- Email: [email protected]
Triple Achilles Tendon Rupture: Case Report
ARTICLE IN PRESS The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery j o u r n a l h o m e p a g e : w w w. j f a s . o r g
Case Reports and Series
Triple Achilles Tendon Rupture: Case Report Amol Saxena, DPM, FACFAS, FAAPSM 1, Deann Hofer, DPM 2 1Podiatrist, 2Fellow,
Department of Sports Medicine, Sutter-Palo Alto, Palo Alto, CA Department of Sports Medicine, Sutter-Palo Alto, Palo Alto, CA
A R T I C L E
I N F O
Level of Clinical Evidence: 4
Keywords: Achilles rupture athlete football running soccer
A B S T R A C T
We present a case report with 1-year follow-up data of a 57-year-old male soccer referee who had sustained an acute triple Achilles tendon rupture injury during a game. His triple Achilles tendon rupture consisted of a rupture of the proximal watershed region, a rupture of the main body (mid-watershed area), and an avulsion-type rupture of insertional calcific tendinosis. The patient was treated surgically with primary repair of the tendon, including tenodesis with anchors. Postoperative treatment included non-weightbearing for 4 weeks and protected weightbearing until 10 weeks postoperative, followed by formal physical therapy, which incorporated an “antigravity” treadmill. The patient was able to return to full activity after 26 weeks, including running and refereeing, without limitations. © 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
The Achilles tendon is the strongest and largest tendinous structure in the body. It is defined anatomically as the distal confluence of the gastrocnemius and soleus muscles (1). The gastrocnemius musculotendinous junction is approximately 15 cm from its insertion on the calcaneus, although the soleus muscle belly extends distally. The Achilles tendon is unique in that it is not surrounded by a synovial sheath like most tendons in the lower extremity but, rather, is enveloped by a paratenon. The paratenon was thought to be responsible for a significant portion of the tendon’s blood supply. However, the paratenon is contiguous with the deep fascia, which is avascular, and that concept is debatable. Investigators have termed this dysvascular area the “watershed band” (2). The tendon has less blood flow approximately 2 to 6 cm proximally to the Achilles tendon’s insertion on the posterior calcaneus. This area is known as the vascular watershed region. This vulnerable area of the tendon is likely to be ruptured in the midportion watershed region, aka the “main body,” approximately 75% of the time. Furthermore, ruptures can occur in the distal insertion, with an incidence of 10% to 20%, and at the myotendinous junction, with an incidence of 5% to 15% (3). The Achilles tendon is the most commonly ruptured tendon in the human body (4). Various predisposing factors and mechanisms of injury can contribute to Achilles tendon ruptures. Such influences include oral and topical corticosteroids (5), fluoroquinolone antibiotics (6,7), exercise-induced hyperthermia (8,9), a pathologically degenerated tendon (10), a decrease in tendon elasticity with aging (11), and meFinancial Disclosure: None reported. Conflict of Interest: A.S. is a stock holder in AlterG, Inc. Address correspondence to: Amol Saxena, DPM, FACFAS, FAAPSM, Palo Alto Medical Center, Clark Building, Level 3, 795 El Camino Real, Palo Alto, CA 94301. E-mail address: [email protected] (A. Saxena).
