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Nilsson N, Stensöta I, Nilsson Helander K, Brorsson A, Carmont MR, Concaro S. Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures - a systematic review. BMC Musculoskelet Disord 2023; 24:951. [PMID: 38066531 PMCID: PMC10704635 DOI: 10.1186/s12891-023-07064-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
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.
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Affiliation(s)
- Niklas Nilsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, Mölndal, 431 80, Sweden.
| | - Immanuel Stensöta
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, Mölndal, 431 80, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, Mölndal, 431 80, Sweden
| | - Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- IFK Kliniken Rehab, Gothenburg, Sweden
| | - Michael R Carmont
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
| | - Sebastian Concaro
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, Mölndal, 431 80, Sweden
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Rashid RH, Ali R, Zahid M, Ali M, Ahmad T. Flexor Hallucis Longus Transfer And V-Y Plasty: An Effective Treatment Modality for Chronic Achilles Rupture - A Case Series. Malays Orthop J 2023; 17:59-65. [PMID: 38107357 PMCID: PMC10722995 DOI: 10.5704/moj.2311.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 12/22/2022] [Indexed: 12/19/2023] Open
Abstract
Introduction To assess outcomes of FHL transfer and V-Y plasty for chronic Achilles rupture due to insertional Achilles tendinopathy. Materials and methods A case series of 12 patients was conducted between 1st January 2017 and 31st December 2018. The patients had short flexor hallucis longus tendon transfer with gastrocnemius lengthening by V-Y plasty for Achilles tendon rupture. Patients were allowed full weight bearing at six weeks post-operatively, and were followed up at three months and six months post-operatively, when the range of motion of the ankle was examined, and the outcome was assessed using the EFAS score. Results Of the 12 patients in the study, the majority were males; the mean age was 50.6±8.96 years. A significant improvement in dorsiflexion and plantarflexion was noted at the six-month follow-up compared to the three-month follow-up (P=<0.001 for both). When compared to the normal side, dorsiflexion and plantarflexion of the affected ankle were significantly less at three months but were comparable at six months post-operatively. A significant improvement was noted in the mean EFAS score at the six-month follow-up (25.5±5.71) compared to three months (18.6±0.90) post-surgery (P=0.001). Males were also noted to have significantly higher EFAS scores at their six-month follow-up than females (P=0.022). In contrast, a negative correlation was noted between the European Foot and Ankle Society (EFAS) score at the final follow-up and age (P=0.011). Conclusion FHL tendon transfer with V-Y plasty in chronic Achilles rupture due to insertional Achilles tendinopathy is an effective procedure resulting in the restoration of the ankle range of motion and improvement in functional scores.
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Affiliation(s)
- R H Rashid
- Section of Orthopaedics, Aga Khan University Hospital, Karachi, Pakistan
| | - R Ali
- Section of Orthopaedics, Aga Khan University Hospital, Karachi, Pakistan
| | - M Zahid
- Section of Orthopaedics, Aga Khan University Hospital, Karachi, Pakistan
| | - M Ali
- Section of Orthopaedics, Aga Khan University Hospital, Karachi, Pakistan
| | - T Ahmad
- Section of Orthopaedics, Aga Khan University Hospital, Karachi, Pakistan
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Maffulli N, Bartoli A, Sammaria G, Migliorini F, Karlsson J, Oliva F. Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:4526-4538. [PMID: 37193823 PMCID: PMC10471519 DOI: 10.1007/s00167-023-07446-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/26/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE After four weeks from injury, tears of the Achilles tendon are considered chronic. Their management is challenging, and the use of a graft is suggested when the gap between proximal and distal stumps is greater than 6 cm. The present study systematically reviews the outcome of free tendon grafts in chronic ruptures of the Achilles tendon, evaluating clinical outcomes, complications and return to sport. METHODS The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in February 2023. All the published clinical studies reporting clinical outcome, return to sport and complications of free tendon grafts used the treatment of chronic rupture of the midportion of the Achilles Tendon were accessed. The mean CMS (Coleman Methodology Score) of 65.7 suggested an overall good quality of the available published articles, attesting to the low risk of bias. RESULTS Data from 22 articles (368 patients with a mean age of 47 years) were retrieved. The average time from rupture to surgery was 25.1 week. At last follow-up, the AOFAS (American Orthopaedic Foot and Ankle Surgery) and ATRS (Achilles Tendon Total Rupture Score) scores improved of 33.8 (P = 0.0004), and 45.1 points (P = 0.0001) respectively. Return to activity was reported in 105 patients, and 82 (78.1%) had no activity limitations, while 19 (18.1%) had limited recreational but not daily activity limitations, and 4 (3.8%) reported limitations in daily activities. Return to sport data was reported in six studies, and 45 of 93 (48.4%) patients returned to sport at an average of 22.6 weeks. CONCLUSION In chronic tears of the Achilles tendon, with a gap of at least 6 cm, free tendon grafts allow predictable return to sport and acceptable recovery function. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG UK
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Thornburrow Drive, Stoke on Trent, ST4 7QB UK
| | - Alessandro Bartoli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
| | - Giuliano Sammaria
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074 Aachen, Germany
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal, 431 80 Gothenburg, Sweden
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
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Azam MT, Butler JJ, Weiss MB, Ubillus HA, Kirschner N, Mercer NP, Kennedy JG. Surgical Management of Chronic Achilles Tendon Ruptures: A Systematic Review and Proposed Treatment Algorithm. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231200491. [PMID: 37810568 PMCID: PMC10557420 DOI: 10.1177/24730114231200491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
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.
