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CASE SERIES
Year : 2020  |  Volume : 13  |  Issue : 6  |  Page : 672-676  

Reconstruction of neglected Tendo-Achilles tears using the technique of Gastrocnemius-Soleus turndown graft: A case series


Department of Orthopaedics, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission13-Sep-2019
Date of Decision21-Nov-2019
Date of Acceptance06-Jan-2020
Date of Web Publication6-Nov-2020

Correspondence Address:
Rajiv Kaul
Department of Orthopaedics, Armed Forces Medical College, Pune 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_255_19

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  Abstract 


Chronic, neglected Achilles tendon ruptures cause a significant impairment of ankle function due to weakness of active plantar flexion which is required in performing day-to-day activities such as walking and climbing stairs. The causes range from trivial trauma like a slip and fall to high impact injuries. Predisposing factors include a history of previous steroid injections, advanced age, and vigorous sporting activities. Tears involving the zone 2, where vascularity is compromised, pose a challenge to surgeons, as the repair is often jeopardized by wound complications and re-ruptures. Of the several techniques described, we have used the Bosworth's technique of gastrocnemius-soleus turndown to reconstruct defects in this zone in 16 patients and have achieved a satisfactory functional outcome at 1 year with a relatively low incidence of complications. However, this technique requires the presence of an intact distal stump of the tendon of adequate length, the absence of which precludes the use of this method.

Keywords: Bosworth's repair, chronic, functional outcome, gastrocnemius-soleus turndown, tendo-Achilles rupture


How to cite this article:
Kaul R, Prasad M, Iqbal MS. Reconstruction of neglected Tendo-Achilles tears using the technique of Gastrocnemius-Soleus turndown graft: A case series. Med J DY Patil Vidyapeeth 2020;13:672-6

How to cite this URL:
Kaul R, Prasad M, Iqbal MS. Reconstruction of neglected Tendo-Achilles tears using the technique of Gastrocnemius-Soleus turndown graft: A case series. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Nov 26];13:672-6. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/672/300136




  Introduction Top


The Achilles tendon was historically known as the “Tendo magnus” or “Chorda Hippocratis“until Dutch anatomist, Philip Verheyden, in 1693 in his book Corporis humani anatomia, coined the phrase “cord of Achilles.[1] Injuries of the tendo-Achilles (TA) are fairly common in middle-aged individuals, the peak age for rupture in both sexes being 30–40 years. Due to its precarious blood supply, the Achilles tendon is divided into three zones based on vascularity: zone 1 lies up to 2 cm, zone 2 lies between 3 and 6 cm, and zone 3 lies beyond 6 cm from the calcaneal insertion of the TA.[2] The predominant blood supply for zones 1 and 3 is derived from the branches of the posterior tibial artery, whereas the zone 2 is predominantly supplied by the branches of the peroneal artery.[3] The major blood supply to the tendon is through its mesotendon, the richest provided by the anterior mesentery. With increasing age, this anterior mesenteric supply decreases. Age-dependent changes in collagen cross-linking result in the loss of viscoelasticity due to increased brittleness, predisposing to injury. Repetitive microtrauma to this area along with hypoperfusion may make it impossible for the reparative process to keep pace and degenerative changes to develop, predisposing to rupture. Furthermore, failure of inhibiting mechanisms at the musculotendinous unit due to fatigue accompanied by eccentric mechanical overloading completes the rupture. Patients with progressive degenerative tendinosis, as seen in rheumatoid arthritis and systemic connective tissue disorders, may develop a more gradual rupture. Most of the injuries are diagnosed late and if they present after 6 weeks, they are termed as chronic ruptures. These tendons are mostly degenerated and unhealthy with calcifications or preexisting tendinosis. A palpable defect may not be evident due to bridging fibrous tissue. The intraoperative problems associated with such cases are that of elongated tendons, difficulty in the mobilization of the ruptured ends, difficulty in achieving an end-to-end apposition, and problems of reconstruction of the gap.

Several surgical procedures have been described with the objective of bridging this defect by grafting and thus restoring the continuity of the tendon. These include direct/primary repair, augmentation with free fascia or tendon grafts, V-Y advancement, gastroc-soleus turndown procedure, local tendon transfers (flexor halluces longus, peroneus brevis, plantaris, and peroneus longus), and allograft or synthetic graft augmentation (using carbon fiber, Dacron or poly-glycolic acid polymers).[4]

Aim and objective

The aim of this study was to analyze the functional outcome following the Bosworth's technique of Achilles tendon repair for chronic ruptures in zone 2 where end-to-end repair is not possible.[5] The outcomes were assessed clinically using the Leppilahti scoring system and radiologically using ultrasonography (USG) to assess the tendon integrity.[6]


