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A case of ‘second rupture’ following open repair of a ruptured Achilles tendon
Foot and Ankle Surgery 17 (2011) e17–e19
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
A case of ‘second rupture’ following open repair of a ruptured Achilles tendon P.R.P. Rushton *, A.K. Singh, R.G. Deshmukh Department of Orthopaedic Surgery, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, Lincolnshire, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 June 2010 Received in revised form 7 August 2010 Accepted 8 August 2010
We present a case of Achilles tendon rupture in a 54-year-old man whilst rehabilitating following endto-end open repair of an acute Achilles tendon rupture. Re-rupture following surgical repair of Achilles tendon is well known. This case however, is atypical as the second rupture occurred significantly proximal to the first rupture. To our knowledge this is the first time this has been described in the English literature. We have termed this incident a ‘second rupture’. We describe the surgical technique used by the operating surgeon during open repair of this ‘second rupture’, involving a gastrocnemius flap turndown. This has lead to the patient making a good recovery, despite complications. This case report serves to inform surgeons of the existence of this type of Achilles tendon rupture, whilst considering possible aetiologies and suggesting a technique for repair of the injury. ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Achilles tendon Rupture Re-rupture
1. Introduction Rupture of the Achilles tendon is a relatively common and serious injury with incidence reported as 7/100,000 [1]. Rupture tends to affect males aged between 30 and 50 years who engage in intermittent physical activity [2]. Management of acute Achilles tendon rupture is controversial; the choice is between nonoperative, involving immobilisation or functional bracing, or operative with an open or percutaneous technique. There is debate over the best choice of treatment with a lack of consensus in the literature. However, to date meta-analyses suggest that operative techniques have a lower rate of re-rupture, around 3%, compared with approximately 13% by non-operative methods [3,4]. Classically re-ruptures occur at the site of the previous rupture. We present a case of re-rupture of the right Achilles tendon occurring in a gentleman whilst rehabilitating post-operatively for a previous Achilles tendon rupture. We have termed this a ‘second rupture’ as this rupture significantly proximal to the first rupture. Seemingly the only other report of a second rupture to date appears in a German case report from 1983 [5]. 2. Methods The 54-year-old man ruptured his right Achilles tendon whilst playing football. He was overweight and well apart from hypertension. He was promptly treated by open end-to-end repair
* Corresponding author at: The Atrium, Western Terrace, The Park, Nottingham, England, NG7 1AF, UK. E-mail address: [email protected] (P.R.P. Rushton).
with a modified Kessler’s suture. This initial rupture lay 5 cm above the tendinous insertion. A single non-absorbable suture was used in a modified Kessler fashion approximately 2 cm from the rupture site. This was augmented with a circumferential suture of absorbable suture. He left hospital the day after the operation and was followed up as outpatient. His initial rehabilitation was unremarkable and he made good progress. His plaster cast was removed after 8 weeks. He then underwent formal physiotherapy and was allowed to weight bear as tolerated with the aid of crutches. However, at 10 weeks postoperatively the patient was carrying out a calf stretching exercise when he briefly lost his balance, stumbled and heard an audible snap. Subsequently the man could palpate a gap in the posterior aspect of his lower right leg. Prompt assessment by the surgeon confirmed a rupture of the right Achilles tendon. As the patient was keen for a surgical repair he underwent a further operation 2 weeks after the second rupture. The patient was positioned prone and underwent general anaesthesia. A medial incision along the scar from the first operation exposed the second rupture, situated 3 cm proximal to the previous rupture and 8 cm from the tendinous insertion. The previous rupture appeared to have healed well. The two severed ends of the tendon were debrided. Following this a large strap of the Achilles tendon aponeurosis (10 cm 2 cm) was fashioned. A 2 cm horizontal incision was then made through the full thickness of the gastrocnemius–soleus complex 2 cm proximal to the severed end of the proximal segment of the tendon. The aponeurosis flap could then be turned back on itself and passed through the incision from posterior to anterior. Interrupted sutures ensured the incision in the fascia would not lengthen under tensioning.
