Medical Journal of Dr. D.Y. Patil Vidyapeeth

CASE REPORT
Year
: 2015  |  Volume : 8  |  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

Correspondence Address:
Rahul R Bagul
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
India

Abstract

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.



How to cite this article:
Bagul RR, Agarwal T, Bendale M, Kukreja T. Chronic tendoachilles rupture.Med J DY Patil Univ 2015;8:203-205


How to cite this URL:
Bagul RR, Agarwal T, Bendale M, Kukreja T. Chronic tendoachilles rupture. Med J DY Patil Univ [serial online] 2015 [cited 2020 Nov 30 ];8:203-205
Available from: https://www.mjdrdypu.org/text.asp?2015/8/2/203/153162


Full Text

 Introduction



The tendoachilles (TA) is among the most commonly ruptured tendons. [1] About 20% of all TA ruptures are initially misdiagnosed, and these make up about 40% of all surgically repaired TA. [2],[3],[4] 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. [5] Chronic TA ruptures are defined as those of >4 weeks duration without treatment. [6]

 Case Reports



Case 1

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.{Figure 1}{Figure 2}{Figure 3}

Case 2

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.{Figure 4}

 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, [7],[8] tendon transfers that involve flexor halluces longus and or peroneus brevis, [9],[10],[11] free autogenous muscle and fascia lata flaps and grafts, [12],[13] tendon and fascia lata allografts, allogeneic tissues [14],[15] and synthetic materials to reconstruct the tendon. [16] 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. [17] 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. [18] 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. [19] 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. [20] Abraham and Pankovich described V-Y tendinous flap for the end to end repair of chronic TA ruptures. [8] 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. [21] 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.

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