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Affiliation(s)
- Mohammad T. Azam
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - James J. Butler
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
- Royal College Surgeons in Ireland, Dublin, Ireland
| | - Matthew. B. Weiss
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Hugo A. Ubillus
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Noah Kirschner
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | | | - John G. Kennedy
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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Jiménez-Carrasco C, Ammari-Sánchez-Villanueva F, Prada-Chamorro E, García-Guirao AJ, Tejero S. Allograft and Autologous Reconstruction Techniques for Neglected Achilles Tendon Rupture: A Mid-Long-Term Follow-Up Analysis. J Clin Med 2023; 12:jcm12031135. [PMID: 36769784 PMCID: PMC9917888 DOI: 10.3390/jcm12031135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023] Open
Abstract
Achilles tendon ruptures that are not immediately recognized and treated are sometimes diagnosed as delayed injuries and may require different surgical repair options based on gap size. The potential complications associated with using an allograft for reconstruction may lead some surgeons to prefer the use of autologous techniques. However, allografts are often considered a salvagement option when large defects are present. In this study, we examined the long-term clinical outcomes and complications of 17 patients who underwent surgical repair for chronic ruptures with large gaps using both autologous and allograft techniques. During an 11-year period, nine patients were treated with autologous techniques (mean gap of 4.33 ± 1.32 cm) and Achilles allograft reconstruction was performed in eight patients (47.1%) (mean gap of 7.75 ± 0.89 cm). At a mean of 82 ± 36.61 months of follow-up, all 17 patients (100%) were able to perform a single heel rise and improved AOFAS (American Orthopaedic Foot and Ankle Society) and ATRS (Achilles Tendon Total Rupture Score) scores. No infections, complications, or re-ruptures were recorded at the end of the follow-up. No significant differences were found in the AOFAS and ATRS scales between both techniques. When an extensive defect is present, the reconstruction with an Achilles tendon allograft can be considered a proper treatment option, as it does not show a higher rate of complications than autologous techniques achieving similar functional outcomes.