chanical abnormalities of the foot (12). Acute ruptures occur most often in men in the third and fourth decades of life who participate in sports intermittently (13). Treatment of acute Achilles tendon ruptures can be conservative (cast immobilization or cast-boot walker) or surgical (open or percutaneous technique). Both open and percutaneous techniques have been shown to be successful. More than 80 of 100 persons who undergo surgery for an Achilles tendon rupture will be able to return to all their activities they did before the injury, including returning to sports (14). We present the case of a soccer (European football) referee during a game, who sustained an Achilles tendon rupture at 3 levels (“triple rupture”) and his successful return to his sport. Case Report A 57-year-old male collegiate soccer referee, with a body mass index of 28.50 kg/m2, sustained an Achilles tendon injury during a game. He had a remote history of an Achilles tendon injury but denied any recent symptoms and corticosteroid or fluoroquinolone use. The injury had been diagnosed as an avulsion-type rupture of the left Achilles tendon at the emergency department on the day of the injury. The patient presented to the senior author’s (A.S.) clinic 2 days later. He was nonweightbearing with bilateral axillary crutches and wearing a posterior splint, which was in an appropriate equinus position. The physical examination showed the neurovascular structures and skin were intact without any evidence of compartment syndrome. Tenderness and pain was present at the Achilles tendon insertion and at the watershed area, with ecchymosis at the posterior heel. He was unable to weight bear or perform a single limb heel raise and had 2 palpable defects in the watershed region, with a firm portion between
1067-2516/$ - see front matter © 2017 by the American College of Foot and Ankle Surgeons. All rights reserved. https://doi.org/10.1053/j.jfas.2017.08.023
ARTICLE IN PRESS 2
A. Saxena, D. Hofer / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
Fig. 1. Lateral radiograph showing calcification within the tendo Achilles and at the insertion. Note the lack of equinus in this non-weightbearing view.
these 2 regions. The Thompson test (15) and Matles sign (16) results were positive. Radiographic imaging showed calcific tendinitis and calcification within the tendon (Fig. 1). Magnetic resonance imaging was performed to determine whether sufficient tendon remained or a tendon transfer would be required for reconstruction. The imaging study showed the remaining tendon morphology was reasonable, without evidence of degeneration. The magnetic resonance imaging scan confirmed a complete tear of the Achilles tendon within the main body and proximal to the watershed region. It also confirmed insertional calcific tendinosis with an avulsion type rupture from the Achilles tendon’s insertion at the posterior calcaneus (Fig. 2). The imaging findings correlated directly with the clinical examination findings. Surgical Technique The patient was placed in a prone position. Monitored anesthesia care was administered in conjunction with local anesthesia. A tourniquet was not used. A curvilinear incision was made along the posterior aspect of the heel starting inferolaterally, coursing within the skin lines posteriorly, and extending proximally along the medial aspect of the medial border of the Achilles tendon. Dissection was carried down to the Achilles tendon using blunt and sharp dissection. The surgical incision was extended proximally to the gastrocnemius myotendinous junction. The proximal portion, cal-
Fig. 3. Intraoperative view showing the watershed region ruptures. Calcification within the main body was palpable.
cific tendinosis, and midportion of the watershed region were identified and further explored to verify the extent of the injuries (Fig. 3). The tendon was debrided of nonviable hematoma and frayed ends. Superior to the calcified mid-portion of the Achilles, there was a transverse rupture. Attention was then directed inferiorly. A significant portion (approximately 65%) of the Achilles tendon was not attached to the posterior calcaneus. Additionally, a longitudinal tear was present, extending proximally from the insertion of the Achilles tendon and terminating at the calcified portion of Achilles. The insertional calcifications within the Achilles tendon and the prominent bone noted along the superoposterior aspect of the calcaneus were removed with a curved osteotome and the edges smoothed with a reciprocating rasp. Pathologic hypertrophic retrocalcaneal bursae due to the retrocalcaneal prominence were excised. Bone wax was then applied to the superior noninsertional portion of the calcaneus to prevent ectopic bone formation. The Achilles tendon was repaired and tenodesed to the calcaneus with one 5.5-mm bioabsorbable anchor and two 5.5-mm knotless bioabsorbable anchors. The tendon was repaired in a Krakow fashion starting with the rupture proximal to the watershed region, continuing distally to the central segment, and then to the insertion
Fig. 2. (A) Lateral T1 magnetic resonance imaging scan showing avulsion and distal and proximal ruptures in the watershed region with central calcification. (B) Coronal magnetic resonance imaging scan showing same findings seen on lateral view and mid-substance calcification.