1268-7731/$ – see front matter ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2010.08.005
[(Fig._1)TD$IG]
P.R.P. Rushton et al. / Foot and Ankle Surgery 17 (2011) e17–e19
e18
Fig. 1. Sagittal section schematic of route of aponeurosis flap.
A 2 cm horizontal incision was then made in the distal portion of the Achilles tendon, distal to the previous rupture. The aponeurosis strap could then be passed through the incision from anterior to posterior, before being turned back, over the site of the first rupture (Fig. 1). Heavy absorbable suture was used to approximate the strap and tendon, in full plantar-flexion. A satisfactory approximation of the ruptured ends of the tendon was achieved using absorbable sutures. Finally the cut edges of the aponeurosis were approximated. Subcutaneous fat and skin were closed with absorbable and non-absorbable sutures respectively. A below knee cast was used to immobilise the foot in a neutral position. 3. Results The patient experienced no acute post-operative complications and was discharged the following day. He was encouraged to undertake non-weight bearing mobilisation for the first 6 weeks post-operatively. From weeks 6 to 9 post-operatively he was allowed to partially weight bear with the cast on. At week 9 his cast was changed for an ankle brace and he was encouraged to bear more weight. This brace was removed at 12 weeks postoperatively and the gentleman allowed to fully weight bear with crutches. At his last follow up, 15 months post-operatively, the patient had made good progress. He has returned to work which involves negotiating ladders. Clinically he can do a single heel raise, has 108 of dorsiflexion and good subtalar joint movement. Complications experienced include a sural nerve palsy described from 10 days post-operatively and reduced range of motion of the ankle. The patient also described some ankle instability from 18 weeks postoperatively, which was well treated with a shoe insole with a lateral heel flare. Overall that patient seems pleased with his outcome, despite these complications. 4. Discussion On extensive searching of the literature there appears to have been only one previous report of second rupture of the Achilles tendon [5]. In this German case report the author outlines two cases of second rupture following end-to-end repair, one with a rupture 1 cm distal to the first rupture and one at the osseous insertion of the tendon. Aside from these cases it remains clear that second rupture is uncommon and until now has not been described proximal to the first rupture. We will first consider the mechanical influence on both ruptures. As the first injury occurred during sport (football) it seems logical that a mechanical cause is largely to blame. Barfred suggested that if the tendon is obliquely loaded, which occurs commonly in football, even healthy tendons could rupture [6]. Studies have found that the majority of Achilles tendon ruptures occur during sporting activity [7]. It is thought the onset of muscle
fatigue predisposes to rupture [2] and most patients admit to being ‘‘out of shape’’ at the time of injury [8]. It is fair to describe the patient in this case as not in peak fitness. Considering the second rupture, Arner and Lindholm proposed that sharp dorsiflexion of the ankle with strong contraction of the triceps surae is a common mechanism for Achilles tendon rupture [9]. It is probable that this strain could have been exerted as the patient stumbled from his calf stretching exercise. The reduced level of activity of the patient, as he recovered from his first rupture, may have influenced his second rupture. It is postulated that on returning to exercise after a time of reduced activity a lack of muscular co-ordination may lead to greater forces across the tendon predisposing to rupture [8]. Experiment on rats support this theory showing increased frequency of ruptures after a time of inactivity [6]. In summary it appears mechanical factors played a large part in the aetiology of both ruptures. It is known that intratendinous degenerative changes have occurred prior to rupture in almost all cases [10]. Thus if we consider the two ruptures as independent of each other, one might imagine the patient may have a known risk factors for intratendinous degeneration or damage, leading to the ruptures. Some studies have implicated the use of fluoroquinolone antibiotics and the injury [11]. However, to our knowledge the patient’s most recent exposure to such drugs was a 12-day course of Ciprofloxacin (500 mg/day) 18 months before his first rupture. Given the time between drug exposure and injury it seems unlikely