G Model
JINJ-6204; No. of Pages 4 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap B. Corradino *, S. Di Lorenzo, C. Calamia, F. Moschella Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sez. Chirurgia Plastica, Universita` di Palermo, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 2 May 2015
Background: Achilles tendon ruptures are becoming more common. Complications after open or minimally invasive surgery are: recurrent rupture (2–8%), wound breakdown, deep infections, granuloma, and fistulas. The authors expose their experience with a personal technique. Materials: In 8 patients with acute rupture of Achilles tendon the surgery was performed at least 25 days after trauma. Clinical exam and MR demonstrated in all case a total lesion of tendon. After a posterolateral skin incision the tendon stumps were debrided and suture in end-to-end fashion. A tendon flap was harvested from the proximal part of the tendon, in order to protect and reinforce the suture itself. A plaster cast was applied for 3 weeks and the patients started the rehabilitation protocol. Results: After 4 months all patients returned to pre-injury daily activities. The mean follow up was 13 months (ranged between 6 and 24 months). No major complications occurred. Conclusion: The posterolateral skin incision, not above the tendon, preserves the vascularity of the soft tissues, allows identifying and not accidentally injuring the sural nerve, and prevents the cutaneous scar is overlapped the tendon. In this way is favoured physiological tendon sliding. The preparation of the flap tendon does not weaken the overall strength of the tendon and protects the tendon suture. The tension on sutured stumps is less than being spread over a larger area. In our sample of 8 patients the absence of short-and long-term complications and the rapid functional recovery after surgery suggest that the technique used is safe and effective. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Achilles tendon rupture Surgical treatment of tendon rupture, Achilles tendon injury
Introduction The Achilles tendon is the strongest tendon in the body. Defects or rupture of the Achilles tendon are most commonly due to trauma and is a common injury in middle-aged athletes [1]. The incidence of acute ruptured Achilles tendon has increased during the past decade reflecting the greater prevalence of people who are involved in sports. Although some authors still prefer the conservative method of treatment, open surgical repair is very common. Controversy still exists as to whether this injury should be treated operatively or non-operatively. Non-operative treatment is associated with an increased rate of tendon re-rupture (rates between 8 and 35%). Surgical repairs of Achilles tendons have shown a lower rate of re-rupture (1–5%) and superior functional results compared with that after conservative treatment by cast [1–4]. * Corresponding author at: Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sez. Chirurgia Plastica, Universita` di Palermo, Via del Vespro 127, 90129 Palermo, Italy. Tel.: +39 091 655 4034; fax: +39 091 6553776. E-mail addresses: [email protected] (B. Corradino), [email protected] (S. Di Lorenzo).
At present, surgical treatments for the repair of acute Achilles tendon ruptures are: open surgery and minimally invasive technique as percutaneous and endoscopic techniques. Percutaneous techniques to repair acute traumatic Achilles tendon ruptures are gaining more popularity amongst foot and ankle surgeons. There have however been concerns that this technique carries a risk to sural nerve injury. However the risk of nerve injury persists even with the use of specific devices (as Achillon) [5]. Operative repair of Achilles tendon rupture is often recommended for younger active patients and for athletes. Reported complications of operative repair are superficial or deep wound infections, granuloma, fistula, skin or tendon necrosis, scar adhesions to the underlying tendon, and sural nerve damage [1–7]. The authors report their experience in the surgical treatment of 8 acute Achilles tendon ruptures with excellent functional longterm results. The described technique allowed the repair of Achilles tendon defects up to 5 cm using the proximal part of the tendon (as turn down flap) to reinforce the end-to-end suture of the tendon stumps.
http://dx.doi.org/10.1016/j.injury.2015.05.014 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Corradino B, et al. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.014
G Model
JINJ-6204; No. of Pages 4 B. Corradino et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
All patients were taken into the operating room for surgical treatment within 25 days after injury (average 19.3 days; range 14–25 days). A block of sciatic and femoral nerves was delivered using naropine 7% injection (40 ml). The patients were placed into a prone position. A posterolateral approach was used to expose the tendon rupture and to avoid further vascular damage of the skin over the defect. On the skin, the extremities of the tendon were marked. In the majority of cases the site of rupture was 3–3.5 cm above the insertion of the os calcis. The main gap was 2.47 cm. Surgical technique
Fig. 1. MR after the trauma showed the Achilles tendon rupture.