ARTICLE IN PRESS A. Saxena, D. Hofer / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
3
Fig. 4. Repair of the Achilles tendon in the watershed region after excision of all calcification with tenodesis inferiorly.
of the tendon (Fig. 3). The foot was placed in a plantarflexed position (equinus) during the repair to determine the appropriate tension and length of the Achilles tendon. The tendon edges were reapproximated in good anatomic alignment and reinforced with a combination of nonabsorbable and absorbable sutures, with deliberate placement of the knots to avoid the risk of irritation or granuloma formation (Fig. 4). Closure involved the distal expansion of the Achilles tendon with absorbable 2-0 suture. The subcutaneous tissue was closed with 3-0 monofilament absorbable suture. The paratenon was not repaired (17). The skin was closed with 3-0 nylon suture (Fig. 5). Postoperative Care Postoperatively, patient was immediately placed in a tall, belowthe-knee boot with 2 heel wedges (approximately 5 cm) and instructed to remain non-weightbearing. His first postoperative follow-up appointment was 3 days after surgery (Fig. 6). At that time, the patient
Fig. 5. Clinical photograph showing skin repair.
Fig. 6. Postoperative radiograph showing reestablishment of heel tension (equinus), drill holes for anchors, and removal of calcified Achilles tendon.
was placed in a well-padded below-the-knee fiberglass cast with the foot in a gravity equinus position and kept non-weightbearing for another 4 weeks. Cross-training with a stationary bicycle with the heel on the pedal was started at 1 week postoperatively. Gentle ankle range of motion exercises were begun at 3 weeks postoperatively, with avoidance of dorsiflexion beyond the neutral position. At 2 weeks postoperatively, the sutures were removed, and the patient was placed in a tall, below-the-knee boot. At 4 weeks postoperatively, the patient initiated weightbearing in the boot and gradually transitioned from a −10° heel lift (a 5-cm heel wedge approximately) during the next 6 weeks to a 0.5-cm heel lift. Gradual reduction of equinus consisted of 2 heel wedges (2.5 cm each) for 2 weeks, 1 heel wedge (2.5 cm) for 2 weeks, 2 heel gel cushions (0.5 cm each) for 1 week, and then 1 gel cushion for one 1. A heel cushion (0.5-cm heel lift) was maintained bilaterally for approximately 6 months (17). At 10 weeks postoperatively, the patient was transitioned to an athletic shoe with a supportive lace-up ankle brace. The patient began physical therapy at 8 weeks postoperatively and focused on balance, strengthening, range of motion, and avoiding excessive dorsiflexion of the ankle joint and eccentric loading exercises of the Achilles tendon. At 12 weeks postoperatively, the patient began walking and performing heel raises using an antigravity AlterG™ treadmill (AlterG™, Fremont, CA) at 70% body weight, with the body weight increased 5% every week, as tolerated. Once able to run without pain at 85% body weight, he was cleared to run outdoors (18). The patient was cleared to return to his usual activities after he had met the following criteria: he was able to perform 5 sets of 25 single-leg concentric heel raises. The surgical calf circumference measured <5 mm of atrophy compared with the contralateral calf, and the ankle dorsiflexion and plantarflexion range of motion were within 5° of the contralateral limb. Finally, he had an acceptable Victorian Institute of Sport Assessment score and negative hop test results (17,18).
ARTICLE IN PRESS A. Saxena, D. Hofer / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
4
Discussion
Fig. 7. View of the repair at 1 year postoperatively.
One-Year Follow-Up Data The patient presented to the clinic for a 1-year follow-up examination of his Achilles tendon triple rupture repair. His incision had healed without complications (Fig. 7). He was satisfied with the end results and had been able to return to all activities, including running and refereeing. His Victorian Institute of Sport Assessment index score was 94%, and he had an excellent heel raise, comparable to that with the opposite limb (Fig. 8).