to have influenced his ruptures. The patient has not being treated with any other drugs linked to rupture of the Achilles tendon, such as corticosteroid therapy [12]. At the time of the second rupture he was only taking lisinopril and co-codamol. Prior to the patients first rupture the patient did not report any local or systemic symptoms indicative of any systemic or tendon pathology that might predispose to rupture. Thus, in this case, like the majority of Achilles tendon rupture, no clear degenerative factors seem to be present [10]. One can also consider that the first rupture may have accelerated the degeneration of the tendon predisposing to the second rupture. Clearly the blood supply to the tendon could have been compromised during the first injury and its subsequent management. It is thought that reduced vascularity may hinder healing of the tendon leading to degenerative changes and increased risk of rupture [13]. To date the blood supply to the Achilles tendon is yet to be fully established but research suggests the mid-portion is relatively hypovascular [14]. It is in this midportion that the first rupture occurred, and the majority of ruptures are found in this area [15]. As the second rupture does not lie in this mid-portion one could conjecture that the initial rupture or its treatment led to reduced blood flow superior to the mid-portion and thus influenced the second rupture. The transverse limb of the Kessler suture would have compressed the tendon in the transverse plane, diminishing its blood supply. However, as the Kessler suture is a relatively successful and popular technique, yet this presentation almost unique. This mechanism of second rupture seems unlikely. In addition patterns of reduced activity followed by increasing activity, such as during the patient’s injury and rehabilitation, have been shown to result in intratendinous degeneration [16]. Several techniques have been described using the gastrocnemius aponeurosis since Christensen’s first account in 1953 [17]. However in this case the surgeon utilised a method he has used previously for neglected ruptures with good success. The technique could be thought of as a modification to the simpler procedure described by Gerdes et al. [18]. Considering the biomechanics of the surgical technique described. The aponeurosis flap acts to counterbalance the intratendinous degeneration and necrosis which affects ruptured
P.R.P. Rushton et al. / Foot and Ankle Surgery 17 (2011) e17–e19
tendons diffusely, impeding successful healing by organisation [19]. It is probable that the Achilles tendon in this case had widespread degeneration. In addition it was felt that due to the loss of tendon from the two debridements the tension on sutures during a simple end-end repair would be too great [10]. Thus the senior author felt an end-end repair alone was unsuitable and a technique used successfully in re-ruptures selected. As the tendon adjacent to the first rupture was still healing and weak, only 12 weeks post first repair, the tendon from proximal to the second rupture to beyond first rupture was assumed to be pathological. The aponeurosis flap was thus passed beyond this zone to an area of seemingly healthy distal tendon. The aponeurosis flap was looped back over the first rupture and sutured, giving a large area of contact with the distal section of tendon, aiding healing by organisation and repair. Passing of the flap through the tendon helps limit the bulk of the repair, which can hinder wound closure in aponeurosis turndown based techniques [20]. A number of complications were encountered following this repair. The sural nerve palsy encountered is of importance and likely to represent iatrogenic injury. The biomechanical challenges to be overcome in the repair of a second rupture are distinct from those of typical re-rupture surgery. As there are two ruptures, the combined surgery necessitated greater tendon resection than typical single site re-rupture techniques. This may explain the reduced ROM and stability. This is the first technique to be described to treat this rare surgical presentation. Until other techniques are described to address this injury we cannot accurately consider the inevitability of these complications in these cases. 5. Conclusion This case demonstrates that re-rupture the Achilles tendon may occur at sites other than that of the first rupture following operative repair. This may occur in a seemingly typical patient with no clear risk factors for recurrent rupture. In this case the rupture could be adequately repaired via an open operative procedure involving an aponeurosis flap turndown.