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Affiliation(s)
- Cristina Jiménez-Carrasco
- Orthopedic Surgery and Traumatology Service, Hospital San Juan de Dios del Aljarafe, 41930 Bormujos, Spain
- Correspondence:
| | | | - Estefanía Prada-Chamorro
- Orthopedic Surgery and Traumatology Service, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain
| | | | - Sergio Tejero
- Orthopedic Surgery and Traumatology Service, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain
- School of Medicine, Universidad de Sevilla, 41009 Sevilla, Spain
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[Less invasive turn-down flap tendinoplasty in chronic Achilles tendon rupture]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2022; 34:381-391. [PMID: 36036248 DOI: 10.1007/s00064-022-00782-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/06/2022] [Accepted: 05/15/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Bridging the defect in chronic ruptures of the Achilles tendon via a turn-down flap of the aponeurosis sparing the skin of the rupture zone. INDICATIONS Chronic Achilles tendon rupture with a defect distance ≤ 6 cm. CONTRAINDICATIONS Extended Achilles tendon defect interval ≥ 7 cm, chronic wounds or infections near the surgical approach, higher degrees of arterial or venous malperfusion, complex regional pain syndrome. SURGICAL TECHNIQUE Dorsomedial surgical approach proximal to the rupture zone, splitting of the crural fascia, loading of the distal Achilles tendon stump with a nonresorbable augmentation suture using the Dresden instrument, preparation of the turn-down flap of the aponeurosis securing the turning point with a catching suture. Transfer of the turn-down tendon flap under the skin bridge and suture to the distal tendon stump tying the augmentation suture under adequate pretension simultaneously closing the gap in the aponeurosis. Alternative technique: free advancement of the autologous tendon graft. POSTOPERATIVE MANAGEMENT Anterior splint in 20° of plantar flexion, consecutive mobilization and rehabilitation similar to the percutaneous technique in acute Achilles tendon rupture with the Dresden instrument. Lower leg orthosis with 20° of plantarflexion for 8 weeks, then stepwise reduction of the heel height. Physiotherapy beginning from the 2nd postoperative week, active full-range of ankle motion from 6 weeks after surgery. RESULTS In general, worse results than in percutaneous reconstruction of acute Achilles tendon injuries. Despite this, high degrees of patient satisfaction with a low rate of postsurgical complications and good functional outcome with admittedly poor data availability. Relevant increase of plantar flexion strength depending on the amount of degeneration of the triceps surae muscle.
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Arshad Z, Lau EJS, Leow SH, Bhatia M. Management of chronic Achilles ruptures: a scoping review. INTERNATIONAL ORTHOPAEDICS 2021; 45:2543-2559. [PMID: 34089355 PMCID: PMC8514369 DOI: 10.1007/s00264-021-05102-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/25/2021] [Indexed: 12/01/2022]
Abstract
Purpose This scoping review aims to systematically map and summarise the available evidence on the management of chronic Achilles ruptures, whilst identifying prognostic factors and areas of future research. Methods A scoping review was performed according to the frameworks of Arksey and O’Malley, Levac and Peters. A computer-based search was performed in PubMed, Embase, EmCare, CINAHL, ISI Web of Science and Scopus, for articles reporting treatment of chronic Achilles ruptures. Two reviewers independently performed title/abstract and full text screening according to pre-defined selection criteria. Results A total of 747 unique articles were identified, of which 73 (9.8%) met all inclusion criteria. A variety of methods are described, with flexor hallucis longus tendon transfer being the most common. The most commonly reported outcome is the American Orthopaedic Foot and Ankle Society (AOFAS) score, although 16 other measures were reported in the literatures. All studies comparing pre- and post-operative outcomes reported significant post-treatment improvement. Complications were reported in 50 studies, with an overall pooled complication rate of 168/1065 (15.8%). Conclusion Although beneficial results were reported following a variety of techniques, comparison between these is challenging due to the low-level study designs used and confounding factors such as treatment delay and tendon gap size. Further research comparing the efficacy of different techniques is required in order to facilitate the development of an evidence-based treatment protocol. Such work would allow clinicians to better understand the suitability of the large variety of reported techniques and select the optimal strategy for each individual patient. Supplementary Information The online version contains supplementary material available at 10.1007/s00264-021-05102-5.
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Affiliation(s)
- Zaki Arshad
- School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Box 111, Cambridge, CB2 0SP, UK.
