Functional and MRI follow-up after reconstruction of chronic ruptures of the Achilles tendon Myerson type III using the triple-loop plantaris tendon wrapped with central turndown flap: a case series

Abstract

BackgroundReconstruction of chronic ruptures of the Achilles tendon poses a great challenge for the orthopaedic surgeon both technically and functionally. The aim of this study was to assess the results of a new technique for reconstruction of chronic Achilles tendon ruptures with defects longer than 5 cm using the triple-loop plantaris tendon autograft wrapped in a central turndown flap from the proximal portion of the Achilles tendon.Patients and methodsEighteen patients (14 female and 4 male; mean age, 40.7 years), having chronic ruptures of the Achilles tendon Myerson type III, were enrolled in this study. The mean follow-up period of our patients was 21.8 months. All patients were assessed via the following parameters: lag of interference since the first complaint, length of the defect, length of the turndown flap and length of the harvested plantaris tendon, surgery time, complications, active range of motion at the ankle and the final score. Average values were presented as means. Independent sample t test, Mann Whitney test, paired sample t test and Pearson’s correlation coefficient were used to evaluate the clinical and functional results. The results were considered statistically significant if a P value was <0.05. To analyse the time course of the gap following surgery, the data from the first MRI session were compared with those from the second and third sessions using the Wilcoxon’s signed rank test. In addition, the paired data of the tendon gap disappearance rate between T1-weighted and T2-weighted images were also compared using the McNemar test.ResultsThe mean preoperative American Orthopaedic Foot and Ankle Society score was 62.2 points while at the patients’ last follow-up, the mean postoperative score was 94.9 points. The results of this study confirmed that both the Achilles tendon healing and tendon gap disappearance have been perceived with higher sensitivity in T2-weighted images than in T1-weighted images.ConclusionsWe believe that this new technique is biologic, synchronous and reliable in cases of chronic Achilles tendon ruptures with defects longer than 5 cm.

Achilles Tendon and Athletes

“…Moreover, acute AT tears can be demonstrated as focal or linear defects particularly on MRI T2 weighted studies. Bony edema and the retrocalcaneal bursa effusion are characteristic for insertional AT ruptures which can be identified on MRI images [85].…”

“…Up to authors' knowledge, there is not yet a consensus on the time-limit after which AT injury could be accurately described as chronic. Generally, AT rupture can be labeled as chronic after 4-6 weeks have passed after the injury [2,6,8,85]. Moreover, cases which did not show healing signs or presented after 4 weeks of initial injury is thought to be "chronic" irrespective of rupture etiology [3,51].…”

“…Furthermore, amount of tissue loss can be measured. Postoperative evaluation of repaired or transferred tissues can be obtained through MRI [85].…”

“…Chronic AT ruptures are categorized into 3 types according to Myerson: type I includes defects under 2 cm; type II which has a defect ranging from 2 to 5 cm; and type III defect which exceeds 5 cm in size [85].…”

“…Tendons of adjacent muscles can be incorporated within AT reconstruction avoiding free graft complications. Sadek et al reported good satisfaction among 18 patients with Myerson type III AT defects following local reconstruction with triple loop of plantaris tendon along with turndown flap [85]. Instead of removing scar tissue filling the tendon defect, Khaimi et al advocated including tubular scar tissue within AT reconstruction procedure.…”