e19
References [1] Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand 1996;67:277–9. [2] Coughlin MJ, Mann RA, Saltzman C. Surgery of foot and ankle. Philadelphia: Mosby Elsevier; 2007. [3] Khan RK, Fick D, Keogh A, Crawford J, Brammar TJ, Parker MJ. Treatment of acute Achilles tendon ruptures a metanalysis of randomised control trials. J Bone Joint Surg Am 2005;87:2202–10. [4] Bhandari M, Guyatt GH, Siddiqui F, Morrow F, Busse J, Leighton RK, Sprague S, Schemitsch EH. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop 2002;400:190–200. [5] Durbin F. Recurrent rupture of the Achilles tendon [abstract]. Unfallchirurgie 1983;93:199–209. [6] Barfred T. Experimental rupture of the Achilles tendon. Comparison of various types of experimental rupture in rats. Acta Orthop Scand 1971;42:528–43. [7] Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 1993;21:791–9. [8] Inglis AE, Sculco TP. Surgical repair of ruptures of the tendo Achillis. Clin Orthop 1981;156:160–9. [9] Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon: a study of 92 cases. Acta Chir Scand 1959;116:1–51. [10] Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81: 1019–36. [11] Sode J, Obel J, Hallas J, Lassen A. Use of fluroquinolone and risk of Achilles tendon rupture: a population-based cohort study. Eur J Clin Pharmacol 2007;63:499–503. [12] Mahler F, Fritschy D. Partial and complete ruptures of the Achilles tendon and local corticosteroid injections. Br J Sports Med 1992;26:7–14. [13] Ahmed IM, Lagopoulos M, McConnell P, Soames RW, Sefton GK. Blood supply of the Achilles tendon. J Orthop Res 1998;16:591–6. [14] Theobald P, Benjamin M, Nokes L, Pugh N. Review of the vascularisation of the human Achilles tendon. Injury 2005;36:1267–72. [15] Leppilahti J, Orava S. Total Achilles tendon rupture: a review. Sports Med 1998;25(2):79–100. [16] Kristensen JK, Andersen PT. Rupture of the Achilles tendon: a series and a review of literature. J Trauma 1972;12:794–8. [17] Christensen I. Rupture of the Achilles tendon; analysis of 57 cases. Acta Chir Scand 1953;106:50–60. [18] Gerdes MH, Brown TD, Bell AL, Baker JA, Levson M, Layer S. A flap augmentation technique for Achilles tendon repair. Clin Orthop 1992;280:241–6. [19] Cetti R, Junge J, Vyberg M. Spontaneous rupture of theAchilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients. Acta Orthop Scand 2003;74:78–84. [20] Nilsson-Helander K, Swa¨rd L, Silbernagel KG, Thomee´ R, Eriksson BI, Karlsson J. A new surgical method to treat chronic ruptures and reruptures of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc 2008;16(6):614–20.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
A case of ‘second rupture’ following open repair of a ruptured Achilles tendon P.R.P. Rushton *, A.K. Singh, R.G. Deshmukh Department of Orthopaedic Surgery, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, Lincolnshire, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 June 2010 Received in revised form 7 August 2010 Accepted 8 August 2010
We present a case of Achilles tendon rupture in a 54-year-old man whilst rehabilitating following endto-end open repair of an acute Achilles tendon rupture. Re-rupture following surgical repair of Achilles tendon is well known. This case however, is atypical as the second rupture occurred significantly proximal to the first rupture. To our knowledge this is the first time this has been described in the English literature. We have termed this incident a ‘second rupture’. We describe the surgical technique used by the operating surgeon during open repair of this ‘second rupture’, involving a gastrocnemius flap turndown. This has lead to the patient making a good recovery, despite complications. This case report serves to inform surgeons of the existence of this type of Achilles tendon rupture, whilst considering possible aetiologies and suggesting a technique for repair of the injury. ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Achilles tendon Rupture Re-rupture
1. Introduction Rupture of the Achilles tendon is a relatively common and serious injury with incidence reported as 7/100,000 [1]. Rupture tends to affect males aged between 30 and 50 years who engage in intermittent physical activity [2]. Management of acute Achilles tendon rupture is controversial; the choice is between nonoperative, involving immobilisation or functional bracing, or operative with an open or percutaneous technique. There is debate over the best choice of treatment with a lack of consensus in the literature. However, to date meta-analyses suggest that operative techniques have a lower rate of re-rupture, around 3%, compared with approximately 13% by non-operative methods [3,4]. Classically re-ruptures occur at the site of the previous rupture. We present a case of re-rupture of the right Achilles tendon occurring in a gentleman whilst rehabilitating post-operatively for a previous Achilles tendon rupture. We have termed this a ‘second rupture’ as this rupture significantly proximal to the first rupture. Seemingly the only other report of a second rupture to date appears in a German case report from 1983 [5]. 2. Methods The 54-year-old man ruptured his right Achilles tendon whilst playing football. He was overweight and well apart from hypertension. He was promptly treated by open end-to-end repair
* Corresponding author at: The Atrium, Western Terrace, The Park, Nottingham, England, NG7 1AF, UK. E-mail address: [email protected] (P.R.P. Rushton).
