A Case of “Fresh Rupture” after Open Repair of a Ruptured Achilles Tendon
Article Outline
Abstract
We present the case of Achilles tendon rupture in a 54-year-old man while rehabilitating after end-to-end open repair of an acute Achilles tendon rupture. Re-rupture after surgical repair of Achilles tendon is well known. The present case, however, is atypical, because the second rupture occurred significantly proximal to the first rupture. To our knowledge, this is the first time this has been described in English language studies. We have termed this incident a fresh rupture. A gastrocnemius turndown flap was used to repair the fresh rupture, which led to a satisfactory recovery. This case report serves to inform surgeons of the existence of this type of Achilles tendon rupture, while considering the possible etiologies and suggesting a technique that has been shown to be successful in the present case.
Level of Clinical Evidence: Level 4
Keywords: ankle, calcaneus, re-rupture, surgery, trauma
Rupture of the Achilles tendon is a relatively common and serious injury, with the incidence reported at 7/100,000 (1). Rupture tends to affect men aged 30 to 50 years who engage in intermittent physical activity (2). Management of acute Achilles tendon rupture is controversial. The choice is between nonoperative, involving immobilization or functional bracing, or operative with an open or percutaneous technique. Debate is ongoing concerning the best choice of treatment, with a lack of consensus in published reports. However, to date meta-analyses suggest that operative techniques have a lower rate of re-rupture, around 3%, compared with approximately 13% using nonoperative methods 3, 4. Classically, re-rupture occurs at the site of the previous rupture.
We present a case of re-rupture of the right Achilles tendon occurring in a man who was rehabilitating postoperatively for a previous Achilles tendon rupture. We termed this second rupture a fresh rupture because the site of the second rupture was significantly proximal to the first rupture (Fig. 1). Seemingly, the only other report of a fresh rupture to date was a German case report from 1983 (5).
Fig. 1
Intraoperative view showing sites of first and second (“fresh”) rupture.
Given the rarity of this injury, it is unsurprising that a surgical technique for repair of a fresh rupture has not yet been described. In the present case, the surgeon used a gastrocnemius aponeurosis flap to augment the end-to-end repair.
Case Report
The 54-year-old man had ruptured his right Achilles tendon while playing soccer. He was promptly treated with an open end-to-end repair with a modified Kessler’s suture. This initial rupture lay 5 cm above the tendinous insertion. He left hospital the day after the operation and was followed up as an outpatient.
His initial rehabilitation was unremarkable, and he made good progress. His plaster cast was removed after 8 weeks. He then underwent formal physiotherapy and was allowed to weight-bear as tolerated, with the aid of crutches. However, at 10 weeks postoperatively, the patient was performing a calf stretching exercise when he briefly lost his balance, stumbled, and heard an audible snap. Subsequently, he could palpate a gap in the posterior aspect of his lower right leg. Prompt assessment by the surgeon confirmed a rupture of the right Achilles tendon.
Because the patient desired surgical repair, he underwent another operation 2 weeks after the fresh rupture. The patient was positioned prone and underwent general anesthesia. A medial incision along the scar from the first operation exposed the fresh rupture, situated about 3 cm proximal to the previous rupture and 8 cm from the tendinous insertion (Fig. 1).
The previous rupture appeared to have healed well. The severed ends of the tendon were debrided. Next, a large strap of the Achilles tendon aponeurosis (10 cm × 2 cm) was fashioned (Fig. 2). A 2-cm horizontal incision was then made through the full thickness of the gastrocnemius-soleus complex 2 cm proximal to the severed end of the proximal segment of the tendon. The aponeurosis flap could then be turned back on itself and passed through the incision from posterior to anterior. Interrupted sutures ensured the incision in the fascia would not lengthen under tension.
Fig. 2
Achilles tendon aponeurosis flap.
A 2-cm horizontal incision was then made in the distal portion of the Achilles tendon, distal to the previous rupture. The aponeurosis strap could then be passed through the incision from anterior to posterior, before being turned back, over the site of the first rupture (Fig. 3). Heavy absorbable suture was used to approximate the strap and tendon, with the foot in full plantar flexion. A satisfactory approximation of the ruptured ends of the tendon was achieved using absorbable sutures. The surgeon used absorbable sutures owing to concern about infection and poor skin incision healing, because this was a revision operation. Finally, the cut edges of the aponeurosis were approximated (Fig. 4). Subcutaneous fat and skin were closed with absorbable and nonabsorbable sutures, respectively. A below the knee cast was used to immobilize the foot in an equinus position for 2 weeks.
Fig. 3
Schematic of sagittal section of route of aponeurosis flap.
Fig. 4
Strap approximated to distal tendon and aponeurosis closed.
The patient experienced no acute postoperative complications and was discharged the following day. He was encouraged to undertake non–weight-bearing mobilization for the first 6 weeks postoperatively. From weeks 6 to 9 postoperatively, he was allowed to partially weight-bear with the cast on. At week 9, his cast was changed for an ankle brace, and he was encouraged to bear more weight. This brace was removed at 12 weeks postoperatively, and he was allowed to fully weight bear with crutches.
At his last follow-up visit, 15 months postoperatively, the patient had made good progress. He had returned to work, which involves negotiating ladders. Clinically, he could perform a single heel raise and had 10° of dorsiflexion and good subtalar joint movement. The complications experienced included a sural nerve palsy reported from 10 days postoperatively and a reduced range of motion of the ankle. The patient also reported some ankle instability from 18 weeks postoperatively that was well treated with a shoe insole with a lateral heel flare. Overall, the patient seemed pleased with his outcome, despite these complications.
