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Final appearance of reconstruction of chronic Achilles tendon rupture with semitendinosus tendon graft.
Source publication
Background
The Achilles tendon, the largest and strongest tendon in the human body, is nevertheless one of the tendons which most commonly undergoes a complete subcutaneous tear. Achilles tendon ruptures are especially common in middle aged men who occasionally participate in sport. Even though Achilles tendon ruptures are frequent, up to 25% of ac...
Context in source publication
Context 1
... maximum equinus. One extremity of the semitendinosus tendon graft is moved again to the proximal incision, beneath the intact skin bridge and passed into the proximal stump through a transverse tenotomy from medial to lateral. Similarly, the other extremity of the semitendinosus tendon is passed again into the distal stump from medial to lateral (Fig. 8). Fig. (5). The semitendinosus tendon is harvested with the patient prone, through a vertical, 2.5-3 cm longitudinal incision over the pes anserinus. Fig. (6). The tendon graft is passed from lateral to medial into the proximal Achilles tendon stump. AT: Achilles tendon; ST: Semitendinosus tendon graft. Fig. (7). The tendon graft is ...
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Abstract
Achilles tendon xanthomas are rarely seen masses. They are highly associated with hyperlipidemia and manifest themselves in two types: xanthomas developed secondary to Familial hypercholesterolemia (FH) and Cerebrotendinous Xanthomatoses (CTX).
In this study, we present a case of bilateral Achilles tendon xanthoma secondary to familial hyp...
Citations
... The Achilles tendon is the strongest in the human body and is commonly affected by spontaneous rupture. 1 Approximately 75% of these injuries occur in recreational activities (primarily men aged 30 to 40), while the remaining 25% occur in more sedentary patients. 2 Although these tears are fairly common, approximately 20% of acute Achilles tears are misdiagnosed, leading to chronic rupture. ...
... 3 Chronic ruptures are typically defined by delayed diagnosis and treatment for more than 4 weeks. 1,3 Managing chronic Achilles tears tends to be more challenging than acute injuries because of increased fibrotic pathways and retracted tendon ends. 1,4 Orthopedic surgeons may offer several surgical options, including flap tissue, local tendon transfer, or autologous graft harvesting. ...
... 1,3 Managing chronic Achilles tears tends to be more challenging than acute injuries because of increased fibrotic pathways and retracted tendon ends. 1,4 Orthopedic surgeons may offer several surgical options, including flap tissue, local tendon transfer, or autologous graft harvesting. 1,5 Several concerns with these surgical interventions include risk of re-rupture, infection, deep vein thrombosis, suture granulomas, hematomas, prolonged rehabilitation, and delayed wound healing. ...
Introduction: We describe a case report of a patient who presented with chronic right Achilles tendon pain and weakness. Without contrast, magnetic resonance imaging of the right Achilles tendon revealed significant expansion of the Achilles tendon in the traverse and anteroposterior dimension with extensive increased T2 signal consistent with large partial-thickness Achilles tendon tear. A musculoskeletal ultrasound using a linear transducer demonstrated an anechoic tendon defect measuring 0.97 cm in the longitudinal axis with a total tendon length measuring 1.53 cm, as well as a 0.9 cm defect in the transverse axis surrounded by homogenous tendon fibers consistent with a large defect involving the distal Achilles tendon proximal to the distal insertion. The patient underwent an ultrasound-guided adipose cellular procedure using micronized fat to fill in the defect and facilitate pain reduction and tissue healing.Conclusion: Ultrasound-guided injection of micro-fragmented adipose tissue of Achilles tendon defect can result in significant improvement in pain and function
... 22 Despite its tensile strength, it is affected by spontaneous rupture. 23 The Achilles tendon is formed by the fusion of the aponeurosis of the two heads of the gastrocnemius with the tendon of the deeper soleus. 4 The free tendon subsequently consists of three subtendons arising from the three muscular heads of the triceps surae. ...
... 50 However, a false-positive test may occur when there is neurologic weakness. 23 Diagnostic imaging is useful to confirm a clinically suspicious acute Achilles tendon rupture. Plain radiographs of the ankle can be performed following an acute injury to evaluate the presence of any concomitant bony fracture and assess the integrity of the Achilles tendon. ...
