffulli N. Peroneus brevis tendon transfer in neglected tears of the Achilles tendon. J Trauma 2001;50:71-8.
Papp C, Todoroff BP, Windhofer C, Gruber S. Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap. Plast Reconstr Surg 2003;112:777-83.
Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon. Treatment by V-Y tendinous flap. J Bone Joint Surg Am 1975;57:253-5.
Wong MW, Ng VW. Modified flexor hallucis longus transfer for Achilles insertional rupture in elderly patients. Clin Orthop Relat Res 2005;431:201-6.
Martin RL, Manning CM, Carcia CR, Conti SF. An outcome study of chronic Achilles tendinosis after excision of the Achilles tendon and flexor hallucis longus tendon transfer. Foot Ankle Int 2005;26:691-7.
Miskulin M, Miskulin A, Klobucar H, Kuvalja S. Neglected rupture of the Achilles tendon treated with peroneus brevis transfer: A functional assessment of 5 cases. J Foot Ankle Surg 2005;44:49-56.
Maffulli N, Leadbetter WB. Free gracilis tendon graft in neglected tears of the achilles tendon. Clin J Sport Med 2005;15:56-61.
Haas F, Seibert FJ, Koch H, Hubmer M, Moshammer HE, Pierer G, et al.
Reconstruction of combined defects of the Achilles tendon and the overlying soft tissue with a fascia lata graft and a free fasciocutaneous lateral arm flap. Ann Plast Surg 2003;51:376-82.
Buinewicz B, Rosen B. Acellular cadaveric dermis (AlloDerm): A new alternative for abdominal hernia repair. Ann Plast Surg 2004;52:188-94.
Lepow GM, Green JB. Reconstruction of a neglected achilles tendon rupture with an achilles tendon allograft: A case report. J Foot Ankle Surg 2006;45:351-5.
Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med 1998;25:79-100.
Christensen I. Rupture of the Achilles tendon; analysis of 57 cases. Acta Chir Scand 1953;106:50-60.
Bosworth DM. Repair of defects in the tendo achillis. J Bone Joint Surg Am 1956;38-A:111-4.
Rush JH. Operative repair of neglected rupture of the tendo Achillis. Aust N Z J Surg 1980;50:420-2.
Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand Suppl 1959;116:1-51.
Parker RG, Repinecz M. Neglected rupture of the achilles tendon. Treatment by modified Strayer gastrocnemius recession. J Am Podiatry Assoc 1979;69:548-55.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]