| | - Edward Jun Shing Lau
- School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Box 111, Cambridge, CB2 0SP, UK
| | - Shu Hui Leow
- School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Box 111, Cambridge, CB2 0SP, UK
| | - Maneesh Bhatia
- Department of Trauma and Orthopaedic Surgery, University Hospitals Leicester NHS Trust, University Hospitals of Leicester Headquarters, Balmoral Building, Level 3, Leicester, UK
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Mwafi N, Alasmar A, Al-Momani M, Alazaydeh S, Alajoulin O, Alsalem M, Kalbouneh H. Alkaptonuria with extensive ochronotic degeneration of the Achilles tendon and its surgical treatment: a case report and literature review. ASIAN BIOMED 2021; 15:129-136. [PMID: 37551372 PMCID: PMC10388780 DOI: 10.2478/abm-2021-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Alkaptonuria is a rare genetic metabolic disorder due to deficiency of homogentisate 1,2-dioxygenase (HGD), an enzyme catalyzing the conversion of homogentisate to 4-maleylacetoacetate in the pathway for the catabolism of phenylalanine and tyrosine. HGD deficiency results in accumulation of homogentisic acid and its pigmented polymer. Ochronosis is a bluish-black discoloration due to the deposition of the polymer in collagenous tissues. Extensive ochronotic involvement of the Achilles tendon in alkaptonuria and its surgical treatment is rarely reported. Case report A 43-year-old man presented to our clinic in March 2019 with sudden onset of left Achilles tendon pain with no history of prior trauma. Surgical exploration revealed a complete disruption of the tendon at its attachment to the calcaneus. Black pigmentation was extensive and reached the calcaneal tuberosity, extending about 7 cm from the insertion. Discussion Achilles reconstruction was performed using flexor hallucis longus tendon transfer. The patient experienced uncomplicated healing with satisfactory functional results. Conclusion Orthopedic surgeons should be aware of the progressive nature of alkaptonuria. Extensive degenerative changes of the ruptured tendon should be suspected so that physicians can plan tendon repair and facilitate prompt surgical intervention.
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Affiliation(s)
- Nesrin Mwafi
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Mutah University, Alkarak61710, Jordan
| | - Ali Alasmar
- Department of Urology, Prince Hussein Urology Center, Jordanian Royal Medical Services, Amman11855, Jordan
| | - Monther Al-Momani
- Department of Radiology, Jordanian Royal Medical Services, Amman11855, Jordan
| | - Sattam Alazaydeh
- Department of Orthopedics and Trauma, Jordanian Royal Medical Services, Amman11855, Jordan
| | - Omar Alajoulin
- Department of Orthopedics and Trauma, Jordanian Royal Medical Services, Amman11855, Jordan
| | - Mohammad Alsalem
- Department of Anatomy and Histology, School of Medicine, The University of Jordan, Amman11942, Jordan
| | - Heba Kalbouneh
- Department of Anatomy and Histology, School of Medicine, The University of Jordan, Amman11942, Jordan
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Borah DN, Rai S, Frank HC, Dutta A. Repair of chronic Achilles tendon rupture using Bosworth’s technique. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491720972713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: A large number of ruptures of the Achilles tendon occurs in the watershed hypovascular region (zone II) of the tendon which is approximately 2–6 cm proximal to the insertion of tendon at calcaneum. Chronic Achilles tendon rupture in the watershed area makes end to end repair of tendon less feasible and the neglected distal stump is often inapt for repair. A number of surgical techniques have been described for repair of chronic Achilles tendon in zone II. Our study was conducted with the objective of determining the efficacy and functional outcome of Bosworth’s technique that involves gastrocnemius-soleus turndown of proximal Achilles tendon. Materials and Methods: The study was conducted in a total of five patients with chronic tear of Achilles tendon and the Bosworth technique was used for repair in all the patients. All the patients were followed up for a period of 1 year and the functional outcome was assessed by scoring system devised by Leppilahti et al. Results: four out of the five patients showed excellent functional at the end of 1 year follow up. A good functional outcome was seen in one of the patients. All the patients were able to resume work 6 months postoperatively. Conclusion: The Bosworth’s technique is an excellent surgical procedure for repair of chronic Achilles tendon rupture in the watershed zone of the tendon.
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Affiliation(s)
- Dhruba Narayan Borah
- Department of Orthopaedic Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Siddhartha Rai
- Department of Orthopaedic Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Herman Conrad Frank
- Department of Orthopaedic Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Anshuman Dutta
- Department of Orthopaedic Surgery, Gauhati Medical College and Hospital, Guwahati, Assam, India
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Shane AM, Reeves CL, Nguyen GB, Sebag JA. Revision Surgery for the Achilles Tendon. Clin Podiatr Med Surg 2020; 37:553-568. [PMID: 32471618 DOI: 10.1016/j.cpm.2020.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Treatment of Achilles tendon ruptures may be surgical or nonsurgical depending on health, history, age, acuity, and severity of the injury. With chronic or revisional injuries, the best method often requires an open repair with reconstructive soft tissue procedures. Revision surgery can be challenging because of the complexity involving tendinous deficits with nonviable and friable tissue. Surgical treatment is based on tendon approximation, size of the defect, tendon integrity, and functional demands. The goal is to restore anatomic and physiologic tension, provide adequate strength for proper ambulation, optimize functional return to activity, decrease pain, and decrease complications.