We have presented an unusual case of an Achilles rupture at 3 levels—a triple rupture—with successful repair. Cases of double rupture are rare. To the best of our knowledge, only 1 documented case of a double rupture has been reported (19). In that case, the Haglund exostosis was implicated in the distal rupture, and the patient had also sustained a rupture in the watershed region. The investigators concluded that in patients with a prominent posterior calcaneus (“Haglund”), resection of this region should be considered if a rupture involves this region (19). Our patient also had a prominent superior calcaneus (“Haglund”) which likely predisposed him to an avulsiontype of rupture. His calcified mid-portion of the Achilles in the watershed region was likely indicative of previous partial rupture and nonideal healing. This may make the tendon more vulnerable to rupture proximal and inferior to the calcification. Repair of Achilles tendons can be performed with tendon transfer; however, the outcomes in athletes are undocumented with the flexor halluces longus procedure. A large study by Cottom et al (20) reported an average patient age of >60 years. No activity level or sports participation was documented in their study. Although flexor halluces longus transfer can be helpful for large deficits, we prefer to avoid sacrificing a tendon in athletes (17). When using another tendon, strength can be compromised. However, the use of the peroneus brevis tendon might be more beneficial than using the flexor tendons for Achilles tendon reconstruction for a successful return to activity, including sports. Maffulli et al (21) documented this in a long-term study. In conclusion, the incidence after Achilles tendon repair for athletes in studies that have documented their ability to return to sport has been reported at ~90%, although some have reported significantly lower rates for professional basketball and American football athletes. The interval to return to activity has ranged from 18 to ≥20 weeks for those with midsubstance ruptures and insertional repairs (17,22,23). We have presented the case of an Achilles rupture that involved injuries in both regions, the insertion and watershed regions, with a total of 3 rupture sites. This might have lengthened the time required to return to activity; however, more cases are needed to assess this. We look forward to more case reports of double or more ruptures of the Achilles tendon, in order to better understand this rare injury. References
Fig. 8. Demonstration of heel raise at 1 year postoperatively, showing achievement of Victorian Institute of Sport Assessment score of 94% for the operated left limb.
1. Kotian SR, Sachin KS, Bhat KM. Bifurcated plantaris with rare relations to the neurovascular bundle in the popliteal fossa. Anat Sci Int 88:239–241, 2013. 2. Saxena A, Bareither D. Magnetic resonance and cadaveric findings of the “watershed band” of the Achilles tendon. J Foot Ankle Surg 40:132–136, 2001. 3. Gwynne-Jones D, Sims M, Handcock D. Epidemiology and outcomes of acute Achilles tendon rupture with operative or nonoperative treatment using an identical functional bracing protocol. Foot Ankle Int 32:337–343, 2011. 4. Jozsa L, Kvist M, Balint JB, Reffy A, Jarvinen M, Lehto M, Barxo M. The role of recreational sports activity in Achilles tendon rupture: a clinical, pathoanatomical and sociological study of 292 cases. Am J Sports Med 17:338–343, 1989. 5. Hearsh BL, Health NS. Achilles tendon rupture as a result of oral steroid therapy. J Am Podiatr Med Assoc 92:355–358, 2002. 6. Vanek D, Saxena A, Boggs J. Fluoroquinolone therapy and Achilles tendon rupture. J Am Podiatr Med Assoc 93:333–335, 2003. 7. Caseperian JM, Luchi M, Moffat RE, Hinthorn D. Quinolones and tendon ruptures. South Med J 93:488–491, 2000. 8. Birch HL, Wilson AM, Goodship AE. The effect of exercise-induced localized hyperthermia on tendon cell survival. J Exp Biol 200(Pt 11):1703–1708, 1997. 9. Wilson AM, Goodship AE. Exercise-induced as a possible mechanism for tendon degeneration. J Biomech 27:899–905, 1994. 10. Tallon C, Maffuli N, Ewen SW. Ruptured Achilles tendons are significantly more degenerated than tendinopathic tendons. Med Sci Sports Exerc 33:1983–1990, 2001. 11. Stanish W. Overuse injuries in athletes: a perspective. Med Sci Sports Exerc 16:1–7, 1984. 12. Khan RJK, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures. J Bone Joint Surg 87:2202–2210, 2005. 13. Hattrup SJ, Johnson KA. A review of ruptures of the Achilles tendon. Foot Ankle 6:34–38, 1985.