... Plain lateral radiographs may reveal an irregular outline or configuration of the low-density appearing KFP as the borders become distorted when the tendon is ruptured. 23 MR imaging can be used to demonstrate tendon disruption; however, static MR imaging does not demonstrate dynamic movement of the tendon ends ( Figure 6). ...
Achilles tendon rupture is a common sports‐related injury which can carry significant morbidity to patients. Ultrasound remains the workhorse of imaging as it can confirm and localise the extent of Achilles tendon injury. The sonographic anatomy, both normal and ruptured sonographic appearances, as well as sonographic technique must be appreciated to accurately image and report findings, critical to patient management. Particular attention should be applied to the measurement of the diastasis between acutely ruptured tendon ends as this information can assist with informing the decision of conservative vs. operative management. Further work is necessary to standardise the measurement technique including correlating the degree of plantarflexion of the foot with the sonographic tendon gap measures.
... Sedentary lifestyle, smokers, Diabetes mellitus, hypercholesterolemia, thyroid disorders, and obesity, corticosteroid local infiltrations or had previous local tendonitis can impair the health of tendons, leading to Achilles tendinopathy and possibly predisposing patients to Achilles tendon ruptures [4,5]. Typically, they are the individuals which have less plantar flexibility, agitation, trouble walking, and chronic discomfort [5,6]. ...
... However, up to 25% of ATRs are overlooked, either because of a physician's incorrect diagnosis or because of the patient's incorrect interpretation of the injury and failure to seek immediate medical attention. Evaluation is more challenging and could result in a false diagnosis, which is typically an ankle sprain or ruptured calf muscle, when the patient's history is atypical and there has not been substantial traumatic [5,6]. ...
Background
Achilles’ tendon chronic rupture is a common entity that is usually misdiagnosed or mistreated. Hence, she was presented to us later or with complications affecting her gait. Surgical resection is needed to either bridge the gap or reinforce the strength of the tendon repair.
Objectives
Our study's goal was to assess the clinical results of repairing chronic Achilles’ tendon lesions employing the middle segment of the proximal portion of the tendon (gastro-soleus), as a turn-down flap.
Methods
Our prospective interventional single arm study included 18 patients with chronic Achilles’ tendon rupture attending at Al-Azhar university hospitals in Cairo, Egypt from May 2020 to April 2023. Diagnosis of the patients was confirmed by radiographic and clinical investigations. They were all treated with the same open reconstruction procedure using a modified GSF. The average follow-up was 12 months. The results of this study were assessed by the Achilles tendon rupture score (ATRS), American Orthopedic Foot and Ankle Society (AOFAS) score, and capacity to perform repeated heel raises on the affected side.
Results
The mean operative time was 72.77 min. The median (IQR) time of reconstruction was 10 (8–12) after the injury. The median (IQR) length of flab was 4.5 (4.3–5) 9 (Table 2). No intraoperative complications occurred. The typical follow-up period was 12 months (6–18 months). In terms of the ATRS, we found a significant reduction from 82.8 ± 3 preoperatively to 20.8 ± 6.7 at 12 months postoperatively (P value = 0.001). As regards the AOFAS score, it was increased from 49.5 ± 10 preoperatively to 83.8 ± 8.5 12 months postoperatively (P = 0.001). In terms of the post operative complications, there was no re-rupture. Two patients experienced superficial wound infection which improved with daily dressing and antibiotics. Additionally, two patients had slight ankle stiffness four months after the operation, which improved after programmed rehabilitation at the sixth month.
Conclusion
The modified GSTF is a simple, safe, well-tolerated and effective method of treatment with excellent functional results and greater patient content.
... The Achilles tendon is important to maintain the standing posture, and during walking, running, and jumping [2,3]. Tears of the Achilles tendon are classified as chronic after a fouror six-week period following the initial injury [4][5][6][7][8][9][10]. Patients with chronic Achilles tendon rupture (CATR) report weakness, instability, increased dorsiflexion of the ankle, swelling, tenderness, and thickening of the tendon, and, at times, persistent pain [11][12][13][14][15][16][17]. ...
Background
Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.
Methods
A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.
Results
Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.
Conclusion
Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.
... The Achilles tendon is the biggest and strongest tendon in the human body [2]. The incidence of the Achilles tendon getting injured has recently increased by 18 in 100,000 [3]. Acute forceful plantar flexion of the foot, direct trauma, chronic tendinopathy, and intra-tendinous degenerative disorders can all result in Achilles tendon rupture [4,5]. ...
