Case Report
Repairing an Achilles Tendon Rupture Using the Partial Lindholm Technique Augmented by the Plantaris Tendon: A Case Report Plantaris Tendonu ile Güçlendirilmiş Parsiyel Lindholm Tekniği ile Aşil Tendon Rüptürü Tamiri: Olgu Sunumu Serdar Toker1, Volkan Kilincoglu1, M.Fahri Yurtgun1 Dumlupınar University, School of Medicine, Department of Orthopaedics and Traumatology, Kütahya, Turkey.
1
Correspondence to: Serdar Toker, M.D., Dumlupınar University School of Medicine Department of Orthopaedics and Traumatology. Tavşanli yolu 10.km., 43270, Kütahya, Turkey. Phone:+90.505.7916054, Fax: +90.274.2652277, e-Mail: [email protected]
Abstract
Özet
Many techniques have been described for the treatment of an acute achilles tendon rupture, but there is unfortunately no agreement between orthopedic surgeons regarding the best repair technique and post-treatment rehabilitation protocol. Overall, the surgical methods can be classified as either an open procedure or as a percutaneous procedure. While numerous techniques have been described for open surgical procedures, the strength of the repaired tendon, the healing time, the rerupture rates, and the changes in the range of motion due to adhesions may be the ultimate determining factors of the success of the procedure. In this case study, we report the results of treating a 35-year-old patient who suffered an achilles tendon rupture by combining two recently described surgical methods into a novel repair technique.
Aşil tendon rüptürü tamiri için pek çok teknik tarif edilmekle beraber en iyi teknik ve tedavi sonrası en iyi rehabilitasyon yöntemi hakkında ortopedik cerrahlar arasında bir fikir birliği yoktur. Genel olarak cerrahi yöntemler açık ve perkütan teknikler olarak sınıflandırılır. Açık teknik için pek çok yöntem tanımlanmıştır. Bu tekniklerin karşılaştırılmasında tamirin gücü, iyileşme süresi, cerrahiye bağlı yapışıklıklar sonucu eklem hareket açıklığında meydana gelen değişiklikler, başarıyı belirleyen faktörlerdir. Bu çalışmada, aşil tendon rüptürü nedeni ile önceden tanımlanan iki farklı tekniğin birleştirilmesi ile oluşturulan yöntemle tedavi edilen 35 yaşında bir hastada, tamir tekniğini ve tedavi sonuçlarını bildirmeyi amaçladık.
Keywords: Achilles rupture, Plantaris tendon, Lindholm technique.
Anahtar Kelimeler: Aşil rüptürü, Plantaris tendonu, Lindholm tekniği
The Eurasian Journal of Medicine
148
Toker et al.
Introduction hile the tendo calcanei (achilles) is the strongest tendon in the body, it is ironically the most often ruptured tendon in humans. The majority of these ruptures occur during the performance of athletic activities such as badminton. The treatment choices include both open and percutaneous repair procedures, in addition to nonsurgical procedures that are typically performed according to both the surgeon’s and patient’s preference. Rerupture of the achilles tendon occurs less often after methods involving surgical repair; however, more conservative methods often lead to less soft tissue complications and have a shorter recovery time. Notably, there is not a universally accepted protocol regarding the postoperative rehabilitation protocol [1,2]. Achilles tendon ruptures incur significant economic and social costs. The diagnosis is usually fairly obvious, as indicated by a sharp, painful click observed by the patient in the region of the tendon upon rupture. The rupture is most often located 5 cm proximal to the calcaneal origin of the tendon. This region is considered to be a border for vascular structures, however, recent studies disproved the hypothesis that these vascular structures are the only reason for tendon rupture, which may be caused by a more complex etiology [1,2]. Various techniques have been described for the surgical treatment of achilles tendon ruptures, such as the suturing techniques used for primary repair augmentation procedures in combination with other soft tissues (for example, tendons), in addition to techniques employing instruments such as mitek-anchors [1,2]. In this report, we aimed to describe the repair of the achilles tendon in a young and active male patient by combining two of these soft tissue procedures into a simple method. The results of the treatment are discussed herein.