Materials and methods From 2009 to 2013 we treated eight patients with a complete rupture of the Achilles tendon sustained few days previously the surgery during sport activities (almost all). In 3 patients the right Achilles tendon was interested, in 5 the left. The most common symptom is stabbing pain in the lower calf at the time of injury. Some also report an audible snap. Walking without pain is impossible especially when trying to push off the toe. Swelling occurs. Standing on tiptoe of the injured foot may also be impossible. In all patients, mean age 36.7 years-old (range 28–54 years), moderate oedema in the posterior ankle and a palpable defect in the Achilles tendon were evident. A Thompson test confirmed a rupture of the Achilles tendon. Confirmation of a rupture of the tendon was performed by a clinical examination and then confirmed by magnetic resonance image (MRI) scans (Fig. 1). The MRI was performed on all patients. MRI evaluation was particularly useful to determine the length of the rupture to be repaired in addition to the severity and exact location of the rupture along the course of the tendon and the location of the tendon stumps. The tendon gap ranged between 1.8 cm and 3 cm in length (Table 1).
A tourniquet was used. A straight skin incision was made, starting from the posterior aspect of the heel up to the middle of the calf, slightly more laterally, in order to preserve the lesser saphenous vein, the sural nerve and the skin blood supply, avoiding scarring over the tendon. In Fig. 2 the steps of the surgery are clearly outlined. In 6 cases there was a haematoma at the rupture site near the tendon gap. The surgical approach (Fig. 2) to the ruptured tendon was extended slightly proximally and distally to the margins of the rupture. The Achilles tendon and the lower part of the gastrocnemius were exposed by a curved skin incision. The tendon ends were debrided (Fig. 3a). A tendon strip, as a tendon flap, was harvested from the proximal part of the tendon, according to the method described in literature [4] for the treatment of neglected Achilles tendon rupture (Fig. 3b). A tendon flap approximately 2.0 cm wide and 7–8 cm long was cut from the lateral side of the proximal part of the Achilles tendon, when the tendon-flap was freed, it was turned over to cover the tendon defect (overturned). The base of the flap is placed 3–4 cm above the line of the tendon rupture (Fig. 2). The tendon stumps were sutured with 2–0 nylon, thread which provides suitable tension with the ankle at the maximum plantar flexed position. Kessler suture was used. When the tendon had been sutured, the strip of tendon was overturned to cover the suture line in the tendon and was fixed to the proximal and distal stumps with a few interrupted sutures of nylon (Fig. 3c and d). Finally, the subcutaneous tissue, and the skin were sutured. Care was taken during the procedure to avoid damage to adjacent neurovascular structures, in particular, the sural nerve. For the first 15 days after surgery, the ankle was immobilized by a plaster cast with the ankle in a 308 plantar flexed position (equines position). Results The postoperative management was important. Movement of the knee was encouraged as soon as possible. Two weeks after the
Table 1 Patient age, cause of injury, time between trauma and surgery, the size of the tendon gap identified during the surgical exploration and follow-up. Age of patient
Side
Cause of injury
Time between injury and surgery (days)
Gap (cm)
Follow-up (months)
36 32 48 54 28 29 30 37 Mean age 36.75
Right Left Left Left Right Right Left Left
Fitness Misstep Climbing stairs Workroom Football Volleyball Falling from the top Football
22 16 24 18 14 16 25 20 Average time between injury and surgical repair 19.3 days
2.5 1.8 2.5 2 2 3 3 3 Mean gap 2.47 cm
24 12 6 6 18 16 12 12 Mean follow up 13 months
Please cite this article in press as: Corradino B, et al. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.014
G Model
JINJ-6204; No. of Pages 4 B. Corradino et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
3
Fig. 2. Steps of surgery.
operation, passive mobilization was performed by the surgeon and the plaster cast was applied again for another 7 days. Three weeks after the operation, the plaster cast was removed, and all the patients started passive mobilization exercises and begun active range-of-motion exercises of the ankle. The patients were instructed to perform isometric contraction of the gastrocnemious–soleus complex early in the rehabilitative process.