The incidence of the Achilles tendon getting injured has recently increased by 18 in 100,000. Compared to non-surgical treatment, surgical results are superior. The Achilles tendon repaired with surgery has a re-rupture rate of only 5%, while if treated non-operatively, it has a rupture rate of 40%. This case report analyses the traumatic Achilles tendon rupture and subsequent surgical repair in a young woman. In this case study, a 19-year-old female patient's severe Achilles tendon injury was successfully managed by integrating prompt surgical intervention and structure. After rehabilitation, the patient's range of motion (ROM), muscle strength, and gait patterns all significantly improved. Scores on the Lower Extremity Functional Scale (LEFS) and the Dynamic Gait Index (DGI) both significantly improved. This case study reiterates the significance of an integrated healthcare strategy for Achilles tendon injuries. An immediate surgical procedure followed by a specific rehabilitation programme accelerates healing and the return to optimal function. The results emphasize the critical role of physical therapy in assisting surgical interventions and underline the necessity of comprehensive patient care in the treatment of complex orthopaedic problems.
... The gait pattern is often affected, with weakness at pushoff and poor balance. 9,27 Acute Achilles tendon ruptures can be treated either surgically or nonsurgically. The preferred method and management of acute Achilles tendon ruptures are still debated, as demonstrated by multiple randomized controlled trials showing similar functional results between the 2 options (ie, operative and nonoperative). ...
Background
Both acute and chronic Achilles tendon ruptures are affected by alterations in the extracellular matrix during the healing process of the tendon. Yet, these alterations in gene expression patterns are not well characterized.
Purpose
To characterize temporal and spatial differences in gene expression patterns after an Achilles tendon rupture and to evaluate if cells from chronic Achilles tendon ruptures have the same ability to form new tendon tissue (tendon constructs) as healthy tendon cells.
Study Design
Controlled laboratory study.
Methods
A total of 35 patients with surgically treated Achilles tendon ruptures were included in the study and divided into 3 groups: acute (<4 weeks), short-term chronic (1-6 months), and long-term chronic (>6 months). Biopsy specimens were collected during surgical repair and were used to analyze the gene expression within the different groups and to compare mRNA levels in the proximal and distal tendon ends. A complementary in vitro experiment was performed to evaluate if cells from chronic Achilles tendon ruptures can form tendon constructs.
Results
The mRNA levels for COL1A1 and COL3A1 were significantly higher in the short-term chronic group compared with the acute group ( P < .05). Both MMP-1 and MMP-13 had the highest mRNA levels in the acute group ( P < .01) compared with the long-term chronic group, while MMP-2 had the highest mRNA level in the short-term chronic group. Significant differences between the proximal and distal tendon ends were only detected for the monocyte and macrophage marker CD163 ( P < .05), which was more expressed proximally. Cells extracted from chronic Achilles tendon ruptures displayed a similar ability and effectiveness to form tendon constructs as healthy tendon cells.
Conclusion
A high collagenase gene activity after an Achilles tendon rupture indicated possible rapid matrix degradation in the acute phase. Chronic ruptures appeared to initiate the healing process even before treatment, indicated by the higher expression of collagen in the short-term chronic group. Cells from chronic Achilles tendon ruptures also displayed an ability to form new tendon tissue in vitro.
Clinical Relevance
The study shows a rapid increase in collagenase gene expression, which could lead to matrix degradation that continues for months after an Achilles tendon rupture.
... Medical history and clinical examinations are considered to be sufficient in establishing the diagnosis of an acute Achilles tendon rupture [34,42]. However, occasionally treatment is delayed due to late presentation or misdiagnosis [8,42]. ...
... Medical history and clinical examinations are considered to be sufficient in establishing the diagnosis of an acute Achilles tendon rupture [34,42]. However, occasionally treatment is delayed due to late presentation or misdiagnosis [8,42]. A delay of treatment leads to larger tendon-end diastasis with interposed scar tissue [9]. ...
... Long-term pain and recurrent swelling are more frequent in patients with chronic ruptures [28]. In addition, altered gait with a weakness at push-off, a poor balance, and a reduced capability of performing heel-rises are commonly reported [17,42]. ...