  Case Report Top


Our study was conducted at a tertiary care center in Western India from 2016 to 2018. A total of 16 patients who presented with neglected tears of the TA underwent a thorough history taking including a history of intake of corticosteroids, fluoroquinolones, previous steroid injections, diabetes, smoking, obesity, rheumatoid arthritis, and connective tissue disorders. The most common mechanism of injury was trivial trauma resulting in sudden hyperdorsiflexion of the ankle. All of these patients presented with difficulty in walking, climbing stairs, toe rising, and pain around the ankle. Due to the long-standing nature of the disease, there was no swelling or ecchymosis around the ankle. On clinical examination, most patients had a knobby swelling around the proximal or distal stumps along with a palpable gap in the substance of the tendon. There was a weakness of active plantar flexion with a positive Thompson's squeeze test. Other useful clinical tests included the Matles hyperdorsiflexion test and the Copeland test. Plain radiographs showed, in some cases, calcification of the tendon stump on the lateral view. USG revealed a discontinuity in the substance of the tendon and the zone involved. From the gathered sonographic data, we limited our study to include only those patients who had a zone 2 tear, in which a portion of the distal stump was still attached to the calcaneum. Those with a complete avulsion of the calcaneal insertion and tears with a negligible portion of stump distally were excluded from the study.

The technique employed was that of gastrocnemius-soleus turndown, as described by Bosworth.[5]

Surgical technique

With the patient prone, under general or spinal anesthesia, a generous, straight posterior midline incision beginning approximately 10 cm below the knee joint and extending up to the calcaneal insertion of the tendon was given. Dissection proceeded in a standard fashion taking care not to damage the sural nerve and short saphenous vein. The proximal and distal tendon stumps were identified and dissected free of surrounding adhesions. No portion of the TA stump was freshened or excised, as this invariably results in a shortening of the tendon, thereby increasing the gap. The median raphe of the gastrocnemius was identified and a strip of the tendon, 1.5 cm in width, was harvested from the central one-third of the TA, leaving it attached around 2 cm proximal to the site of rupture. The graft was freed from the muscle fibers and twisted such that its smooth outer surface now faced inward. The gastrocnemius fascia was closed using running nonabsorbable sutures. A tunnel was made in the proximal and distal stumps by blunt dissection using artery forceps. The graft was passed first through the proximal stump, then through the distal stump, looped out, and retrieved proximally [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Care was taken to ensure that a safe distance be maintained from the margins of the torn portion of the stump to prevent the cutout of the graft. It was anchored at all the entry and exit points using nonabsorbable polypropylene sutures. With the ankle in slight plantar flexion, the graft was again looped through the proximal stump and finally sutured to the distal stump after eliminating the slack. Meticulous closure of the subcutaneous tissues with absorbable sutures and skin using modified Allgöwer–Donati stitches was done. This technique of suturing is beneficial in areas where vascularity is compromised, such as around the ankle, by spreading the tension force over a large area, thereby preventing unnecessary strangulation of tissues and wound breakdown.[7] Finally, an above knee, anterior, dorsiflexion-restricting plaster of paris (POP) slab was applied for 3 weeks, which was converted to a short leg gravity-assisted equinus cast for 3 weeks followed by a plantigrade walking cast or functional brace for 6 weeks.
Figure 1: (a-d) Identification of stumps, harvesting of graft, anchoring graft distally, completed repair

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The weight-bearing protocol was as follows: nonweight-bearing with a walker: 0–6 weeks, partial weight-bearing with crutches: weeks 6–12, and full weight-bearing with/without crutches from 12 weeks onward along with anti-edema measures such as compression stockings.

The functional outcome was assessed at 6- and 12-month follow-up using the scoring system devised by Leppilahti et al. [Table 1].[6] This was accompanied by an ultrasonographic evaluation for graft integration at 3, 6, and 12 months.
Table 1: Leppilahti scoring system

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  Results Top


Of the total of 16 patients, 12 had excellent results, 3 had a good result, and 1 had a fair result at the end of 12 months [Graph 1]. All patients resumed normal walking and stair climbing at 6 months [Figure 2]. Postoperative range of motion improved to near-normal values at 6–12 months in all patients. USG showed a continuity of fibers at the repair site with an increase in thickness of the graft, suggestive of good integration [Figure 3]a, [Figure 3]b, [Figure 3]c. Complications included superficial surgical site infections in 2 patients, which responded to oral antibiotics and local dressings and delayed wound healing in 1 patient. There was no incidence of re-rupture at 1 year postsurgery.
Figure 2: Clinical outcome

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Figure 3: (a-c) Ultrasonography following repair, ultrasonography at 3 months showing partial integration, ultrasonography at 1 year showing complete graft integration

