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DEGENERATIVE TEAR OF TENDO ACHILLES: TREATMENT BY PRIMARY LENGTHENING AND RESUTURING

Hetal A Chiniwala*, Ragjuprasad Verma**, Sushil K Sabnis***
*Registrar; **House Surgeon; ***Honorary; Dept. of Orthopedic Surgery; Harilal Bhagwati Municipal General Hospital, Borivli.

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Acute spontaneous rupture of tendoachilles is very common disabling condition especially after the age of 40-45 yr. The classical mode of treatment i.e. end to end suturing of the cut ends leads to various complications leading to failure due to devitalized cut tendon ends. We studied 10 patients which we treated with excision of the devitalized tendon ends, lengthening of the proximal end of the tendon to refill the gap and primary end to end suturing. This procedure along with a careful postoperative rehabilitation regime gave very good results.

INTRODUCTION

Acute rupture of tendoachilles is common after the age of forty five in India not only in athletes playing badminton, tennis etc. but also in working active individuals, which results in considerable disability to the patients. Our initial experience in treating these patients was to suture the tendon end to end and give a plaster cast. However this led to many dreaded complications which required complex treatment leading to considerable morbidity to the patients. After going through the literature we decided to change the mode of treatment and started doing excision of the ruptured ends, primary lengthening and resuturing of the tendon. Following is the study of 10 patients treated by this method which gave us promising results.

MATERIAL AND METHODS

Ten cases were studied. Patients were evaluated; Patients presented either acutely or came after a few days with a disability of inability to walk normally. Clinical presentation was typical and as follows:

Sudden pain and snapping behind ankle after a sudden jerk while playing or otherwise.

On examination : Swelling, tenderness locally, inability to plantarflex the ankle, pain on passive dorsiflexion. Patients also had a marked limp while walking.

We took an X-ray of the ankle to rule out any fractures and to look for calcific deposits in the tendon if any.

Patients were subjected to operative treatment as described here.

Procedure: (see diagram)

Position : Prone

• A midline lazy S shaped incision of around 9 inches along the tendoachilles.
• Thorough debridement of the dead tendon ends and excision of the calcific deposits creating an average gap of 4 to a max. 6 cm.
• An inverted V shaped incision made in the tendinous portion of the tendoachilles below the gastrocnemius belly. The limbs of the V should be one and half times the gap in the tendoachilles with the ankle in the neutral position.
• The V is sutured as Y (as shown in the diagram) and the gap in the tendoachilles closed
  by approximation and suturing of the cut ends by taking two box stitches and a bunnel stitch. The material used was monofilament nylon.
• The paratenon sutured over the tendon.
• Patients put in a plaster cast with ankle in 10-15 degree plantarflexion and knee in 60-80 degree of flexion for 4 weeks. After 4 weeks the sutures are removed and mobilization started. Weight bearing is avoided for about 6 weeks maximum.

Post operative Rehabilitation

1. Gradual increase in weight bearing.
2. Simple exercises like tip toeing initially with support and later without support.
3. Range of motion exercises.
   

RESULTS

Results were evaluated on following criteria.

1. Post operative wound complications.
2. Post operative pain on walking.
3. Strength of tendoachilles.
4. Independent tiptoe stance.
5. Range of motion at ankle.
6. Gait.

Results were graded by the following criteria.

1. Restriction of movement of dorsiflexion

Fig. 1: V-Y repair of neglected rupture of tendoachilles regrawn from Abraham and Pankowich JBJS 57 (A) 2, 253 1975.

25% - Very Good
50% - Good
100% - Bad

2. Limp

Absent - Very Good
Mild to moderate - Good

3. Push off while walking comparison with the pre operative status as experienced by the patient.

Significant improvement : Very Good
Some improvement : Good
No improvement : Bad

Results

Very good - 8 cases
Good -2 cases
Bad Nil

Complications

1. Keloid formation : 2 cases
2. Wound dehiscence : Nil

DISCUSSION

Our initial experience of tendoachilles was to repair the tendon by end to end suturing of the cut ends. However we found many dreadful complications like sloughing off of skin over the tendon, sloughing of the dead tendon ends and rerupture etc. Hence we reviewed the literature to find out the possible causes and the satisfactory solutions.

We found out the following:

1. Lagergren and Lindhoim : They noted that area of tendoachilles 2 to 6 cm above the calcaneal insertion had the poorest blood supply. [3]
2. Carr and Norris : They demonstrated that the midsection of the tendon is the part where there is reduction in the percentage and number of blood vessels, thus more prone to rupture. [2]
3. Tendoachilles is devoid of a true synovial sheath and has only a paratenon which is more prone to inflammation. Biomechanical factors like overstraining, sudden jumping, twisting are also the cause of the rupture.
4. Mark Scioli state that there is always a dilemma regarding the reapproximation of the tendon ends. [4]
5. In most of the cases with acute ruptures, mucinoid degeneration and lipomatous infiltration and fibrillation in the tendon was seen.
6. Turco and Spinelli identified following factors that challenge successful repair of the tendoachilles. [4]

   i. Suturing of the shredded tendon.
   ii. Re establishment of the physiological tension.
   iii. Revitalization of the ischaemic injured tendon.
   iv. Weakness associated with the lengthened tendon.
   v. Difficulty in obtaining a secure fixation when the insertion is avulsed from thecalcaneal tuberosity.

Thus it is evident that there is combination of multiple factors that results in weakening of the tendon substance resulting in the tear. This proves that the ruptured tendon ends are a compromised tissue with element of hypovascularity of degeneration and suturing these would result in delayed and compromised healing.

Hence we decided to repair in such a way so as to provide sufficient vascularity to the sutured tendon. This led us to the procedure above. The results confirmed our faith in the procedure.

CONCLUSION

The ruptured tendon ends are always a compromised tissue which does not heal in time and physiologically.
In treating degenerative rupture of tendoachilles whether fresh or old the Gold standards are:

1. Primary debridement of the tendon ends, more in proximal portion and less in the distal portion.
2. Lazy S incision which prevents sloughing off of the skin.
3. High tendoachilles lengthening with end to end suturing of the live cut ends of the tendon.

REFERENCES

1. Abraham E, Pankovich. Neglected rupture of Achilles tendon by V-Y tendinous flap. JBJS 1975; 57A (2) : 253-5.
2. Carr AJ, Norris SH. The blood supply of calcaneal tendon. JBJS 1989; 71B (1) : 100-1.
3. Lagergren C, Lindholm A. Vascular distribution of Achilles tendon. Acta Chir Scandinav 1958; 116 : 491-5.
4. Orthopedic Clinics of North America. Jan. 1994; 25 : 1.
   

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