with a modified Kessler’s suture. This initial rupture lay 5 cm above the tendinous insertion. A single non-absorbable suture was used in a modified Kessler fashion approximately 2 cm from the rupture site. This was augmented with a circumferential suture of absorbable suture. He left hospital the day after the operation and was followed up as outpatient. His initial rehabilitation was unremarkable and he made good progress. His plaster cast was removed after 8 weeks. He then underwent formal physiotherapy and was allowed to weight bear as tolerated with the aid of crutches. However, at 10 weeks postoperatively the patient was carrying out a calf stretching exercise when he briefly lost his balance, stumbled and heard an audible snap. Subsequently the man could palpate a gap in the posterior aspect of his lower right leg. Prompt assessment by the surgeon confirmed a rupture of the right Achilles tendon. As the patient was keen for a surgical repair he underwent a further operation 2 weeks after the second rupture. The patient was positioned prone and underwent general anaesthesia. A medial incision along the scar from the first operation exposed the second rupture, situated 3 cm proximal to the previous rupture and 8 cm from the tendinous insertion. The previous rupture appeared to have healed well. The two severed ends of the tendon were debrided. Following this a large strap of the Achilles tendon aponeurosis (10 cm 2 cm) was fashioned. A 2 cm horizontal incision was then made through the full thickness of the gastrocnemius–soleus complex 2 cm proximal to the severed end of the proximal segment of the tendon. The aponeurosis flap could then be turned back on itself and passed through the incision from posterior to anterior. Interrupted sutures ensured the incision in the fascia would not lengthen under tensioning.
1268-7731/$ – see front matter ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2010.08.005
[(Fig._1)TD$IG]
P.R.P. Rushton et al. / Foot and Ankle Surgery 17 (2011) e17–e19
e18
Fig. 1. Sagittal section schematic of route of aponeurosis flap.
A 2 cm horizontal incision was then made in the distal portion of the Achilles tendon, distal to the previous rupture. The aponeurosis strap could then be passed through the incision from anterior to posterior, before being turned back, over the site of the first rupture (Fig. 1). Heavy absorbable suture was used to approximate the strap and tendon, in full plantar-flexion. A satisfactory approximation of the ruptured ends of the tendon was achieved using absorbable sutures. Finally the cut edges of the aponeurosis were approximated. Subcutaneous fat and skin were closed with absorbable and non-absorbable sutures respectively. A below knee cast was used to immobilise the foot in a neutral position. 3. Results The patient experienced no acute post-operative complications and was discharged the following day. He was encouraged to undertake non-weight bearing mobilisation for the first 6 weeks post-operatively. From weeks 6 to 9 post-operatively he was allowed to partially weight bear with the cast on. At week 9 his cast was changed for an ankle brace and he was encouraged to bear more weight. This brace was removed at 12 weeks postoperatively and the gentleman allowed to fully weight bear with crutches. At his last follow up, 15 months post-operatively, the patient had made good progress. He has returned to work which involves negotiating ladders. Clinically he can do a single heel raise, has 108 of dorsiflexion and good subtalar joint movement. Complications experienced include a sural nerve palsy described from 10 days post-operatively and reduced range of motion of the ankle. The patient also described some ankle instability from 18 weeks postoperatively, which was well treated with a shoe insole with a lateral heel flare. Overall that patient seems pleased with his outcome, despite these complications. 4. Discussion On extensive searching of the literature there appears to have been only one previous report of second rupture of the Achilles tendon [5]. In this German case report the author outlines two cases of second rupture following end-to-end repair, one with a rupture 1 cm distal to the first rupture and one at the osseous insertion of the tendon. Aside from these cases it remains clear that second rupture is uncommon and until now has not been described proximal to the first rupture. We will first consider the mechanical influence on both ruptures. As the first injury occurred during sport (football) it seems logical that a mechanical cause is largely to blame. Barfred suggested that if the tendon is obliquely loaded, which occurs commonly in football, even healthy tendons could rupture [6]. Studies have found that the majority of Achilles tendon ruptures occur during sporting activity [7]. It is thought the onset of muscle