ARTICLE IN PRESS A. Saxena, D. Hofer / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
14. Khan RJK, Smith RLC. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev (9):CD003674, 2010. 15. Simmonds FA. The diagnosis of the ruptured Achilles tendon. Practitioner 179:56–58, 1957. 16. Matles AL. Rupture of the tendo Achilles: another diagnostic sign. Bull Hosp Joint Dis 36:48–51, 1975. 17. Saxena A, Ewen B, Maffulli N. Rehabilitation of the operated Achilles tendon: parameters for predicting return to activity. J Foot Ankle Surg 50:37–40, 2011. 18. Saxena A, Granot A. Use of an anti-gravity treadmill in the rehabilitation of the operated Achilles tendon: a pilot study. J Foot Ankle Surg 50:558–561, 2011. 19. Porsch M, Hackenbroch MH, König DP. Atypical Achilles tendon rupture in Haglund exostosis—a case report. Z Orthop Ihre Grenzgeb 136:568–570, 1998.
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20. Cottom JM, Hyer CF, Berlet GC, Lee TH. Flexor hallucis tendon transfer with an interference screw for chronic Achilles tendinosis: a report of 62 cases. Foot Ankle Spec 1:280–287, 2008. 21. Maffulli N, Spiezia F, Pintore E, Longo UG, Testa V, Capasso G, Denaro V. Peroneus brevis tendon transfer for reconstruction of chronic tears of the Achilles tendon: a long-term follow-up study. J Bone Joint Surg Am 94:901–905, 2012. 22. Ververidis AN, Kalifis KG, Touzopoulos P, Drosos GI, Tilkeridis KE, Kazakos KI. Percutaneous repair of the Achilles tendon rupture in athletic population. J Orthop 13:57–61, 2015. 23. McCullough KA, Shaw CM, Anderson RB. Mini-open repair of Achilles rupture in the national football league. J Surg Orthop Adv 23:179–183, 2014.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery j o u r n a l h o m e p a g e : w w w. j f a s . o r g
Case Reports and Series
Triple Achilles Tendon Rupture: Case Report Amol Saxena, DPM, FACFAS, FAAPSM 1, Deann Hofer, DPM 2 1Podiatrist, 2Fellow,
Department of Sports Medicine, Sutter-Palo Alto, Palo Alto, CA Department of Sports Medicine, Sutter-Palo Alto, Palo Alto, CA
A R T I C L E
I N F O
Level of Clinical Evidence: 4
Keywords: Achilles rupture athlete football running soccer
A B S T R A C T
We present a case report with 1-year follow-up data of a 57-year-old male soccer referee who had sustained an acute triple Achilles tendon rupture injury during a game. His triple Achilles tendon rupture consisted of a rupture of the proximal watershed region, a rupture of the main body (mid-watershed area), and an avulsion-type rupture of insertional calcific tendinosis. The patient was treated surgically with primary repair of the tendon, including tenodesis with anchors. Postoperative treatment included non-weightbearing for 4 weeks and protected weightbearing until 10 weeks postoperative, followed by formal physical therapy, which incorporated an “antigravity” treadmill. The patient was able to return to full activity after 26 weeks, including running and refereeing, without limitations. © 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
The Achilles tendon is the strongest and largest tendinous structure in the body. It is defined anatomically as the distal confluence of the gastrocnemius and soleus muscles (1). The gastrocnemius musculotendinous junction is approximately 15 cm from its insertion on the calcaneus, although the soleus muscle belly extends distally. The Achilles tendon is unique in that it is not surrounded by a synovial sheath like most tendons in the lower extremity but, rather, is enveloped by a paratenon. The paratenon was thought to be responsible for a significant portion of the tendon’s blood supply. However, the paratenon is contiguous with the deep fascia, which is avascular, and that concept is debatable. Investigators have termed this dysvascular area the “watershed band” (2). The tendon has less blood flow approximately 2 to 6 cm proximally to the Achilles tendon’s insertion on the posterior calcaneus. This area is known as the vascular watershed region. This vulnerable area of the tendon is likely to be ruptured in the midportion watershed region, aka the “main body,” approximately 75% of the time. Furthermore, ruptures can occur in the distal insertion, with an incidence of 10% to 20%, and at the myotendinous junction, with an incidence of 5% to 15% (3). The Achilles tendon is the most commonly ruptured tendon in the human body (4). Various predisposing factors and mechanisms of injury can contribute to Achilles tendon ruptures. Such influences include oral and topical corticosteroids (5), fluoroquinolone antibiotics (6,7), exercise-induced hyperthermia (8,9), a pathologically degenerated tendon (10), a decrease in tendon elasticity with aging (11), and meFinancial Disclosure: None reported. Conflict of Interest: A.S. is a stock holder in AlterG, Inc. Address correspondence to: Amol Saxena, DPM, FACFAS, FAAPSM, Palo Alto Medical Center, Clark Building, Level 3, 795 El Camino Real, Palo Alto, CA 94301. E-mail address: [email protected] (A. Saxena).