Patients were advised to increase weight-bearing gradually. Full weight-bearing was allowed after 5 weeks. Sport activities were not allowed for 3 months after the operation. In all cases the surgical technique employed restored the tendon length. The mean follow up was 13 months (min. 6 months, max. 24 months). In one patient, after 3 weeks postoperatively,
Fig. 3. (a) Skin incision and tendon stumps debridement. (b) End-to-end suture of the tendon stumps. (c) Tendon flap harvested. (d) Tendon flap overturned and sutured.
Please cite this article in press as: Corradino B, et al. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.014
G Model
JINJ-6204; No. of Pages 4 B. Corradino et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
4
and by prolong the period of morbidity. This is like to be attributed to poor vascularization tendon and the overlying soft tissue. Our technique provides coverage of the end-to-end tendon suture with a strip of tendon folded to cover and protect the suture itself. The rapid functional recovery after this surgery shows that the preparation of the flap tendon from the proximal portion of the Achilles tendon does not weaken the tendon itself nor its overall strength to strength. Our experience suggests that this technique is indicated for the treatment of the acute rupture of the Achilles tendon and could be employed for the treatment of old ruptures with a gap between the tendons ends lower than 5 cm in length (caused by tendon retraction). The immobilization of tibiotarsic articulation in plantar flexion (20–308) for no more than 3 weeks and also the early passive and active mobilization could reduce the tenocutaneous adhesion due to the scaring, thus preserving the tendineous ability of sliding under the skin. As reported in literature open surgical repair is the most effective method to restore anatomy and function. The posterolateral skin incision, not over the tendineous defect, should preserve the skin vascularization, thus facilitating the tendon healing, preventing adhesion between skin scar and tendon scar and preventing other local complications (as granuloma for example). No re-rupture, in a mean follow-up of 13 months, was observed. This makes the technique potentially safer than the closed techniques, the minimally invasive or the open techniques involving the simple reapproximation of the tendon stumps. The limitations of this study are essentially the small number of patients and the short follow-up. The local ethics commission approved this study and the publication of the work. Fig. 4. Outcome after 8 weeks.
there has been a cutaneous suture dehiscence that required only a debridement and a stitch. No patients have shown signs of infection or granulomas in the weeks following the operation. No case of re-rupture. The patients reported no pain, (NRS pain between 0 and 2), no stiffness or tenderness in the ankle, no limitation in recreational or daily activities and no footwear restrictions (Fig. 4). Active ankle motion was good. Patients returned to pre-injury daily activities by the fourth postoperative month. All patients are satisfied. Satisfaction was assessed through observations and interviews conducted during hospitalization and 1 and 4 months after surgery. Conclusions The described technique allowed the surgical repair of Achilles tendon defects up to 5 cm using the proximal part of the tendon to reinforce the end-to-end suture of the tendon stumps. The first step of the technique is the suture of the tendon stumps in end-to-end fashion and the turnover of a tendon flap harvested from the residual proximal part of the Achilles tendon to improve the suture line. Simple suture of the tendon stumps, even with the technique of Kessler, may be complicated by the formation of granulomas, infections or fistulas that retard healing
Conflict of interest No conflicts of interest. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. References [1] Winter E, Weise K, Weller S, Ambacher T. Surgical repair of Achilles tendon rupture. Comparison of surgical with conservative treatment. Arch Orthop Trauma Surg 1998;117:364–7. [2] Massoud EIE. Repair of fresh open tear of Achilles tendon tension regulation at the suture line. Foot Ankle Surg 2011;17:131–5. [3] Branch JP. A tendon graft weave using an acellular dermal matrix for repair of the Achilles tendon and other foot and ankle tendons. J Foot Ankle Surg 2011;50:257–65. [4] Takao M, Ochi M, Naito K, Uchio Y, Matsusaki M, Oae K. Repair of neglected Achilles tendon rupture using gastrocnemius fascial flaps. Arch Orthop Trauma Surg 2003;123:471–4. [5] Porter KJ, Robati S, Karia P, Portet M, Szarko M, Amin A. An anatomical and cadaveric study examining the risk of sural nerve injury in percutaneous Achilles tendon repair using the Achillon device. Foot Ankle Surg 2014;20:90–3. [6] Strauss EJ, Isah C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes. Injury 2007;38:832–8. [7] Gigante A, Moschini A, Verdenelli A, del Torto M, Ulisse S, De palma L. Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study. Knee Surg Sports Traumatol Arthrosc 2008;16:204–9.