W
Case Report A 35-year-old volleyball trainer was admitted to our hospital complaining of a sharp and painful click and a limitation in the range of motion of his ankle after a fall during jumping exercises. X-ray radiographies revealed no osseous pathology. During the physical examination, the Thomas test was positive and a gap was palpated just proximal to the calcaneal origin of the achilles tendon. The patient’s history included a report of pain surrounding the achilles tendon for a period of approximately one month. The day after injury, the patient underwent an operation where degenerative changes regarding tendinosis were observed. Due to the observation that the distal portion of the tendon was fragile as a consequence of the tendinosis, it was not possible to perform a primary repair of the damaged tendon, which appeared to require the use of the plantaris tendon for augmentation. The
EAJM: 40, December 2008
Plantaris tendon was explored and was initially cut proximally before being passed across the lateral side of the tendon’s proximal region. The tendon was then distally passed across the medial side of the distal region of the achilles tendon and was subsequently sutured over the rupture area using no: 2/0 prolene sutures (Figure 1). While the augmentation provided strength to the repair, the tendon required additional strength due to the patient’s occupation, which involved excessive jumping and physical strain. We subsequently decided to use the gastrocnemius fascia, as described in the Lindholm’s technique. In the original Lindholm technique, the transfer of the two split fascia from the sides of the gastrocnemius coupled with the suturing of the ruptured area after a 180 degrees turn is recommended. However, we only used one central split fascia because we used the plantaris tendon and previously augmented both the lateral and medial sides. After examining the repaired area, we concluded that the range of motion was adequate and that the repair was sufficiently strong (Figure 2). Upon closing the wound, a belowthe-knee cast was applied in the gravity equinus position. The cast was changed on the 15th and on the 30th day of the first postoperative month, after which a walking cast was provided to the patient for a subsequent 30 days. The patient’s ankle was allowed to bear the full weight of his body after the cast and physical therapy was initiated. The patient began running during the 6th postoperative month. The patient is currently undergoing follow-up treatment at 9 months following the operation and neither pain nor functional limitation has been reported.
Discussion The Achilles tendon is the widest and strongest tendon in the human body. Ruptures of the Achilles tendon are mostly observed in the 3rd decade of life and in males. Notably, there is not complete agreement about the best surgical technique, incision type, suture material, surgical type, and postoperative follow-up procedure among surgeons [3]. One of the objectives of the surgical treatment is to achieve
Fig. 1
_ Augmentation performed using the Plantaris tendon. 149
Achilles Tendon Rupture Repair
maximum primary stability [4]. For this reason, many studies were performed to either evaluate the results of various surgical techniques or compare the mechanical stabilities of various techniques [4,5]. Hosey et al. [6] reported satisfactory results by employing a modified Lindholm technique, however none of their patients returned to their full preoperative athletic capabilities. While it is not reasonable to reach a reliable conclusion with only one individual from one study, the patient in this case study, who was an active volleyball trainer and sportsman, began running and returned to normal athletic activities six and eight months after the operation, respectively . Jung et al. [7] reported good or excellent results in 27 of 30 consecutive patients treated via the primary repair technique involving limited open surgery. During the procedure, several surgical complications were noted, including re-rupture in two cases, a deep infection in one patient, and sural nerve injury in one patient. All of the patients, with the exception of the three patients with a re-rupture or infection, returned to work two months after the operation, resumed light exercise at three months, and sporting activities at six months. Although these results seem to indicate a successful technique, a 10% failure rate is somewhat significant. We emphasize that this is due to the limited open surgery and lack of augmentation employed in these procedures. However, more satisfactory results were reported using minimally invasive surgery in new achilles tendon ruptures [8]. We also argue that such primary repair techniques should be reserved for fresh ruptures while augmentation procedures should be performed for neglected ruptures or ruptures that are due to complications such as tendinosis. Thus, Lee et al. [9] reported positive results in addition to patient satisfaction following a flexor hallucis augmentation procedure performed in three neglected ruptures after a five-year follow-up period. However, despite these good results, we believe that the technique of flexor hallucis tendon is, at a minimum, more technically difficult than the method we performed. Schönberger et al. [10] reported that when comparing recoveries of patients undergoing primary repair and the Mitek-anchor techniques, it took patients in the Mitek-group longer to return to work and sport activities than in the former group. In addition, a greater loss of strength was observed in the injured leg of patients from the Mitek-group. Mitek-anchors are preferred by some of surgeons but this technique has disadvantages as mentioned previously. Moreover, the instrumentation required for the Mitek-anchor techniques incur
Fig. 2
_ Plantaris and single central split fascia of the gastrocnemius re-
sulted in a fairly strong repair.
additional economic expenses. Notably in our technique, we used only prolene sutures, as opposed to many other studies in which relatively expensive PDS sutures were used. We ultimately achieved an extremely stable closure and the patient was able to return to full preoperative sporting activity. Many surgical procedures have been described for treating acute and neglected achilles tendon ruptures. Primary repair of such ruptures by the percutaneous or the limited open technique is suitable for acute and noncomplicated cases, however, we conclude that neglected ruptures, ruptures due to tendinosis, and ruptures in patients who plan to return to competitive sports activities, need to be augmented. We believe that this study is original because there have been no reports regarding the repair of an achilles tendon rupture using the partial Lindholm technique augmented by the plantaris tendon. Long-term studies of our technique using a higher number of patients should be performed to compare the stability, range of motion, wound healing, and time required to return back to sport activities. Yet, the data reported here are extremely encouraging. Conflict interest statement The authors declare that they have no conflict of interest to the publication of this article.
