Anatomic Reconstruction of Neglected Achilles Tendon Rupture With Autogenous Peroneal Longus Tendon by EndoButton Fixation

Revision Surgery for the Achilles Tendon

Treatment of Achilles tendon ruptures may be surgical or nonsurgical depending on health, history, age, acuity, and severity of the injury. With chronic or revisional injuries, the best method often requires an open repair with reconstructive soft tissue procedures. Revision surgery can be challenging because of the complexity involving tendinous deficits with nonviable and friable tissue. Surgical treatment is based on tendon approximation, size of the defect, tendon integrity, and functional demands. The goal is to restore anatomic and physiologic tension, provide adequate strength for proper ambulation, optimize functional return to activity, decrease pain, and decrease complications.

Healing ulcers and preventing their recurrences in the diabetic foot

Fifteen percent of people with diabetes develop an ulcer in the course of their lifetime. Eighty-five percent of the major amputations in diabetes mellitus are preceded by an ulcer. Management of ulcers and preventing their recurrence is important for the quality of life of the individual and reducing the cost of care of treatment. The main causative factors of ulceration are neuropathy, vasculopathy and limited joint mobility. Altered bio-mechanics due to the deformities secondary to neuropathy and limited joint mobility leads to focal points of increased pressure, which compromises circulation leading to ulcers. Ulcer management must not only address the healing of ulcers but also should correct the altered bio-mechanics to reduce the focal pressure points and prevent recurrence. An analysis of 700 patients presenting with foot problems to the Diabetic Clinic of Ganga Hospital led to the stratification of these patients into four classes of incremental severity. Class 1 – the foot at risk, Class 2 – superficial ulcers without infection, Class 3 – the crippled foot and Class 4 – the critical foot. Almost 77.5% presented in either Class 3 or 4 with complicated foot ulcers requiring major reconstruction or amputation. Class 1 foot can be managed conservatively with foot care and appropriate foot wear. Class 2 in addition to measures for ulcer healing would need surgery to correct the altered bio-mechanics to prevent the recurrence. The procedures called surgical offloading would depend on the site of the ulcer and would need an in-depth clinical study of the foot. Class 3 would need major reconstructive procedures and Class 4 would need amputation since it may be life-threatening. As clinicians, our main efforts must be focused towards identifying patients in Class 1 and offer advice on foot care and Class 2 where appropriate surgical offloading procedure would help preserve the foot.

Use of the semitendinosus tendon for foot and ankle tendon reconstructions

Objective

To demonstrate the results obtained from foot and ankle tendon reconstructions using the tendon of the semitendinosus muscle. The clinical results, the patient's degree of satisfaction and complications in the graft donor and recipient areas were evaluated.

Methods

This was a retrospective study in which the medical files of 38 patients who underwent this surgical procedure between 2006 and 2010 were surveyed. The functional results from this technique, the complications in the donor and recipient areas and the patients’ degree of satisfaction were evaluated.

Results

Three patients presented complications in the recipient area (skin necrosis); one patient showed complications in the donor area (pain and insensitivity); and all patients had satisfactory functional results, with complete range of motion.

Conclusion

The semitendinosus muscle is a good option for treatments for foot and ankle tendon injuries.

A minimally invasive "overwrapping" technique for repairing neglected ruptures of the Achilles tendon

About 10% to 25% of acute ruptures of the Achilles tendon go undiagnosed for some time beyond what would be optimal for repair and a return to optimal function. Managing these chronic or neglected ruptures is a surgical challenge, because the tendon ends retract and atrophy and could develop a short, fibrous distal stump. In the present report, a patient with a ruptured right Achilles tendon, neglected for approximately 10 years, is described. The chronically injured tendon was successfully treated by overwrapping the interposed scar at the rupture site. This minimally invasive technique restored tension to the tendon, a prerequisite for which was the presence of functional triceps surae, confirmed by identification of gross contraction of the muscle during tiptoeing. The procedure is contraindicated when the scar tissue is not intact and does not have sufficient laxity to allow adequate dorsiflexion of the ankle after overwrapping the tendon or when the triceps surae are nonfunctional.

Combined decellularisation and dehydration improves the mechanical properties of tissue-engineered sinews

Novel sources of replacement sinews are needed to repair damaged tissue after injury. The current methods of repair ultilise autografts, allografts or xenografts, although each method has distinct disadvantages that limit their success. Decellularisation of harvested tissues has been previously investigated for sinew repair with the long-term aim of repopulating the structure with autologous cells. Although this procedure shows promise, the demand for donor scaffolds will always outweigh supply. Here, we report the fabrication of fibrin-based tissue-engineered sinews, which can be decellularised, dehydrated and stored. The sinews may then be rehydrated and repopulated with an autologous cell population. In addition to enabling production of patient-specific implants, interestingly, the process of combined decellularisation, dehydration and rehydration enhanced the mechanical properties of the sinew. The treated sinews exhibited a 2.6-fold increase in maximum load and 8-fold increase in ultimate tensile strength when compared with the control group (p < 0.05 in both cases).

Surgical management of chronic ruptures of the Achilles tendon remains unclear: a systematic review of the management options

BACKGROUND

Chronic ruptures of the Achilles tendon cause marked functional impairment. Given the different repair techniques used, there is a need for a systematic review of the literature to investigate whether these procedure are comparable with one another when performed by experienced surgeons.

SOURCES OF DATA

A systematic literature search using the Medline (Pubmed), EMBASE and CINHAL databases.

AREAS OF AGREEMENT

Provided there are no contraindications, surgery is regarded the best management option.

AREAS OF CONTROVERSY

Most reports are case series with small sample sizes using non-validated measures.

GROWING POINTS

Long-term results of surgical repair procedures are now available.

AREAS TIMELY FOR DEVELOPING RESEARCH

The current literature does not allow clinicians to definitively determine the optimal management modality for chronic rupture of the Achilles tendon. There is a need for randomized controlled trials which use validated functional outcome measures.

Chronic Achilles rupture reconstructed with Achilles tendon allograft: a case report

Chronic ruptures of the Achilles tendon are more difficult to treat than acute tendon rupture. It has been shown that surgical treatment of chronic Achilles tendon rupture provides better functional results than nonoperative treatment. We present a case of neglected Achilles tendon rupture with a 12-cm defect that was repaired using an Achilles tendon allograft with interferential screws to fix the graft in the calcaneus. The patient recovered his ankle function to normal activities after rehabilitation.

Surgical reconstruction of chronic achilles tendon ruptures using various methods

The purpose of this study was to evaluate the surgical outcomes of reconstruction of chronic Achilles tendon ruptures using various methods, including Achilles tendon allograft. Between October 2003 and March 2010, twelve patients with chronic Achilles tendon ruptures and a defect gap of >4 cm underwent surgical reconstruction with V-Y advancement, gastrocnemius fascial turn-down flap, flexor hallucis longus tendon transfer, or Achilles tendon allograft. The study group comprised 11 men and 1 woman. At last follow-up, all patients were assessed with regard to postoperative complications, self-reported level of satisfaction, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score, repetitive single-heel rises, single-leg hopping test, and ankle range of motion. The AOFAS scores increased from an average of 68.7 (range, 50-87) preoperatively to 98.0 (range, 88-100) postoperatively. All patients were able to perform 10 repetitive single-heel raises and single-leg hops at last follow-up. No patient experienced wound complications or deep infection. Seven patients were rated as excellent, 4 as good, and 1 as fair. Chronic Achilles tendon ruptures can be successfully treated by careful selection of the reconstruction method according to the length of defect gap and state of the remaining tissue. With an extensive defect, use of an Achilles tendon allograft can be a good option.