Introduction
A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to summarize the outcomes of chronic ATR treated using either a gastrocnemius aponeurosis flap or semitendinosus tendon graft.
Methods
A systematic search was conducted in three databases (PubMed, Scopus and Cochrane), for studies describing outcomes after surgical treatment of chronic ATR using gastrocnemius aponeurosis flaps or semitendinosus tendon grafts with more than 10 patients included. The studies were assessed for quality and risk of bias using the Methodological Items used to assess risk of bias in Non-Randomized Studies (MINORS).
Results
Out of the 818 studies identified with the initial search, a total of 36 studies with 763 individual patients were included in this systematic review. Gastrocnemius aponeurosis flap was used in 21 and semitendinosus tendon graft was used in 13 of the studies. The mean (SD) postoperative Achilles tendon Total Rupture Score (ATRS) for patients treated with a gastrocnemius aponeurosis flap was 83 (14) points and the mean (SD) American Orthopaedic Foot and Ankle Score (AOFAS) was 96 (1.7) points compared with ATRS 88 (6.9) points and AOFAS 92 (5.6) points for patients treated with a semitendinosus tendon graft. The included studies generally had low-quality according to MINORS, with a median of 8 (range 2–13) for all studies.
Conclusion
Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts give acceptable results with minimal complications and are valid methods for treating chronic ATR. The main difference is more wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries in patients treated with a semitendinosus grafts. The current literature on the subject is of mainly low quality and the absence of a patient-related outcome measure validated for chronic ATR makes comparisons between studies difficult.
Level of evidence
Level IV.
... Given the prevalence of this injury, there is a need to determine the best in class of the surgical treatments described in the literature. 33 We performed a systematic review to evaluate the clinical outcomes, level, and quality of evidence of the surgical techniques for CATR and proposed an algorithmic approach to the treatment of CATR, based on current best available evidence. ...
Background
As no evidence-based treatment guidelines exist for chronic Achilles tendon rupture (CATR), a systematic review of the literature was performed to compare the different treatment options and recommend a literature-based algorithm.
Methods
In June 2022, MEDLINE, Embase, and Cochrane Library databases were systematically reviewed based on the PRISMA guidelines. The level of evidence (LOE) and quality of evidence were evaluated, and statistics on clinical outcomes and complications were calculated.
Results
Twenty-seven studies with 614 patients were included. Three studies were LOE III and 25 studies were LOE IV. The mean Achilles tendon rupture score improved from a preoperative weighted mean of 38.8 ± 12.4 to a postoperative score 90.6 ± 4.7. The overall complication rate was 11.4%. Single techniques were used in 23 studies and dual techniques were used in 5 studies. The FHL tendon transfer was the most frequently used technique. We devised an algorithmic approach based on time from injury to surgical intervention and the length of the gap between the tendon stumps: >3 months: FHL transfer; <3 months (a) gap <2 cm, end-to-end repair; (b) gap 2 to 5 cm, gastrocnemius transfer, (c) gap >5 cm, semitendinosus autograft.
Conclusion
Surgical management of CATR produced improvements in patient-reported outcome scores at midterm follow up, but a high complication rate (11.4%) was noted. Our proposed treatment algorithm may assist in shared decision making for this complex problem.
... [1,2] It most frequently occurs in age of 30 to 40 years old during recreational sports activities. [3] Furthermore, there is evidence that male, and professional white-collar workers are more prone to suffer from AT rupture, due to a sedentary lifestyle with sudden or repetitive exercise. [4] The incidence of AT rupture is still increasing in recent years for both sports-related and non-sports-related injuries. ...
... The diagnosis of chronic rupture was defined as delayed or neglected diagnosis for more than 4 to 6 weeks after injury, time nodes of 4 and 6 weeks were both found in current studies, but the actual terms of 4 or 6 has not been explicitly defined. [3,18] At 4 weeks after injury, highly vascularized collagen scar tissue fills the retraction gap of ruptured AT, which is the earliest manifestation of chronic healing. [19] Therefore, the chronic AT rupture was diagnosed in this study when duration was more than 4 weeks after injury according to a systematic review. ...