References 1. 2. 3. 4.
5.
Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br 1989; 71:100-1. Hargrove R, Mclean C. Achilles tendon pathology. eMedicine, 2005. Ersan Ö, Seyfettinoğlu F, Duygun F. Aşil tendon rüptürü:Olgu sunumu. Sted 2004; 13: 352. Gebauer M, Beil FT, Beckmann J, et al. Mechanical evaluation of different techniques for Achilles tendon repair. Arch Orthop Trauma Surg 2007; 127: 795-9. Aktas S, Kocaoglu B, Nalbantoglu U, Seyhan
EAJM: 40, December 2008
6. 7.
8.
M, Guven OJ. End-to-end versus augmented repair in the treatment of Achilles tendon ruptures. Foot Ankle Surg 2007; 46: 336-40. Hosey T, Wertheimer S. A retrospective study on surgical repair of the Achilles tendon. J Foot Surg 1984; 23: 112-5. Jung HG, Lee KB, Cho SG, Yoon TR. Outcome of achilles tendon ruptures treated by a limited open technique. Foot Ankle Int 2008; 29: 803-7. Chan SK, Chung SC, Ho YF. Minimally invasive repair of ruptured Achilles tendon. Hong Kong Med J 2008; 14: 255-8.
9.
Lee KB, Park YH, Yoon TR, Chung JY. Reconstruction of neglected Achilles tendon rupture using the flexor hallucis tendon. Knee Surg Sports Traumatol Arthrosc 2008; 16: 83-5. 10. Schönberger TJ, Janzing HM, Morrenhof JW, de Visser AC, Muitjens P. Operative treatment of acute Achilles tendon rupture: Open endto-end-reconstruction versus reconstruction with Mitek-anchors. Acta Chir Belg 2008; 108: 236-9.
150
Repairing an Achilles Tendon Rupture Using the Partial Lindholm Technique Augmented by the Plantaris Tendon: A Case Report Plantaris Tendonu ile Güçlendirilmiş Parsiyel Lindholm Tekniği ile Aşil Tendon Rüptürü Tamiri: Olgu Sunumu Serdar Toker1, Volkan Kilincoglu1, M.Fahri Yurtgun1 Dumlupınar University, School of Medicine, Department of Orthopaedics and Traumatology, Kütahya, Turkey.
1
Correspondence to: Serdar Toker, M.D., Dumlupınar University School of Medicine Department of Orthopaedics and Traumatology. Tavşanli yolu 10.km., 43270, Kütahya, Turkey. Phone:+90.505.7916054, Fax: +90.274.2652277, e-Mail: [email protected]
Abstract
Özet
Many techniques have been described for the treatment of an acute achilles tendon rupture, but there is unfortunately no agreement between orthopedic surgeons regarding the best repair technique and post-treatment rehabilitation protocol. Overall, the surgical methods can be classified as either an open procedure or as a percutaneous procedure. While numerous techniques have been described for open surgical procedures, the strength of the repaired tendon, the healing time, the rerupture rates, and the changes in the range of motion due to adhesions may be the ultimate determining factors of the success of the procedure. In this case study, we report the results of treating a 35-year-old patient who suffered an achilles tendon rupture by combining two recently described surgical methods into a novel repair technique.
Aşil tendon rüptürü tamiri için pek çok teknik tarif edilmekle beraber en iyi teknik ve tedavi sonrası en iyi rehabilitasyon yöntemi hakkında ortopedik cerrahlar arasında bir fikir birliği yoktur. Genel olarak cerrahi yöntemler açık ve perkütan teknikler olarak sınıflandırılır. Açık teknik için pek çok yöntem tanımlanmıştır. Bu tekniklerin karşılaştırılmasında tamirin gücü, iyileşme süresi, cerrahiye bağlı yapışıklıklar sonucu eklem hareket açıklığında meydana gelen değişiklikler, başarıyı belirleyen faktörlerdir. Bu çalışmada, aşil tendon rüptürü nedeni ile önceden tanımlanan iki farklı tekniğin birleştirilmesi ile oluşturulan yöntemle tedavi edilen 35 yaşında bir hastada, tamir tekniğini ve tedavi sonuçlarını bildirmeyi amaçladık.