Please cite this article in press as: Corradino B, et al. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.014
JINJ-6204; No. of Pages 4 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap B. Corradino *, S. Di Lorenzo, C. Calamia, F. Moschella Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sez. Chirurgia Plastica, Universita` di Palermo, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 2 May 2015
Background: Achilles tendon ruptures are becoming more common. Complications after open or minimally invasive surgery are: recurrent rupture (2–8%), wound breakdown, deep infections, granuloma, and fistulas. The authors expose their experience with a personal technique. Materials: In 8 patients with acute rupture of Achilles tendon the surgery was performed at least 25 days after trauma. Clinical exam and MR demonstrated in all case a total lesion of tendon. After a posterolateral skin incision the tendon stumps were debrided and suture in end-to-end fashion. A tendon flap was harvested from the proximal part of the tendon, in order to protect and reinforce the suture itself. A plaster cast was applied for 3 weeks and the patients started the rehabilitation protocol. Results: After 4 months all patients returned to pre-injury daily activities. The mean follow up was 13 months (ranged between 6 and 24 months). No major complications occurred. Conclusion: The posterolateral skin incision, not above the tendon, preserves the vascularity of the soft tissues, allows identifying and not accidentally injuring the sural nerve, and prevents the cutaneous scar is overlapped the tendon. In this way is favoured physiological tendon sliding. The preparation of the flap tendon does not weaken the overall strength of the tendon and protects the tendon suture. The tension on sutured stumps is less than being spread over a larger area. In our sample of 8 patients the absence of short-and long-term complications and the rapid functional recovery after surgery suggest that the technique used is safe and effective. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Achilles tendon rupture Surgical treatment of tendon rupture, Achilles tendon injury
Introduction The Achilles tendon is the strongest tendon in the body. Defects or rupture of the Achilles tendon are most commonly due to trauma and is a common injury in middle-aged athletes [1]. The incidence of acute ruptured Achilles tendon has increased during the past decade reflecting the greater prevalence of people who are involved in sports. Although some authors still prefer the conservative method of treatment, open surgical repair is very common. Controversy still exists as to whether this injury should be treated operatively or non-operatively. Non-operative treatment is associated with an increased rate of tendon re-rupture (rates between 8 and 35%). Surgical repairs of Achilles tendons have shown a lower rate of re-rupture (1–5%) and superior functional results compared with that after conservative treatment by cast [1–4]. * Corresponding author at: Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sez. Chirurgia Plastica, Universita` di Palermo, Via del Vespro 127, 90129 Palermo, Italy. Tel.: +39 091 655 4034; fax: +39 091 6553776. E-mail addresses: [email protected] (B. Corradino), [email protected] (S. Di Lorenzo).
At present, surgical treatments for the repair of acute Achilles tendon ruptures are: open surgery and minimally invasive technique as percutaneous and endoscopic techniques. Percutaneous techniques to repair acute traumatic Achilles tendon ruptures are gaining more popularity amongst foot and ankle surgeons. There have however been concerns that this technique carries a risk to sural nerve injury. However the risk of nerve injury persists even with the use of specific devices (as Achillon) [5]. Operative repair of Achilles tendon rupture is often recommended for younger active patients and for athletes. Reported complications of operative repair are superficial or deep wound infections, granuloma, fistula, skin or tendon necrosis, scar adhesions to the underlying tendon, and sural nerve damage [1–7]. The authors report their experience in the surgical treatment of 8 acute Achilles tendon ruptures with excellent functional longterm results. The described technique allowed the repair of Achilles tendon defects up to 5 cm using the proximal part of the tendon (as turn down flap) to reinforce the end-to-end suture of the tendon stumps.
http://dx.doi.org/10.1016/j.injury.2015.05.014 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Corradino B, et al. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.014
G Model
JINJ-6204; No. of Pages 4 B. Corradino et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
All patients were taken into the operating room for surgical treatment within 25 days after injury (average 19.3 days; range 14–25 days). A block of sciatic and femoral nerves was delivered using naropine 7% injection (40 ml). The patients were placed into a prone position. A posterolateral approach was used to expose the tendon rupture and to avoid further vascular damage of the skin over the defect. On the skin, the extremities of the tendon were marked. In the majority of cases the site of rupture was 3–3.5 cm above the insertion of the os calcis. The main gap was 2.47 cm. Surgical technique
Fig. 1. MR after the trauma showed the Achilles tendon rupture.