... Several surgical techniques for chronic AT rupture have been reported in the literature, including direct repair, scar tissue repair, V-Y alignment, turndown flaps, local tendon transfer, tendon autograft or allograft and so on. [3,[23][24][25][26][27] In general, a surgical plan can be made based on the length of defect according to Kuwada or Myerson classifications. [28,29] End-to-end direct repair seems to be best suited to the rupture considered as Myerson type I or Kuwada type II where the defect is 2 to 3 cm or less. ...
There are multiple surgical options for treatment of chronic Achilles tendon (AT) rupture according to the classifications and length of defect. However, no gold standard method has been confirmed, and there is no clear evidence to support the superiority of 1 procedure over others. This study aimed to evaluate the long-term clinical outcome of flexor hallucis longus tendon (FHL) transfer for chronic AT rupture with large defect. Clinical data of patients treated with FHL transfer due to chronic AT rupture between January 2009 and October 2019 were reviewed retrospectively. All cases were presented with AT rupture for more than 4 weeks after injury. The gap between ruptured ends was > 5 cm after debridement in all patients. The harvest of FHL was performed through a single incision in accordance with AT rupture debridement in all cases. Clinical outcomes were assessed with AOFAS ankle-hindfoot scale, Achilles tendon total rupture score and AOFAS hallux metatarsophalangeal-interphalangeal scale. Twenty-eight patients were followed successfully for 62.6 ± 22.2 months. According to the complete datasets obtained from 28 patients, none of the tendons re-ruptured. The AOFAS ankle-hindfoot scale and Achilles tendon total rupture score at last follow-up visit was 90.4 ± 5.7 and 89.8 ± 5.3 respectively, which revealed statistically significant improvement from the preoperative score of 61.1 ± 6.7 and 53.8 ± 8.3. The AOFAS hallux metatarsophalangeal-interphalangeal scale at last follow-up visit was 87.5 ± 6.1. The FHL transfer through a single incision for chronic AT rupture with large defect is a safe and simple method with low risk of morbidity and complications.
... Misdiagnosed/chronic Achilles tendon rupture has an incidence of 10%-25% in all cases of complete tendon injury. 1 Physical examination is sufficient to confirm tendon rupture with evident structural gap on palpation, a positive Thompson test, with associated bruising and peritendinous soft tissue imbibition. 2 The patient, of any age, who aspires to an improvement in clinical/functional conditions and in the absence of absolute contraindications, should be treated surgically. 3 One of the outcomes of surgical treatment is to avoid failure of the repair and clinical relapse. ...
Objective
Misdiagnosed/chronic Achilles tendon injuries are rare and disabling for patients. The surgical treatment of these rare injuries aims to ensure the tendon heals mechanically and biologically. This is the prerequisite for a good clinical and functional outcome and reduces recurrences. The main aim of the study is to present a surgical technique that has proven to be original, reproducible, and capable of guaranteeing solid tendon repair and optimal tissue regeneration.
Methods
We treated five patients, four males and one female, with the one‐step double augmentation technique. All patients of this study complained of pain, but above all severe functional limitation that Achilles tendon injury had been causing for more than a month. In this study, we widely described the surgical technique, original and not found in the literature, which provides a biological graft (allograft of decellularized dermis) and homologous, thrombin‐activated, platelet‐rich plasma (H‐PRP) in a single step. Surgical approach, always used by the first author, respected predefined steps: careful dissection and preparation of the peritendinous tissues from suture to the end of the procedure, tenorrhaphy, and augmentation with allopatch to obtain a mechanically effective repair to avoid recurrences, and finally “biological” augmentation with a unit of homologous, thrombin activated, PRP. We offered to all patients a regenerative rehabilitation program post‐operatively.
Results
All patients were evaluated clinically (functional clinical tests and questionnaires) and instrumentally (elastic‐sonography and perfusion MRI). The obtained results have been evaluated at a minimum follow‐up of 18 months and a maximum of 24 months. In all patients pain was resolved, and district function and kinetic chains improved with resumption of daily activities, work, and sports.
Conclusion
The present study confirmed the regenerative potential of decellularized dermis allograft and PRP (homologous and thrombin‐activated). The same approach can also be exploited in cases of severe tendon destructuring and limited “intrinsic” regenerative potential at any age. The proposed one‐step surgical technique of a double augmentation therefore appears useful, safe, reproducible, and applicable in all chronic tendon lesions with low regenerative potential.