chanical abnormalities of the foot (12). Acute ruptures occur most often in men in the third and fourth decades of life who participate in sports intermittently (13). Treatment of acute Achilles tendon ruptures can be conservative (cast immobilization or cast-boot walker) or surgical (open or percutaneous technique). Both open and percutaneous techniques have been shown to be successful. More than 80 of 100 persons who undergo surgery for an Achilles tendon rupture will be able to return to all their activities they did before the injury, including returning to sports (14). We present the case of a soccer (European football) referee during a game, who sustained an Achilles tendon rupture at 3 levels (“triple rupture”) and his successful return to his sport. Case Report A 57-year-old male collegiate soccer referee, with a body mass index of 28.50 kg/m2, sustained an Achilles tendon injury during a game. He had a remote history of an Achilles tendon injury but denied any recent symptoms and corticosteroid or fluoroquinolone use. The injury had been diagnosed as an avulsion-type rupture of the left Achilles tendon at the emergency department on the day of the injury. The patient presented to the senior author’s (A.S.) clinic 2 days later. He was nonweightbearing with bilateral axillary crutches and wearing a posterior splint, which was in an appropriate equinus position. The physical examination showed the neurovascular structures and skin were intact without any evidence of compartment syndrome. Tenderness and pain was present at the Achilles tendon insertion and at the watershed area, with ecchymosis at the posterior heel. He was unable to weight bear or perform a single limb heel raise and had 2 palpable defects in the watershed region, with a firm portion between
1067-2516/$ - see front matter © 2017 by the American College of Foot and Ankle Surgeons. All rights reserved. https://doi.org/10.1053/j.jfas.2017.08.023
ARTICLE IN PRESS 2
A. Saxena, D. Hofer / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
Fig. 1. Lateral radiograph showing calcification within the tendo Achilles and at the insertion. Note the lack of equinus in this non-weightbearing view.
these 2 regions. The Thompson test (15) and Matles sign (16) results were positive. Radiographic imaging showed calcific tendinitis and calcification within the tendon (Fig. 1). Magnetic resonance imaging was performed to determine whether sufficient tendon remained or a tendon transfer would be required for reconstruction. The imaging study showed the remaining tendon morphology was reasonable, without evidence of degeneration. The magnetic resonance imaging scan confirmed a complete tear of the Achilles tendon within the main body and proximal to the watershed region. It also confirmed insertional calcific tendinosis with an avulsion type rupture from the Achilles tendon’s insertion at the posterior calcaneus (Fig. 2). The imaging findings correlated directly with the clinical examination findings. Surgical Technique The patient was placed in a prone position. Monitored anesthesia care was administered in conjunction with local anesthesia. A tourniquet was not used. A curvilinear incision was made along the posterior aspect of the heel starting inferolaterally, coursing within the skin lines posteriorly, and extending proximally along the medial aspect of the medial border of the Achilles tendon. Dissection was carried down to the Achilles tendon using blunt and sharp dissection. The surgical incision was extended proximally to the gastrocnemius myotendinous junction. The proximal portion, cal-
Fig. 3. Intraoperative view showing the watershed region ruptures. Calcification within the main body was palpable.