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Affiliation(s)
- Amber M Shane
- Advent Health East Orlando Podiatric Surgery Residency, Orlando Foot and Ankle Clinic- Upperline Health, 250 North Alafaya Trail Suite 115, Orlando, FL 32828, USA.
| | - Christopher L Reeves
- Advent Health East Orlando Podiatric Surgery Residency, Orlando Foot and Ankle Clinic- Upperline Health, 250 North Alafaya Trail Suite 115, Orlando, FL 32828, USA
| | - Garrett B Nguyen
- Department of Podiatric Surgery, Advent Health East Orlando Podiatric Surgery Residency, 250 North Alafaya Trail Suite 1115, Orlando, FL 32828, USA
| | - Joshua A Sebag
- Department of Podiatric Surgery, Advent Health East Orlando Podiatric Surgery Residency, 250 North Alafaya Trail Suite 1115, Orlando, FL 32828, USA
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Modified Percutaneous Achilles Tendon Lengthening by Triple Hemisection for Achilles Tendon Contracture. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1491796. [PMID: 31781592 PMCID: PMC6874878 DOI: 10.1155/2019/1491796] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/10/2019] [Indexed: 01/04/2023]
Abstract
Background Both percutaneous Achilles tendon lengthening by triple hemisection and the traditional open Z-lengthening are effective methods for Achilles tendon contracture. This study aims to evaluate the efficacy and safety of this new therapeutic method, which is based on the percutaneous sliding technique with three hemi-cuts in the tendon, as compared with the traditional open Z-lengthening. Methods Retrospective analysis of the Achilles tendon contracture cases in our hospital between January 2010 and September 2016 was conducted. Twenty-five cases received percutaneous Achilles tendon lengthening (group A), and 30 patients who underwent open Z-lengthening during the same period were in the control group (group B). Operative time and hospital stay were statistically analyzed. Incision complication, equinus recurrence rate and Achilles tendon rupture morbidity were recorded. The function was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) score. All cases in group A received Magnetic Resonance Imaging (MRI) of ankle preoperatively and in the follow-ups. Results The mean follow-up period was 42.04 months in group A and 61.7 months in group B. The entire operative time and the mean hospitalization days were lower in group A than in group B. No incision and infection complication occurred in group A. The infection rate in group B was 3.3%. Equinus recurrence rate was 4% in group A and the equinus recurrence rate in group B was 21.4%. In group A, the mean AOFAS score increased from 64 ± 10.16 points preoperatively to 96.08 ± 3.17 at final follow-up, while the score in group B increased from 63.48 ± 6.2 points to 85.4 ± 10.3. MRI showed continuity of the Achilles tendon and homogeneous signal in group A. Conclusion Modified surgery can significantly reduce the risk of Achilles tendon rupture, provide better balance in soft tissue strength between ankle dorsiflexion and ankle plantarflexion, helping to avoid recurrence of the deformity.
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Manfreda F, Ceccarini P, Corzani M, Petruccelli R, Antinolfi P, Rinonapoli G, Caraffa A. A silent massive ossification of Achilles tendon as a suspected rare late effect of surgery for club foot. SAGE Open Med Case Rep 2018; 6:2050313X18775587. [PMID: 29785267 PMCID: PMC5954578 DOI: 10.1177/2050313x18775587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/16/2018] [Indexed: 11/17/2022] Open
Abstract
We report the case of a 66-year-old male patient with massive ossification of the distal portion of the Achilles tendon, as a late consequence of a surgical release for club foot conducted in his childhood. The singularity of the case report derives from its clinical features: the bone mass was of abnormal dimensions, almost substituting the entire tendon; the condition had always been asymptomatic, without deficits in range of motion, in absence of either pain or biomechanical defects with age. In fact, the condition was diagnosed just recently as a consequence of a tear. Despite an ultrasound diagnosis after the injury, only during the surgical treatment, a proper evaluation of the entity of the pathology was possible. Although the ossification of Achilles tendon is a rare clinical condition with a complex multifactorial etiology, in our case report, some of the elements in the patient's medical history could be useful for the pathogenesis and early diagnosis of the disease. The aim of this case report is to emphasize the importance both of a correct evaluation of clinical history and of an accurate diagnosis, in order to conduct a proper management of this pathology.