Keywords: Achilles rupture, Plantaris tendon, Lindholm technique.
Anahtar Kelimeler: Aşil rüptürü, Plantaris tendonu, Lindholm tekniği
The Eurasian Journal of Medicine
148
Toker et al.
Introduction hile the tendo calcanei (achilles) is the strongest tendon in the body, it is ironically the most often ruptured tendon in humans. The majority of these ruptures occur during the performance of athletic activities such as badminton. The treatment choices include both open and percutaneous repair procedures, in addition to nonsurgical procedures that are typically performed according to both the surgeon’s and patient’s preference. Rerupture of the achilles tendon occurs less often after methods involving surgical repair; however, more conservative methods often lead to less soft tissue complications and have a shorter recovery time. Notably, there is not a universally accepted protocol regarding the postoperative rehabilitation protocol [1,2]. Achilles tendon ruptures incur significant economic and social costs. The diagnosis is usually fairly obvious, as indicated by a sharp, painful click observed by the patient in the region of the tendon upon rupture. The rupture is most often located 5 cm proximal to the calcaneal origin of the tendon. This region is considered to be a border for vascular structures, however, recent studies disproved the hypothesis that these vascular structures are the only reason for tendon rupture, which may be caused by a more complex etiology [1,2]. Various techniques have been described for the surgical treatment of achilles tendon ruptures, such as the suturing techniques used for primary repair augmentation procedures in combination with other soft tissues (for example, tendons), in addition to techniques employing instruments such as mitek-anchors [1,2]. In this report, we aimed to describe the repair of the achilles tendon in a young and active male patient by combining two of these soft tissue procedures into a simple method. The results of the treatment are discussed herein.
W
Case Report A 35-year-old volleyball trainer was admitted to our hospital complaining of a sharp and painful click and a limitation in the range of motion of his ankle after a fall during jumping exercises. X-ray radiographies revealed no osseous pathology. During the physical examination, the Thomas test was positive and a gap was palpated just proximal to the calcaneal origin of the achilles tendon. The patient’s history included a report of pain surrounding the achilles tendon for a period of approximately one month. The day after injury, the patient underwent an operation where degenerative changes regarding tendinosis were observed. Due to the observation that the distal portion of the tendon was fragile as a consequence of the tendinosis, it was not possible to perform a primary repair of the damaged tendon, which appeared to require the use of the plantaris tendon for augmentation. The
EAJM: 40, December 2008
Plantaris tendon was explored and was initially cut proximally before being passed across the lateral side of the tendon’s proximal region. The tendon was then distally passed across the medial side of the distal region of the achilles tendon and was subsequently sutured over the rupture area using no: 2/0 prolene sutures (Figure 1). While the augmentation provided strength to the repair, the tendon required additional strength due to the patient’s occupation, which involved excessive jumping and physical strain. We subsequently decided to use the gastrocnemius fascia, as described in the Lindholm’s technique. In the original Lindholm technique, the transfer of the two split fascia from the sides of the gastrocnemius coupled with the suturing of the ruptured area after a 180 degrees turn is recommended. However, we only used one central split fascia because we used the plantaris tendon and previously augmented both the lateral and medial sides. After examining the repaired area, we concluded that the range of motion was adequate and that the repair was sufficiently strong (Figure 2). Upon closing the wound, a belowthe-knee cast was applied in the gravity equinus position. The cast was changed on the 15th and on the 30th day of the first postoperative month, after which a walking cast was provided to the patient for a subsequent 30 days. The patient’s ankle was allowed to bear the full weight of his body after the cast and physical therapy was initiated. The patient began running during the 6th postoperative month. The patient is currently undergoing follow-up treatment at 9 months following the operation and neither pain nor functional limitation has been reported.
