|Year : 2019 | Volume
| Issue : 4 | Page : 57-60
Spontaneous atraumatic bilateral Achilles tendon tear: surgical reconstruction of flexor hallucis longus graft
Mruthyunjaya Mruthyunjaya, Supreeth Nekkanti, Punith Nanjesh
Department of Orthopedics, Jagadguru Sri Shivarathreeshwara Hospital, Mysore, India
|Date of Submission||02-Oct-2019|
|Date of Decision||12-Oct-2019|
|Date of Acceptance||02-Nov-2019|
|Date of Web Publication||18-Dec-2019|
Department of Orthopedics, Jagadguru Sri Shivarathreeshwara Hospital, Mysore
Source of Support: None, Conflict of Interest: None
Background and objective: Spontaneous atraumatic bilateral Achilles tendon tears are very rare. The most common risk factors for sudden bilateral Achilles tendon tears have been attributed to prolonged corticosteroid use. This study aimed to present the efficiency of surgical reconstruction of bilateral flexor hallucis longus graft on spontaneous atraumatic bilateral Achilles tendon tear.
Subject and methods: This study reported a 25-year-old male who suffered from spontaneous atraumatic bilateral Achilles tendon tear. The patient was surgically managed by surgical reconstruction of bilateral flexor hallucis longus graft and immobilised with above knee cast in plantarflexion for six weeks. The patient was then subjected to physiotherapy at 6 weeks after surgery. This study was approved by the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India.
Results: Flexor strength at the time of removal of the cast was 3/5. After graded physiotherapy targeted at calf strengthening, flexor strength improved to 4/5. At the end of one-year follow-up, foot function recovered well. The Leppilahti score was recorded to be 78 for the right calf and 76 for the left calf at the last follow-up.
Conclusion: Idiopathic spontaneous bilateral Achilles tendon tear was successfully managed by surgical reconstruction of flexor hallucis longus graft.
Keywords: flexor hallucis longus graft; flexor strength; immobilization; spontaneous atraumatic Achilles tendon tear; surgical reconstruction
|How to cite this article:|
Mruthyunjaya M, Nekkanti S, Nanjesh P. Spontaneous atraumatic bilateral Achilles tendon tear: surgical reconstruction of flexor hallucis longus graft. Clin Trials Orthop Disord 2019;4:57-60
|How to cite this URL:|
Mruthyunjaya M, Nekkanti S, Nanjesh P. Spontaneous atraumatic bilateral Achilles tendon tear: surgical reconstruction of flexor hallucis longus graft. Clin Trials Orthop Disord [serial online] 2019 [cited 2020 Apr 2];4:57-60. Available from: http://www.clinicalto.com/text.asp?2019/4/4/57/272835
| Introduction|| |
Achilles tendon is the thickest and strongest tendon in the body. It is able to withstand loads of upto 12 times the body weight. The mechanism of traumatic Achilles tendon tear is due to powerful sudden contraction of the gastrocnemius soleus muscles on a dorsiflexed foot. Spontaneous atraumatic bilateral Achilles tendon tears are very rare. The most common risk factors for sudden bilateral Achilles tendon tears have been attributed to prolonged corticosteroid use due to an underlying chronic disease or local injections of cortisone or prolonged use of fluroquinolones.,,, The purpose of this report is to present a similar case of a 25-year-old male who suffered from spontaneous atraumatic bilateral Achilles tendon tear who was successfully managed by surgical reconstruction of bilateral Achilles tendon. The uniqueness of our report is that there is no real etiology that could explain this injury in our patient and all the possible risk factors have been studied in depth and ruled out.
| Subject and Methods|| |
This report has been submitted after the approval from the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India. This study was conducted in accordance with the Declaration of Helsinki. The patient signed the written informed consent [Additional file 1].
A 25-year-old male patient came with a 1.5-month history of difficulty in walking. He suffered a trivial injury (tripped over a stone) while working in his farm 1.5 months ago following which he had increasing difficulty in walking & noticed a depression on the posterior aspect of both the lower legs above the heel. Patient experienced difficulty in trying to stand up from squatting & cross-legged sitting position. Over the period of 1.5 months, he started having difficulty while standing & had apprehension of falling. The patient was non-smoker, did not consume alcohol. He was diagnosed with hypertension only around two months ago and was taking medicines. He had not been on any other medication in the past.
On examination, a depression was seen in the distal part of Achilles tendon on both sides above the calcaneal insertion. No scars/open wound/discharging sinus was found. Skin over the site was normal, and no signs of inflammation were seen [Figure 1]. On inspection, he was found trying to stand by gripping his toes on the floor. On palpation, there was no local rise of temperature or tenderness. A depression and discontinuity of the Achilles tendon substance was felt 4–5 cm above the calcaneal insertion of Achilles tendon. Thompson test was positive for both legs (more pronounced on the right side). Routine blood investigations were normal. Ultasonography of the affected part showed full thickness tear of bilateral Achilles tendon.
|Figure 1: Depression and swelling of the Achilles tendon near its insertion in the calcaneum.|
Click here to view
The patient was surgically managed by augmentation of Achilles tendon with ipsilateral flexor hallucis longus and immobilised with above knee cast in plantarflexion for 6 weeks [Figure 2]. The patient was then subjected to physiotherapy at 6 weeks after surgery.
|Figure 2: Intraoperative photos.|
Note: (A, B) Achilles tendon tears in the left (A) and right (B) ankles. (C) Identifying the flexor hallucis longus tendon as a graft for reconstruction of Achilles tendon. (D, E) Achilles tendon tear reconstruction using flexor hallucis longus graft in the left (D) and right (E) ankles.