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Affiliation(s)
- Francesco Manfreda
- Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy
| | - Paolo Ceccarini
- Division of Orthopedics and Trauma Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Marco Corzani
- Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy
| | - Rosario Petruccelli
- Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy
| | - Pierluigi Antinolfi
- Division of Orthopedics and Trauma Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Giuseppe Rinonapoli
- Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy.,Division of Orthopedics and Trauma Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Auro Caraffa
- Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy.,Division of Orthopedics and Trauma Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
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Sanada T, Uchiyama E. Gravity Equinus Position to Control the Tendon Length of Reversed Free Tendon Flap Reconstruction for Chronic Achilles Tendon Rupture. J Foot Ankle Surg 2017; 56:37-41. [PMID: 27989345 DOI: 10.1053/j.jfas.2016.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Indexed: 02/03/2023]
Abstract
Repair of chronic Achilles tendon rupture is a surgical challenge. We describe the use of a free turndown tendon flap augmentation raised from the proximal gastrocnemius aponeurosis. To control optimal tension or the reconstructed Achilles tendon length, we used an original method by referring to the gravity planter flexion ankle angle of the contralateral limb. Key aspects of the technique are described. A retrospective analysis of the short-term outcomes achieved in a case series (n = 56) is presented. The postoperative anthropometric findings are also presented to indicate the successful outcomes achieved with this technique.
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Affiliation(s)
- Takaki Sanada
- Surgeon, Sports Orthopedics Surgery, Kanto Rosai Hospital, Kawasaki City, Japan.
| | - Eiji Uchiyama
- Surgeon, Sports Orthopedics Surgery, Kanto Rosai Hospital, Kawasaki City, Japan
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Gedam PN, Rushnaiwala FM. Endoscopy-Assisted Achilles Tendon Reconstruction With a Central Turndown Flap and Semitendinosus Augmentation. Foot Ankle Int 2016; 37:1333-1342. [PMID: 27654043 DOI: 10.1177/1071100716666365] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to report the results of a new minimally invasive Achilles reconstruction technique and to assess the perioperative morbidity, medium- to long-term outcomes, and functional results. METHODS Our series was comprised 14 patients (11 men and 3 women), with a mean age of 45.6 years at surgery. Each patient had a chronic Achilles tendon rupture. The mean interval from rupture to surgery was 5.5 months (range, 2-10). The mean total follow-up was 30.1 months (range, 12-78). All patients were operated with a central turndown flap augmented with free semitendinosus tendon graft and percutaneous sutures in a minimally invasive approach assisted by endoscopy. The patients underwent retrospective assessment by clinical examination, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, and the Achilles Tendon Total Rupture Score (ATRS). Paired t tests were used to assess the preoperative and postoperative AOFAS scores, ATRS scores, and ankle range of motion. RESULTS The length of the defect ranged from 3 to 8 cm (mean, 5.1), while the length of the turndown flap ranged from 8 to 13 cm (mean, 10.1). The mean AOFAS score improved from 64.5 points preoperatively to 96.9 points at last follow-up. The mean ATRS score improved from 49.4 preoperatively to 91.4 points at last follow-up. None of the patients developed a wound complication. No patient had a rerupture or sural nerve damage. CONCLUSION All patients in our study had a favorable outcome with no complications. We believe that with this triple-repair technique, one can achieve a strong and robust repair such as in open surgery while at the same time reducing the incidence of complications. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Prashant N Gedam
- Department of Orthopaedics, Topiwala National Medical College & B. Y. L. Nair Charitable Hospital, Mumbai, India
| | - Faizaan M Rushnaiwala
- Department of Orthopaedics, Topiwala National Medical College & B. Y. L. Nair Charitable Hospital, Mumbai, India
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Surgical Strategy for the Chronic Achilles Tendon Rupture. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1416971. [PMID: 27847806 PMCID: PMC5099495 DOI: 10.1155/2016/1416971] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/04/2016] [Indexed: 12/14/2022]
Abstract
Background. Chronic Achilles tendon rupture is usually misdiagnosed and treated improperly. This study aims to better understand the treatment of chronic Achilles tendon rupture. Methods. Patients who were not able to perform a single-limb heel rise were chosen. Pre- and postoperative magnetic resonance imaging (MRI) were conducted. By evaluating the presence or absence of Achilles tendon stumps and the gap length of rupture, V-Y advancement, gastrocnemius fascial turndown flap, or flexor halluces longus tendon transfer were selected for tendon repair. The function of ankle and foot was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and Achilles Tendon Total Rupture Score (ATRS). Results. Twenty-nine patients were followed up. One patient had superficial incision infection, which was healed after debridement and oral antibiotics. Three months postoperatively, MRI showed some signs of inflammation, which disappeared at one or two years postoperatively. All patients were able to perform a single-limb heel rise. Mean AOFAS scores and ATRS scores were increased at the latest follow-up. Conclusion. Surgical options can be determined by evaluating the presence of the Achilles tendon stumps and the gap length, which can avoid using the nearby tendon and yield satisfactory functional results.