cific tendinosis, and midportion of the watershed region were identified and further explored to verify the extent of the injuries (Fig. 3). The tendon was debrided of nonviable hematoma and frayed ends. Superior to the calcified mid-portion of the Achilles, there was a transverse rupture. Attention was then directed inferiorly. A significant portion (approximately 65%) of the Achilles tendon was not attached to the posterior calcaneus. Additionally, a longitudinal tear was present, extending proximally from the insertion of the Achilles tendon and terminating at the calcified portion of Achilles. The insertional calcifications within the Achilles tendon and the prominent bone noted along the superoposterior aspect of the calcaneus were removed with a curved osteotome and the edges smoothed with a reciprocating rasp. Pathologic hypertrophic retrocalcaneal bursae due to the retrocalcaneal prominence were excised. Bone wax was then applied to the superior noninsertional portion of the calcaneus to prevent ectopic bone formation. The Achilles tendon was repaired and tenodesed to the calcaneus with one 5.5-mm bioabsorbable anchor and two 5.5-mm knotless bioabsorbable anchors. The tendon was repaired in a Krakow fashion starting with the rupture proximal to the watershed region, continuing distally to the central segment, and then to the insertion
Fig. 2. (A) Lateral T1 magnetic resonance imaging scan showing avulsion and distal and proximal ruptures in the watershed region with central calcification. (B) Coronal magnetic resonance imaging scan showing same findings seen on lateral view and mid-substance calcification.
ARTICLE IN PRESS A. Saxena, D. Hofer / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
3
Fig. 4. Repair of the Achilles tendon in the watershed region after excision of all calcification with tenodesis inferiorly.
of the tendon (Fig. 3). The foot was placed in a plantarflexed position (equinus) during the repair to determine the appropriate tension and length of the Achilles tendon. The tendon edges were reapproximated in good anatomic alignment and reinforced with a combination of nonabsorbable and absorbable sutures, with deliberate placement of the knots to avoid the risk of irritation or granuloma formation (Fig. 4). Closure involved the distal expansion of the Achilles tendon with absorbable 2-0 suture. The subcutaneous tissue was closed with 3-0 monofilament absorbable suture. The paratenon was not repaired (17). The skin was closed with 3-0 nylon suture (Fig. 5). Postoperative Care Postoperatively, patient was immediately placed in a tall, belowthe-knee boot with 2 heel wedges (approximately 5 cm) and instructed to remain non-weightbearing. His first postoperative follow-up appointment was 3 days after surgery (Fig. 6). At that time, the patient
Fig. 5. Clinical photograph showing skin repair.
Fig. 6. Postoperative radiograph showing reestablishment of heel tension (equinus), drill holes for anchors, and removal of calcified Achilles tendon.