Materials and methods From 2009 to 2013 we treated eight patients with a complete rupture of the Achilles tendon sustained few days previously the surgery during sport activities (almost all). In 3 patients the right Achilles tendon was interested, in 5 the left. The most common symptom is stabbing pain in the lower calf at the time of injury. Some also report an audible snap. Walking without pain is impossible especially when trying to push off the toe. Swelling occurs. Standing on tiptoe of the injured foot may also be impossible. In all patients, mean age 36.7 years-old (range 28–54 years), moderate oedema in the posterior ankle and a palpable defect in the Achilles tendon were evident. A Thompson test confirmed a rupture of the Achilles tendon. Confirmation of a rupture of the tendon was performed by a clinical examination and then confirmed by magnetic resonance image (MRI) scans (Fig. 1). The MRI was performed on all patients. MRI evaluation was particularly useful to determine the length of the rupture to be repaired in addition to the severity and exact location of the rupture along the course of the tendon and the location of the tendon stumps. The tendon gap ranged between 1.8 cm and 3 cm in length (Table 1).
A tourniquet was used. A straight skin incision was made, starting from the posterior aspect of the heel up to the middle of the calf, slightly more laterally, in order to preserve the lesser saphenous vein, the sural nerve and the skin blood supply, avoiding scarring over the tendon. In Fig. 2 the steps of the surgery are clearly outlined. In 6 cases there was a haematoma at the rupture site near the tendon gap. The surgical approach (Fig. 2) to the ruptured tendon was extended slightly proximally and distally to the margins of the rupture. The Achilles tendon and the lower part of the gastrocnemius were exposed by a curved skin incision. The tendon ends were debrided (Fig. 3a). A tendon strip, as a tendon flap, was harvested from the proximal part of the tendon, according to the method described in literature [4] for the treatment of neglected Achilles tendon rupture (Fig. 3b). A tendon flap approximately 2.0 cm wide and 7–8 cm long was cut from the lateral side of the proximal part of the Achilles tendon, when the tendon-flap was freed, it was turned over to cover the tendon defect (overturned). The base of the flap is placed 3–4 cm above the line of the tendon rupture (Fig. 2). The tendon stumps were sutured with 2–0 nylon, thread which provides suitable tension with the ankle at the maximum plantar flexed position. Kessler suture was used. When the tendon had been sutured, the strip of tendon was overturned to cover the suture line in the tendon and was fixed to the proximal and distal stumps with a few interrupted sutures of nylon (Fig. 3c and d). Finally, the subcutaneous tissue, and the skin were sutured. Care was taken during the procedure to avoid damage to adjacent neurovascular structures, in particular, the sural nerve. For the first 15 days after surgery, the ankle was immobilized by a plaster cast with the ankle in a 308 plantar flexed position (equines position). Results The postoperative management was important. Movement of the knee was encouraged as soon as possible. Two weeks after the
Table 1 Patient age, cause of injury, time between trauma and surgery, the size of the tendon gap identified during the surgical exploration and follow-up. Age of patient
Side
Cause of injury
Time between injury and surgery (days)
Gap (cm)
Follow-up (months)
36 32 48 54 28 29 30 37 Mean age 36.75
Right Left Left Left Right Right Left Left
Fitness Misstep Climbing stairs Workroom Football Volleyball Falling from the top Football
22 16 24 18 14 16 25 20 Average time between injury and surgical repair 19.3 days
2.5 1.8 2.5 2 2 3 3 3 Mean gap 2.47 cm
24 12 6 6 18 16 12 12 Mean follow up 13 months
Please cite this article in press as: Corradino B, et al. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.014
G Model
JINJ-6204; No. of Pages 4 B. Corradino et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
3
Fig. 2. Steps of surgery.
operation, passive mobilization was performed by the surgeon and the plaster cast was applied again for another 7 days. Three weeks after the operation, the plaster cast was removed, and all the patients started passive mobilization exercises and begun active range-of-motion exercises of the ankle. The patients were instructed to perform isometric contraction of the gastrocnemious–soleus complex early in the rehabilitative process.
Patients were advised to increase weight-bearing gradually. Full weight-bearing was allowed after 5 weeks. Sport activities were not allowed for 3 months after the operation. In all cases the surgical technique employed restored the tendon length. The mean follow up was 13 months (min. 6 months, max. 24 months). In one patient, after 3 weeks postoperatively,
Fig. 3. (a) Skin incision and tendon stumps debridement. (b) End-to-end suture of the tendon stumps. (c) Tendon flap harvested. (d) Tendon flap overturned and sutured.