fatigue predisposes to rupture [2] and most patients admit to being ‘‘out of shape’’ at the time of injury [8]. It is fair to describe the patient in this case as not in peak fitness. Considering the second rupture, Arner and Lindholm proposed that sharp dorsiflexion of the ankle with strong contraction of the triceps surae is a common mechanism for Achilles tendon rupture [9]. It is probable that this strain could have been exerted as the patient stumbled from his calf stretching exercise. The reduced level of activity of the patient, as he recovered from his first rupture, may have influenced his second rupture. It is postulated that on returning to exercise after a time of reduced activity a lack of muscular co-ordination may lead to greater forces across the tendon predisposing to rupture [8]. Experiment on rats support this theory showing increased frequency of ruptures after a time of inactivity [6]. In summary it appears mechanical factors played a large part in the aetiology of both ruptures. It is known that intratendinous degenerative changes have occurred prior to rupture in almost all cases [10]. Thus if we consider the two ruptures as independent of each other, one might imagine the patient may have a known risk factors for intratendinous degeneration or damage, leading to the ruptures. Some studies have implicated the use of fluoroquinolone antibiotics and the injury [11]. However, to our knowledge the patient’s most recent exposure to such drugs was a 12-day course of Ciprofloxacin (500 mg/day) 18 months before his first rupture. Given the time between drug exposure and injury it seems unlikely to have influenced his ruptures. The patient has not being treated with any other drugs linked to rupture of the Achilles tendon, such as corticosteroid therapy [12]. At the time of the second rupture he was only taking lisinopril and co-codamol. Prior to the patients first rupture the patient did not report any local or systemic symptoms indicative of any systemic or tendon pathology that might predispose to rupture. Thus, in this case, like the majority of Achilles tendon rupture, no clear degenerative factors seem to be present [10]. One can also consider that the first rupture may have accelerated the degeneration of the tendon predisposing to the second rupture. Clearly the blood supply to the tendon could have been compromised during the first injury and its subsequent management. It is thought that reduced vascularity may hinder healing of the tendon leading to degenerative changes and increased risk of rupture [13]. To date the blood supply to the Achilles tendon is yet to be fully established but research suggests the mid-portion is relatively hypovascular [14]. It is in this midportion that the first rupture occurred, and the majority of ruptures are found in this area [15]. As the second rupture does not lie in this mid-portion one could conjecture that the initial rupture or its treatment led to reduced blood flow superior to the mid-portion and thus influenced the second rupture. The transverse limb of the Kessler suture would have compressed the tendon in the transverse plane, diminishing its blood supply. However, as the Kessler suture is a relatively successful and popular technique, yet this presentation almost unique. This mechanism of second rupture seems unlikely. In addition patterns of reduced activity followed by increasing activity, such as during the patient’s injury and rehabilitation, have been shown to result in intratendinous degeneration [16]. Several techniques have been described using the gastrocnemius aponeurosis since Christensen’s first account in 1953 [17]. However in this case the surgeon utilised a method he has used previously for neglected ruptures with good success. The technique could be thought of as a modification to the simpler procedure described by Gerdes et al. [18]. Considering the biomechanics of the surgical technique described. The aponeurosis flap acts to counterbalance the intratendinous degeneration and necrosis which affects ruptured
P.R.P. Rushton et al. / Foot and Ankle Surgery 17 (2011) e17–e19