was placed in a well-padded below-the-knee fiberglass cast with the foot in a gravity equinus position and kept non-weightbearing for another 4 weeks. Cross-training with a stationary bicycle with the heel on the pedal was started at 1 week postoperatively. Gentle ankle range of motion exercises were begun at 3 weeks postoperatively, with avoidance of dorsiflexion beyond the neutral position. At 2 weeks postoperatively, the sutures were removed, and the patient was placed in a tall, below-the-knee boot. At 4 weeks postoperatively, the patient initiated weightbearing in the boot and gradually transitioned from a −10° heel lift (a 5-cm heel wedge approximately) during the next 6 weeks to a 0.5-cm heel lift. Gradual reduction of equinus consisted of 2 heel wedges (2.5 cm each) for 2 weeks, 1 heel wedge (2.5 cm) for 2 weeks, 2 heel gel cushions (0.5 cm each) for 1 week, and then 1 gel cushion for one 1. A heel cushion (0.5-cm heel lift) was maintained bilaterally for approximately 6 months (17). At 10 weeks postoperatively, the patient was transitioned to an athletic shoe with a supportive lace-up ankle brace. The patient began physical therapy at 8 weeks postoperatively and focused on balance, strengthening, range of motion, and avoiding excessive dorsiflexion of the ankle joint and eccentric loading exercises of the Achilles tendon. At 12 weeks postoperatively, the patient began walking and performing heel raises using an antigravity AlterG™ treadmill (AlterG™, Fremont, CA) at 70% body weight, with the body weight increased 5% every week, as tolerated. Once able to run without pain at 85% body weight, he was cleared to run outdoors (18). The patient was cleared to return to his usual activities after he had met the following criteria: he was able to perform 5 sets of 25 single-leg concentric heel raises. The surgical calf circumference measured <5 mm of atrophy compared with the contralateral calf, and the ankle dorsiflexion and plantarflexion range of motion were within 5° of the contralateral limb. Finally, he had an acceptable Victorian Institute of Sport Assessment score and negative hop test results (17,18).
ARTICLE IN PRESS A. Saxena, D. Hofer / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
4
Discussion
Fig. 7. View of the repair at 1 year postoperatively.
One-Year Follow-Up Data The patient presented to the clinic for a 1-year follow-up examination of his Achilles tendon triple rupture repair. His incision had healed without complications (Fig. 7). He was satisfied with the end results and had been able to return to all activities, including running and refereeing. His Victorian Institute of Sport Assessment index score was 94%, and he had an excellent heel raise, comparable to that with the opposite limb (Fig. 8).
We have presented an unusual case of an Achilles rupture at 3 levels—a triple rupture—with successful repair. Cases of double rupture are rare. To the best of our knowledge, only 1 documented case of a double rupture has been reported (19). In that case, the Haglund exostosis was implicated in the distal rupture, and the patient had also sustained a rupture in the watershed region. The investigators concluded that in patients with a prominent posterior calcaneus (“Haglund”), resection of this region should be considered if a rupture involves this region (19). Our patient also had a prominent superior calcaneus (“Haglund”) which likely predisposed him to an avulsiontype of rupture. His calcified mid-portion of the Achilles in the watershed region was likely indicative of previous partial rupture and nonideal healing. This may make the tendon more vulnerable to rupture proximal and inferior to the calcification. Repair of Achilles tendons can be performed with tendon transfer; however, the outcomes in athletes are undocumented with the flexor halluces longus procedure. A large study by Cottom et al (20) reported an average patient age of >60 years. No activity level or sports participation was documented in their study. Although flexor halluces longus transfer can be helpful for large deficits, we prefer to avoid sacrificing a tendon in athletes (17). When using another tendon, strength can be compromised. However, the use of the peroneus brevis tendon might be more beneficial than using the flexor tendons for Achilles tendon reconstruction for a successful return to activity, including sports. Maffulli et al (21) documented this in a long-term study. In conclusion, the incidence after Achilles tendon repair for athletes in studies that have documented their ability to return to sport has been reported at ~90%, although some have reported significantly lower rates for professional basketball and American football athletes. The interval to return to activity has ranged from 18 to ≥20 weeks for those with midsubstance ruptures and insertional repairs (17,22,23). We have presented the case of an Achilles rupture that involved injuries in both regions, the insertion and watershed regions, with a total of 3 rupture sites. This might have lengthened the time required to return to activity; however, more cases are needed to assess this. We look forward to more case reports of double or more ruptures of the Achilles tendon, in order to better understand this rare injury. References
Fig. 8. Demonstration of heel raise at 1 year postoperatively, showing achievement of Victorian Institute of Sport Assessment score of 94% for the operated left limb.
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