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  Discussion Top


There exist a multitude of injuries resulting in acute tears of the TA, which if misdiagnosed or left untreated results in a significant derangement of function. Accurate diagnosis and prompt treatment is critical in predicting the final outcome. The goal of all surgeries is to restore the integrity of the tendon at the appropriate length to enable early rehabilitation. A multitude of surgical techniques using various grafts exist for the reconstruction of these defects such as the plantaris tendon (Lynn),[8] peroneus brevis (Turco and Spinella),[9] V-Y advancement (Abraham and Pankovich),[10] flexor digitorum longus (Mann),[11] flexor hallucis longus (Wapner),[12] gracilis (Maffulli),[13] Marlex mesh (Ozaki),[14] and the recently described minimally invasive technique (Miao).[15] The Bosworth's technique is advantageous in situ ations in which a sizeable gap is present since an adequate length of graft can be obtained by simply extending the incision proximally, harvesting a longer portion of the tendon, and turning the gastroc-soleus fascial slip upon itself. The donor site morbidity is minimal, and the strength of the graft is identical to that of the original tendon. There is no loss of excursion of ankle movements. Complications include delayed wound healing, superficial and deep infections, and re-rupture of the repaired tendon. To avoid these, a meticulous closure should be performed avoiding strangulation of the overlying soft tissues by the use of appropriately tensioned sutures and protecting the repair by some form of immobilization until healing occurs. The only drawback of this technique is that it requires some portion of the distal stump to be intact to secure the graft, thereby precluding its use in zone 1 and avulsion type injuries.[16]


  Conclusion Top


Overall, in our clinical practice, the Bosworth technique has been found to be a safe, technically simple, and cost-effective procedure with excellent functional outcome and patient satisfaction.

Patient declaration statement

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Suy R. Philip verheyen (1648-1710) and his corporis humani anatomiae. Acta Chir Belg 2007;107:343-54.  Back to cited text no. 1
    
2.
Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon; an angiographic and microangiographic study. Acta Chir Scand 1959;116:491-5.  Back to cited text no. 2
    
3.
Chen TM, Rozen WM, Pan WR, Ashton MW, Richardson MD, Taylor GI, et al. The arterial anatomy of the Achilles tendon: Anatomical study and clinical implications. Clin Anat 2009;22:377-85.  Back to cited text no. 3
    
4.
Canale ST, Beaty JH. Campbell's operative orthopaedics e-book. Elsevier Health Sciences; 2012.  Back to cited text no. 4
    
5.
Bosworth DM. Repair of defects in the tendo Achillis. J Bone Joint Surg Am 1956;38-A: 111-4.  Back to cited text no. 5
    
6.
Leppilahti J, Forsman K, Puranen J, Orava S. Outcome and prognostic factors of achilles rupture repair using a new scoring method. Clinical orthopaedics and related research 1998;(346):152-61.  Back to cited text no. 6
    
7.
Shannon SF, Houdek MT, Wyles CC, Yuan BJ, Cross WW 3rd, Cass JR, et al. Allgöwer-donati versus vertical mattress suture technique impact on perfusion in ankle fracture surgery: A Randomized clinical trial using intraoperative angiography. J Orthop Trauma 2017;31:97-102.  Back to cited text no. 7
    
8.
Lynn TA. Repair of the torn Achilles tendon, using the plantaris tendon as a reinforcing membrane. J Bone Joint Surg Am 1966;48:268-72.  Back to cited text no. 8
    
9.
Turco VJ, Spinella AJ. Achilles tendon ruptures – Peroneus brevis transfer. Foot Ankle 1987;7:253-9.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
Mann RA, Holmes GB Jr., Seale KS, Collins DN. Chronic rupture of the Achilles tendon: A new technique of repair. J Bone Joint Surg Am 1991;73:214-9.  Back to cited text no. 11
    
12.
Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle 1993;14:443-9.  Back to cited text no. 12
    
13.
Maffulli N, Leadbetter WB. Free gracilis tendon graft in neglected tears of the Achilles tendon. Clin J Sport Med 2005;15:56-61.  Back to cited text no. 13
    
14.
Ozaki JI, Fujiki JU, Sugimoto KE, Tamai SU, Masuhara KE. Reconstruction of neglected Achilles tendon rupture with Marlex mesh. Clinical orthopaedics and related research 1989;(238):204-8.  Back to cited text no. 14
    
15.
Miao X, Wu Y, Tao H, Yang D, Huang L. Reconstruction of kuwada grade IV chronic Achilles tendon rupture by minimally invasive technique. Indian J Orthop 2016;50:523-8.  Back to cited text no. 15
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16.
Pavan Kumar A, Shashikiran R, Raghuram C. A novel modification of Bosworth's technique to repair zone I Achilles tendon ruptures. J Orthop Traumatol 2013;14:59-65.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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