Please cite this article in press as: Corradino B, et al. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.014
G Model
JINJ-6204; No. of Pages 4 B. Corradino et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
4
and by prolong the period of morbidity. This is like to be attributed to poor vascularization tendon and the overlying soft tissue. Our technique provides coverage of the end-to-end tendon suture with a strip of tendon folded to cover and protect the suture itself. The rapid functional recovery after this surgery shows that the preparation of the flap tendon from the proximal portion of the Achilles tendon does not weaken the tendon itself nor its overall strength to strength. Our experience suggests that this technique is indicated for the treatment of the acute rupture of the Achilles tendon and could be employed for the treatment of old ruptures with a gap between the tendons ends lower than 5 cm in length (caused by tendon retraction). The immobilization of tibiotarsic articulation in plantar flexion (20–308) for no more than 3 weeks and also the early passive and active mobilization could reduce the tenocutaneous adhesion due to the scaring, thus preserving the tendineous ability of sliding under the skin. As reported in literature open surgical repair is the most effective method to restore anatomy and function. The posterolateral skin incision, not over the tendineous defect, should preserve the skin vascularization, thus facilitating the tendon healing, preventing adhesion between skin scar and tendon scar and preventing other local complications (as granuloma for example). No re-rupture, in a mean follow-up of 13 months, was observed. This makes the technique potentially safer than the closed techniques, the minimally invasive or the open techniques involving the simple reapproximation of the tendon stumps. The limitations of this study are essentially the small number of patients and the short follow-up. The local ethics commission approved this study and the publication of the work. Fig. 4. Outcome after 8 weeks.
there has been a cutaneous suture dehiscence that required only a debridement and a stitch. No patients have shown signs of infection or granulomas in the weeks following the operation. No case of re-rupture. The patients reported no pain, (NRS pain between 0 and 2), no stiffness or tenderness in the ankle, no limitation in recreational or daily activities and no footwear restrictions (Fig. 4). Active ankle motion was good. Patients returned to pre-injury daily activities by the fourth postoperative month. All patients are satisfied. Satisfaction was assessed through observations and interviews conducted during hospitalization and 1 and 4 months after surgery. Conclusions The described technique allowed the surgical repair of Achilles tendon defects up to 5 cm using the proximal part of the tendon to reinforce the end-to-end suture of the tendon stumps. The first step of the technique is the suture of the tendon stumps in end-to-end fashion and the turnover of a tendon flap harvested from the residual proximal part of the Achilles tendon to improve the suture line. Simple suture of the tendon stumps, even with the technique of Kessler, may be complicated by the formation of granulomas, infections or fistulas that retard healing
Conflict of interest No conflicts of interest. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. References [1] Winter E, Weise K, Weller S, Ambacher T. Surgical repair of Achilles tendon rupture. Comparison of surgical with conservative treatment. Arch Orthop Trauma Surg 1998;117:364–7. [2] Massoud EIE. Repair of fresh open tear of Achilles tendon tension regulation at the suture line. Foot Ankle Surg 2011;17:131–5. [3] Branch JP. A tendon graft weave using an acellular dermal matrix for repair of the Achilles tendon and other foot and ankle tendons. J Foot Ankle Surg 2011;50:257–65. [4] Takao M, Ochi M, Naito K, Uchio Y, Matsusaki M, Oae K. Repair of neglected Achilles tendon rupture using gastrocnemius fascial flaps. Arch Orthop Trauma Surg 2003;123:471–4. [5] Porter KJ, Robati S, Karia P, Portet M, Szarko M, Amin A. An anatomical and cadaveric study examining the risk of sural nerve injury in percutaneous Achilles tendon repair using the Achillon device. Foot Ankle Surg 2014;20:90–3. [6] Strauss EJ, Isah C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes. Injury 2007;38:832–8. [7] Gigante A, Moschini A, Verdenelli A, del Torto M, Ulisse S, De palma L. Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study. Knee Surg Sports Traumatol Arthrosc 2008;16:204–9.
Please cite this article in press as: Corradino B, et al. Surgical repair of acute Achilles tendon rupture with an end-to-end tendon suture and tendon flap. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.05.014