Click here to view
| Results|| |
Post-operative radiograph showed good position of the screw used to fix the graft in the calcaneal tuberosity [Figure 3]. The post-operative period was uneventful and sutures were removed on the 10th day. Both legs were operated staged 6 months apart.
|Figure 3: Post-operative radiographs showing the graft fixed with a screw into calcaneal tuberosity.|
Click here to view
Flexor strength at the time of removal of the cast was 3/5. After graded physiotherapy targeted at calf strengthening, flexor strength improved to 4/5. At the end of 1-year follow-up, the patient was able to toe walk. He was pain free and there was no limitation in performing his activities of daily living. The Leppilahti score was recorded to be 78 for the right calf and 76 for the left calf at the last follow-up.
| Discussion|| |
Achilles tendon ruptures constitute 20% of all large tendon injuries. Males aged 30–50 years are susceptible to Achilles tendon tears. Achilles tendon tears occur most commonly due to a large traumatic force or a minor trauma on a weakened tendon. Majority of tears occur in the watershed area, which is an area of structural weakness approximately 6 cm proximal to its insertion at the calcaneum. Risk factors that may be associated with Achilles tendon ruptures are intrinsic or extrinsic factors. Intrinsic factors include previous trauma, degenerative changes of the tendon, systemic disorders such as Cushing’s disease, rheumatoid arthritis, systemic lupus erythematosus, hyperthyroidism or gout. Extrinsic risk factors include drugs such as corticosteroids,, and fluroquinolones.,
Corticosteroids use has been implicated as the most common cause of bilateral Achilles tendon tear with incidence of almost 90% of the cases. Steroids are believed to alter the collagen structure of tendons causing dysplasia of the collagen fibers and thus reducing the tensile strength of the tendon. They also interfere with collagen fiber cross-linking which also inturn affects the healing of the Achilles tendon tear.,, The dose or the duration of steroid intake has not been reported to contribute to the susceptibility of the tendon to structural failure. There is no concensus in the role of local cortisone injection in inducing spontaneous Achilles tendon tears. Certain reports may indicate the susceptibility of the Achilles tendon to fail after local cortisone injections. Leppilahti et al. reported an incidence of Achilles tendon tear to be only 2% following a local cortisone injection.
Fluroquinolones causing Achilles tendon tear does not seem to be dose dependent. Decreased cell proliferation, increase in matrix-degrading protease activity from fibroblasts and inhibitory effect of fibroblast metabolism have been reported as the pathophysiological mechanism underlying fluroquinolone-induced Achilles tendon ruptures. Vasculitis-induced lower limb ischemia has also been implicated with use of fluroquinolones.
The diagnosis of Achilles tendon tear is usually by clinical symptoms and examination. The most common symptom is the patient hearing a pop sound after a fall with onset of pain in posterior heel and ankle. Patients often are unable to stand on their toes. Clinical palpation along the calf muscle usually reveals a gap or a discontinuity in the substance of the Achilles tendon. Clinical tests reported include Thompsons test, Simmonds test and copelands sphygmomanometer test.
The plain radiography, ultrasonography and magnetic resonance imaging are commonly used to diagnose Achilles tendon tears. Plain radiography is useful in detecting calcifications in the Achilles tendon and avulsion fractures of the calcaneum. Ultrasonography is useful in detecting the discontinuity in the Achilles tendon.,, Magnetic resonance imaging may be used in case of doubtful diagnosis and to precisely localize the tear and the extent of the tear.
Surgical repair or reconstruction of the Achilles tendon is the preferred treatment for Achilles tendon ruptures, because it allows earlier motion, increases strength of the ankle and allows the patient to return to work sooner., Complication rates are much lower with surgery compared to conservative management. Many operating techniques have been described.,,
Open end-to-end repair is the most commonly used treatment. In chronic tears, or if the cut ends of the Achilles tendon are retracted or fibrosed and the surgeon feels that end-to-end healing may be poor, the Achilles tendon reconstruction by using a graft such as flexor hallucis longus tendon may be considered. Surgical management of Achilles tendon has reported much lesser complications compared to conservative management. The re-rupture rate after surgical repair is as low as 2.2% compared to 9.8% when managed conservatively. Return to work is earlier with surgical management and higher plantar flexion strength is also observed with surgical repair.,
Open surgical repair is associated with complication rates of 11.8% to 21.6% when compared to conservative management which has ranged 4–10%.,,, Wound sepsis is the most common complication reported. Superficial deep vein thrombosis, chronic fistula, pulmonary embolism and death have been reported. Minor complications included superficial infection, wound hematoma, delayed wound healing, skin necrosis and chronic pain. Percutaneous Achilles tendon repair has gained popularity versus open repair due to reduced skin-related complications and comparable functional results as open repair.,
| Conclusion|| |
This study reported a rare case of idiopathic spontaneous bilateral Achilles tendon tear successfully managed by surgical reconstruction using flexor hallucis longus graft. Common etiologies of spontaneous bilateral Achilles tendon tears usually include systemic disorders such as Cushing’s disease, rheumatoid arthritis or use of drugs such as corticosteroids or fluroquinolones. Our patient did not fit into any etiological group and hence it is rare. The reconstruction of the Achilles tendon has a good effect.