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Malagelada F, Clark C, Dega R. Management of chronic Achilles tendon ruptures-A review. Foot (Edinb) 2016; 28:54-60. [PMID: 27744047 DOI: 10.1016/j.foot.2016.05.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 05/25/2016] [Indexed: 02/04/2023]
Abstract
Achilles tendon ruptures are increasingly common yet up to a fifth of them are undiagnosed after medical consultation. Those undiagnosed will become chronic ruptures causing considerable functional morbidity and represent a challenge to the treating doctor. The purpose of this article is to discuss the presentation and management of chronic Achilles tendon ruptures. Due to the paucity of data, evidence-based recommendations are unavailable. A number of different surgical techniques are presented and a working algorithm is described to aid in the treatment of these lesions.
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Affiliation(s)
- Francesc Malagelada
- Heatherwood and Wexham Park Hospitals, Frimley Health NHS Trust London Rd., Ascot, Berkshire SL5 8AA, United Kingdom.
| | - Callum Clark
- Heatherwood and Wexham Park Hospitals, Frimley Health NHS Trust London Rd., Ascot, Berkshire SL5 8AA, United Kingdom.
| | - Raman Dega
- Heatherwood and Wexham Park Hospitals, Frimley Health NHS Trust London Rd., Ascot, Berkshire SL5 8AA, United Kingdom.
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Results of surgical treatment of calcaneus insertional tendinopathy in middle- and long-distance runners. Knee Surg Sports Traumatol Arthrosc 2015; 23:2494-501. [PMID: 24748271 DOI: 10.1007/s00167-014-2986-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Calcaneus insertional tendinopathy in runners is common and involves important therapeutic controversies. The object of this study was to determine the delay and level of return to sport after insertional surgery in runners, with and without tendon damage. METHODS Eighteen runners underwent surgery for insertional calcaneus tendinopathy. Nine required an exostosectomy/bursectomy, and nine others required a tendon reinsertion/autograft. All patients were clinically assessed pre- and post-operatively with AOFAS scores and post-operatively with ATRS. This series included analysis of "pure conflicts" and "severe insertional lesion" scores. If the insertional tendon was free or the lesion was smaller than 50 %, the group was classified as "pure conflict/minor tendon damage". In the situation in which a loss of tendon occurred or the tendon lesion was greater than 50 %, the group was classified as "major tendon damage". Pre-operatively, the AOFAS "overall", "pure conflicts/minor tendon damage" and "major tendon damage" groups' scores were 58.5 ± 15, 68.2 ± 8.8 and 48.9 ± 13.9/100, respectively. RESULTS Post-operatively, the AOFAS "overall", "pure conflicts/minor tendon" and "major tendon damage" groups' scores were 93.7 ± 8.2, 93.2 ± 10.2 and 95.2 ± 5.7/100, respectively. The AOFAS score gain for each group was, respectively, 35.2 ± 19, 24 ± 17 and 46.3 ± 14.1. The ATRS "overall", "pure conflicts/minor tendon damage" and "major tendon damage" groups' scores were 81.5 ± 14.9, 78.3 ± 20.1 and 84.7 ± 6.7/100, respectively. The global sport recovery delay was 9.3 ± 4.1 months; it was 6 ± 3.3 months for the pure conflict/minor tendon damage subgroup and 10 ± 4.6 months for the severe tendon damages subgroup. CONCLUSION Achilles insertional tendinopathy surgery on this population results in few complications with good functional results if the surgical technique is adapted to the type of tendon injury. The clinical relevance of this study is that it highlights the various forms of calcaneus insertional tendinopathy and various treatment options. The authors show that in the case of major tendon damage, time to return to sport is longer.
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