Discussion
Based on an extensive search of the published studies, there appears to have been only 1 previous report of a fresh rupture of the Achilles tendon following an earlier repair (5). In that German case report, the investigator outlined 2 cases of fresh rupture after end-to-end repair, 1 with a rupture 1 cm distal to the first and 1 at the osseous insertion of the tendon. Aside from these cases, it remains clear that “fresh rupture” is uncommon and until now had not been described proximal to the first rupture.
Given the current lack of consensus regarding the etiology of rupture of the Achilles tendon, it would not be feasible to make any strong conclusions concerning the causes of this fresh rupture. However, it is thought that Achilles tendon rupture often results from a combination of mechanical stress and intratendinous degeneration (2). Thus, we have considered the influence of these factors in the present case.
We first considered the mechanical influence on both ruptures. Because the first injury occurred during sport (soccer), it seems logical that a mechanical cause was largely to blame. Barfred (6) suggested that if the tendon is obliquely loaded, which occurs commonly in soccer, even healthy tendons could rupture (6). Studies have found that most Achilles tendon ruptures occur during a sporting activity (7). In particular, it is thought that the onset of muscle fatigue predisposes to rupture (2), and most patients have admitted to being “out of shape” at the time of the injury (8). It is fair to describe the patient in the present case was not at peak fitness. Considering the fresh rupture, Arner and Lindholm (9) proposed that sharp dorsiflexion of the ankle with strong contraction of the triceps surae is a common mechanism for Achilles tendon rupture. It is probable that this strain could have been exerted, because the patient stumbled during his calf stretching exercise. The reduced level of activity of the patient, as he recovered from his first rupture, could have been a factor leading to his fresh rupture. It has been postulated that on returning to exercise after a time of reduced activity, a lack of muscular coordination can lead to greater forces across the tendon, predisposing it to rupture (8). Experiments on rats have supported this theory, showing an increased frequency of ruptures after a period of inactivity (6). In summary, it appears that mechanical factors played a large part in the etiology of both ruptures.
It is known that intratendinous degenerative changes have occurred before rupture in almost all cases (10). Thus, if we consider the 2 ruptures as independent of each other, one could imagine the patient might have a known risk factor for intratendinous degeneration or damage, leading to the ruptures. Some studies have implicated the use of fluoroquinolone antibiotics with tendon injury (11). However, to our knowledge, the patient’s most recent exposure to such drugs was a 12-day course of ciprofloxacin (500 mg/day) 18 months before his first rupture. Given the interval between the drug exposure and injury, it seems unlikely to have been a factor influencing the ruptures. The patient had not been treated with any other drugs linked to rupture of the Achilles tendon, such as corticosteroid therapy (12). At the occurrence of the fresh rupture, he was only taking lisinopril and co-codamol. Before the patient’s first rupture, he had not reported any local or systemic symptoms indicative of any systemic or tendon pathologic features that might have predisposed the tendon to rupture. Thus, in the present case, just as with most Achilles tendon ruptures, no clear degenerative factors seemed to be present (10).
One could also consider that the first rupture might have accelerated the degeneration of the tendon, predisposing it to the fresh rupture. Clearly, the blood supply to the tendon could have been compromised during the first injury and its subsequent management. It is thought that the reduced vascularity could hinder healing of the tendon, leading to degenerative changes and an increased risk of rupture (13). To date, the blood supply to the Achilles tendon has not yet been fully established; however, research suggests the mid-portion is relatively hypovascular (14). It is in this mid-portion that the first rupture occurred, and most ruptures are found in this area (15). Because the fresh rupture did not lie in this mid-portion, one could conjecture that the initial rupture or its treatment led to a reduced blood flow superior to the mid-portion and thus influenced the fresh rupture. In addition, the patterns of reduced activity followed by increasing activity, such as during the patient’s injury and rehabilitation, have been shown to result in intratendinous degeneration (16).
Several techniques have been described using the gastrocnemius aponeurosis since Christensen’s first account in 1953 (17). However, in the present case, we used a method we had used previously for neglected ruptures with good success. The technique could be thought of as a modification of a simpler procedure described by Gerdes et al (18).
In the biomechanics of the surgical technique described, the aponeurosis flap acts to counterbalance the intratendinous degeneration and necrosis that affects ruptured tendons diffusely, impeding successful healing by organization (19). It is probable that the Achilles tendon in the present case was severely degenerate, making end-to-end repair alone less suitable. The technique also respects those who believe that end-to-end repair alone is inappropriate for re-ruptures owing to the increased tension on the sutured tendon ends after debridement (10). Furthermore, passing the flap through the tendon will help limit the bulk of the repair, which can hinder wound closure in aponeurosis turndown-based techniques (20). A shortcoming of the operation could include weakening of the tendon by the incisions created through it. Also, the sural nerve palsy our patient experienced is important.
The present case has demonstrated that re-rupture of the Achilles tendon can occur at sites other than that of the first rupture after operative repair. This can occur in a seemingly typical patient with no clear risk factors for recurrent rupture. In the present case, the rupture was adequately repaired using an open operative procedure with an aponeurosis flap turndown.
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PII: S1067-2516(11)00254-7
doi:10.1053/j.jfas.2011.05.004
© 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