Additional file 1: Patient informed consent form.
All authors contributed to study design, data collection, paper writing, and approved the final paper.
Conflicts of interest
The authors have no conflicts of interests to declare.
Institutional review board statement
This report has been submitted after the approval from the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India. This study was conducted in accordance with the Declaration of Helsinki.
Declaration of patient consent
The authors certify that they have obtained the patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
This study followed the Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals developed by the International Committee of Medical Journal Editors.
Copyright license agreement
The Copyright License Agreement has been signed by the authors before publication.
Data sharing statement
Individual participant data that underlie the results reported in this article, after deidentification (text, and tables), will be available upon request. Data will be available immediately following publication, no end date for anyone who wishes to access the data. In order to gain access, data requestors will need to sign a data access agreement. Proposals should be directed to email@example.com.
Checked twice by iThenticate.
Externally peer reviewed.
Open access statement
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
P-Reviewers: Zhu LW, Yue W; S-Editor: Li CH; L-Editors: Qiu Y, Wang L; T-Editor: Jia Y
| References|| |
Mehra A, Maheshwari R, Case R, Croucher C. Bilateral simultaneous spontaneous rupture of the Achilles tendon. Hosp Med
Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med
Józsa L, Kvist M, Bálint BJ, et al. The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases. Am J Sports Med
Orava S, Hurme M, Leppilahti J. Bilateral Achilles tendon rupture: a report on two cases. Scand J Med Sci Sports
Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med
Kowatari K, Nakashima K, Ono A, Yoshihara M, Amano M, Toh S. Levofloxacin-induced bilateral Achilles tendon rupture: a case report and review of the literature. J Orthop Sci
Lee WT, Collins JF. Ciprofloxacin associated bilateral achilles tendon rupture. Aust N Z J Med
Habusta SF. Bilateral simultaneous rupture of the Achilles tendon. A rare traumatic injury. Clin Orthop Relat Res
Matsumoto K, Hukuda S, Nishioka J, Asajima S. Rupture of the Achilles tendon in rheumatoid arthritis with histologic evidence of enthesitis. A case report. Clin Orthop Relat Res
Potasman I, Bassan HM. Multiple tendon rupture in systemic lupus erythematosus: case report and review of the literature. Ann Rheum Dis
Garneti N, Holton C, Shenolikar A. Bilateral Achilles tendon rupture: a case report. Accid Emerg Nurs
Kotnis RA, Halstead JC, Hormbrey PJ. Atraumatic bilateral Achilles tendon rupture: an association of systemic steroid treatment. J Accid Emerg Med
Poon CC, Sundaram NA. Spontaneous bilateral Achilles tendon rupture associated with ciprofloxacin. Med J Aust
Kelly M, Dodds M, Huntley JS, Robinson CM. Bilateral concurrent rupture of the Achilles tendon in the absence of risk factors. Hosp Med
Kotnis RA, Halstead JC, Hormbrey PJ. Atraumatic bilateral Achilles tendon rupture: an association of systemic steroid treatment. Emerg Med J
Ofer N, Akselrod S, Nyska M, Werner M, Glaser E, Shabat S. Motion-based tendon diagnosis using sequence processing of ultrasound images. J Orthop Res
Dekens-Konter JA, Knol A, Olsson S, Meyboom RH, de Koning GH. Tendinitis of the Achilles tendon caused by pefloxacin and other fluoroquinolone derivatives. Ned Tijdschr Geneeskd
Maffulli N. Ultrasound of the Achilles tendon after surgical repair: morphology and function. BJR
Krueger-Franke M, Siebert CH, Scherzer S. Surgical treatment of ruptures of the Achilles tendon: a review of long-term results. Br J Sports Med
Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of achilles tendon ruptures. Am J Sports Med
Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture. A review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop Relat Res
Popovic N, Lemaire R. Diagnosis and treatment of acute ruptures of the Achilles tendon. Current concepts review. Acta Orthop Belg
Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon; an angiographic and microangiographic study. Acta Chir Scand
Khanzada Z, Rethnam U, Widdowson D, Mirza A. Bilateral spontaneous non-traumatic rupture of the Achilles tendon: a case report. J Med Case Reports
[Figure 1], [Figure 2], [Figure 3]