Discussion The Achilles tendon is the widest and strongest tendon in the human body. Ruptures of the Achilles tendon are mostly observed in the 3rd decade of life and in males. Notably, there is not complete agreement about the best surgical technique, incision type, suture material, surgical type, and postoperative follow-up procedure among surgeons [3]. One of the objectives of the surgical treatment is to achieve
Fig. 1
_ Augmentation performed using the Plantaris tendon. 149
Achilles Tendon Rupture Repair
maximum primary stability [4]. For this reason, many studies were performed to either evaluate the results of various surgical techniques or compare the mechanical stabilities of various techniques [4,5]. Hosey et al. [6] reported satisfactory results by employing a modified Lindholm technique, however none of their patients returned to their full preoperative athletic capabilities. While it is not reasonable to reach a reliable conclusion with only one individual from one study, the patient in this case study, who was an active volleyball trainer and sportsman, began running and returned to normal athletic activities six and eight months after the operation, respectively . Jung et al. [7] reported good or excellent results in 27 of 30 consecutive patients treated via the primary repair technique involving limited open surgery. During the procedure, several surgical complications were noted, including re-rupture in two cases, a deep infection in one patient, and sural nerve injury in one patient. All of the patients, with the exception of the three patients with a re-rupture or infection, returned to work two months after the operation, resumed light exercise at three months, and sporting activities at six months. Although these results seem to indicate a successful technique, a 10% failure rate is somewhat significant. We emphasize that this is due to the limited open surgery and lack of augmentation employed in these procedures. However, more satisfactory results were reported using minimally invasive surgery in new achilles tendon ruptures [8]. We also argue that such primary repair techniques should be reserved for fresh ruptures while augmentation procedures should be performed for neglected ruptures or ruptures that are due to complications such as tendinosis. Thus, Lee et al. [9] reported positive results in addition to patient satisfaction following a flexor hallucis augmentation procedure performed in three neglected ruptures after a five-year follow-up period. However, despite these good results, we believe that the technique of flexor hallucis tendon is, at a minimum, more technically difficult than the method we performed. Schönberger et al. [10] reported that when comparing recoveries of patients undergoing primary repair and the Mitek-anchor techniques, it took patients in the Mitek-group longer to return to work and sport activities than in the former group. In addition, a greater loss of strength was observed in the injured leg of patients from the Mitek-group. Mitek-anchors are preferred by some of surgeons but this technique has disadvantages as mentioned previously. Moreover, the instrumentation required for the Mitek-anchor techniques incur
Fig. 2
_ Plantaris and single central split fascia of the gastrocnemius re-
sulted in a fairly strong repair.
additional economic expenses. Notably in our technique, we used only prolene sutures, as opposed to many other studies in which relatively expensive PDS sutures were used. We ultimately achieved an extremely stable closure and the patient was able to return to full preoperative sporting activity. Many surgical procedures have been described for treating acute and neglected achilles tendon ruptures. Primary repair of such ruptures by the percutaneous or the limited open technique is suitable for acute and noncomplicated cases, however, we conclude that neglected ruptures, ruptures due to tendinosis, and ruptures in patients who plan to return to competitive sports activities, need to be augmented. We believe that this study is original because there have been no reports regarding the repair of an achilles tendon rupture using the partial Lindholm technique augmented by the plantaris tendon. Long-term studies of our technique using a higher number of patients should be performed to compare the stability, range of motion, wound healing, and time required to return back to sport activities. Yet, the data reported here are extremely encouraging. Conflict interest statement The authors declare that they have no conflict of interest to the publication of this article.
References 1. 2. 3. 4.
5.
Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br 1989; 71:100-1. Hargrove R, Mclean C. Achilles tendon pathology. eMedicine, 2005. Ersan Ö, Seyfettinoğlu F, Duygun F. Aşil tendon rüptürü:Olgu sunumu. Sted 2004; 13: 352. Gebauer M, Beil FT, Beckmann J, et al. Mechanical evaluation of different techniques for Achilles tendon repair. Arch Orthop Trauma Surg 2007; 127: 795-9. Aktas S, Kocaoglu B, Nalbantoglu U, Seyhan
EAJM: 40, December 2008
6. 7.
8.
M, Guven OJ. End-to-end versus augmented repair in the treatment of Achilles tendon ruptures. Foot Ankle Surg 2007; 46: 336-40. Hosey T, Wertheimer S. A retrospective study on surgical repair of the Achilles tendon. J Foot Surg 1984; 23: 112-5. Jung HG, Lee KB, Cho SG, Yoon TR. Outcome of achilles tendon ruptures treated by a limited open technique. Foot Ankle Int 2008; 29: 803-7. Chan SK, Chung SC, Ho YF. Minimally invasive repair of ruptured Achilles tendon. Hong Kong Med J 2008; 14: 255-8.
9.
Lee KB, Park YH, Yoon TR, Chung JY. Reconstruction of neglected Achilles tendon rupture using the flexor hallucis tendon. Knee Surg Sports Traumatol Arthrosc 2008; 16: 83-5. 10. Schönberger TJ, Janzing HM, Morrenhof JW, de Visser AC, Muitjens P. Operative treatment of acute Achilles tendon rupture: Open endto-end-reconstruction versus reconstruction with Mitek-anchors. Acta Chir Belg 2008; 108: 236-9.
150