tendons diffusely, impeding successful healing by organisation [19]. It is probable that the Achilles tendon in this case had widespread degeneration. In addition it was felt that due to the loss of tendon from the two debridements the tension on sutures during a simple end-end repair would be too great [10]. Thus the senior author felt an end-end repair alone was unsuitable and a technique used successfully in re-ruptures selected. As the tendon adjacent to the first rupture was still healing and weak, only 12 weeks post first repair, the tendon from proximal to the second rupture to beyond first rupture was assumed to be pathological. The aponeurosis flap was thus passed beyond this zone to an area of seemingly healthy distal tendon. The aponeurosis flap was looped back over the first rupture and sutured, giving a large area of contact with the distal section of tendon, aiding healing by organisation and repair. Passing of the flap through the tendon helps limit the bulk of the repair, which can hinder wound closure in aponeurosis turndown based techniques [20]. A number of complications were encountered following this repair. The sural nerve palsy encountered is of importance and likely to represent iatrogenic injury. The biomechanical challenges to be overcome in the repair of a second rupture are distinct from those of typical re-rupture surgery. As there are two ruptures, the combined surgery necessitated greater tendon resection than typical single site re-rupture techniques. This may explain the reduced ROM and stability. This is the first technique to be described to treat this rare surgical presentation. Until other techniques are described to address this injury we cannot accurately consider the inevitability of these complications in these cases. 5. Conclusion This case demonstrates that re-rupture the Achilles tendon may occur at sites other than that of the first rupture following operative repair. This may occur in a seemingly typical patient with no clear risk factors for recurrent rupture. In this case the rupture could be adequately repaired via an open operative procedure involving an aponeurosis flap turndown.
e19
References [1] Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand 1996;67:277–9. [2] Coughlin MJ, Mann RA, Saltzman C. Surgery of foot and ankle. Philadelphia: Mosby Elsevier; 2007. [3] Khan RK, Fick D, Keogh A, Crawford J, Brammar TJ, Parker MJ. Treatment of acute Achilles tendon ruptures a metanalysis of randomised control trials. J Bone Joint Surg Am 2005;87:2202–10. [4] Bhandari M, Guyatt GH, Siddiqui F, Morrow F, Busse J, Leighton RK, Sprague S, Schemitsch EH. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop 2002;400:190–200. [5] Durbin F. Recurrent rupture of the Achilles tendon [abstract]. Unfallchirurgie 1983;93:199–209. [6] Barfred T. Experimental rupture of the Achilles tendon. Comparison of various types of experimental rupture in rats. Acta Orthop Scand 1971;42:528–43. [7] Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 1993;21:791–9. [8] Inglis AE, Sculco TP. Surgical repair of ruptures of the tendo Achillis. Clin Orthop 1981;156:160–9. [9] Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon: a study of 92 cases. Acta Chir Scand 1959;116:1–51. [10] Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81: 1019–36. [11] Sode J, Obel J, Hallas J, Lassen A. Use of fluroquinolone and risk of Achilles tendon rupture: a population-based cohort study. Eur J Clin Pharmacol 2007;63:499–503. [12] Mahler F, Fritschy D. Partial and complete ruptures of the Achilles tendon and local corticosteroid injections. Br J Sports Med 1992;26:7–14. [13] Ahmed IM, Lagopoulos M, McConnell P, Soames RW, Sefton GK. Blood supply of the Achilles tendon. J Orthop Res 1998;16:591–6. [14] Theobald P, Benjamin M, Nokes L, Pugh N. Review of the vascularisation of the human Achilles tendon. Injury 2005;36:1267–72. [15] Leppilahti J, Orava S. Total Achilles tendon rupture: a review. Sports Med 1998;25(2):79–100. [16] Kristensen JK, Andersen PT. Rupture of the Achilles tendon: a series and a review of literature. J Trauma 1972;12:794–8. [17] Christensen I. Rupture of the Achilles tendon; analysis of 57 cases. Acta Chir Scand 1953;106:50–60. [18] Gerdes MH, Brown TD, Bell AL, Baker JA, Levson M, Layer S. A flap augmentation technique for Achilles tendon repair. Clin Orthop 1992;280:241–6. [19] Cetti R, Junge J, Vyberg M. Spontaneous rupture of theAchilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients. Acta Orthop Scand 2003;74:78–84. [20] Nilsson-Helander K, Swa¨rd L, Silbernagel KG, Thomee´ R, Eriksson BI, Karlsson J. A new surgical method to treat chronic ruptures and reruptures of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc 2008;16(6):614–20.