A rare case of tendoachilles rupture at 2 junctions
Introduction :-
The Achilles tendon, commonly known as the heel cord or calcaneal tendon, connects the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus bone at the back of the leg. It is the largest and most powerful tendon in the human body; the fibres of this tendon rotate by 90 degrees internally allowing the tendon to store and release energy through elongation and elastic recoil. The muscles act by means of the tendon resulting in plantar flexion of the foot at the ankle and (apart from soleus) flexion at the knee. A rupture of the Achilles tendon is a partial or complete tear of the tendon connecting the calf muscle and the heel bone. The gastrocnemius and soleus muscles are an essential component of contraction; the weakest point is the blood supply at the union of these two muscles, 2.16 cm above the insertion. The incidence of the Achilles tendon rupture, at this most common site, with a resulting loss of plantar flexion, is about 7 per 100,000 individuals. Tendoachilles tear is more common in middle-aged individuals, especially males, although there have been reports in women involved in sports. Diagnosing an acute tendoachilles rupture is hardly difficult, though the extent of the injury is overlooked by the initial evaluating physician in almost 25% patients. Missing or delaying a diagnosis can be a distressing issue with significant compromise of the clinical outcome. An individual typically narrates a feeling of a sudden snap in the calf or heel or that something struck the calf. Since the acute pain could subside
fairly quickly the patient might defer an evaluation, considering the injury as minor. A careful physical
examination is the foundation of a successful diagnosis of a complete rupture. The three common signs, the Simmonds’ triad, of weakness of ankle plantarflexion, palpable and (often) visible gap in the tendon, and a positive squeeze test are the hallmarks of an Achilles tendon rupture.
Case report :-
This is a case of a 28–year old male patient with a posttraumatic right sided compound grade 3a tear due to an alleged history of fall in the bathroom. In the casualty, the patient presented with an open lacerated wound over the posterior aspect of the right ankle; he did not have history of playing any sports. An ultrasound was performed over the swelling on the right ankle on the same day. There was complete discontinuity of the fibres of the tendoachilles tendon, which were suggestive of complete tear. The posterior tibial artery showed normal colour flow with biphasic spectral waveform pattern, and the posterior tibial vein showed normal colour flow and compressibility. There was no evidence of any free fluid; the underlying bony cortices visualised appeared normal. The clinical diagnosis of tendoachilles tendon rupture was confirmed on the basis of a positive Thompson’s squeeze test and an ultrasound. Radiographs were taken to rule out any bony abnormality (Fig. 2), after which the patient was given a
slab. The patient was then hospitalised on the same day and started on intravenous antibiotics. After 3 days, the patient underwent surgical intervention for the tendoachilles tendon tear. Once taken on the operation table, the patient was placed in the prone position, and a tourniquet was applied. The area to be operated was scrubbed, painted a n d d r a p e d . T h e tourniquet was then inflated to a pressure of
350 mmHg , and an incision was made to expose the tendoachilles tendon. On dissection, contamination of wound was noted, and complete rupture of tendoachilles tendon was seen at both the musculotendinous junction and insertion (Fig. 3). The peroneii muscle and plantaris muscle were found to be cut, blood clots present, margins of the wound were ill-defined, and the edges were ragged. The region was thoroughly washed with normal saline and betadine. A suture anchor of diameter 5 mm was inserted in the calcaneum and confirmed using a c-arm, after which the tendoachilles tendon repair was done. The muscle was then repaired with the suture anchor (Fig. 4). A thorough wash with normal saline and betadine were repeated. Vacuumassisted closure, applied to a pressure of 40 mmHg, was performed using 3-0 Ethlilon. After suturing, the Thompsons test was found to be negative. The patient
tolerated the procedure well and was shifted to recovery Post-operatively a repeat radiograph was repeated to ensure the position of the suture anchor, and was found to be satisfactory (Fig. 5). The patient was given a dorsal slab and strict limb elevation, and was continued on the intravenous antibiotics. The wound dressings were changed on the 2nd and 5th post-operative days and the patient was subsequently discharged.
Discussion :-
We have presented a rare case of a tendoachilles tear at two junctions – the musculotendinous junction and insertion. Very few cases of tendoachilles rupture at multiple joints have been documented. Saxena A and Hofer D presented a case report with one-year follow-up data of a 57-year-old male soccer referee with an acute triple Achilles tendon rupture injury at the proximal watershed region, the main body (mid-watershed area), and an avulsion-type rupture of insertional calcific tendinosis. The patient underwent
surgical intervention with primary repair of the tendon, including tenodesis with anchors. He was postoperatively treated with non-weightbearing for 4 weeks and protected weightbearing until 10 weeks, which was followed by formal physical therapy that included an “anti-gravity” treadmill. The patient returned to full activity after a period of 26 weeks, including running and refereeing, without limitations[9]. Garneti N et al presented a case of bilateral Achilles tendon rupture in a 59-year old male who sustained the tendon rupture under normal physiological load. The patient was treated operatively with V-Y plasty on the left side and a fascial turn down to re-enforce the repair on the right side, with post-operative plaster immobilisation for 12 weeks. Most evidence available in literature report patients with an achilles rupture at a single junction. Hagen M and Pandya NK reported a case series of three young female basketball players over a duration of nine months with complete achilles tendon ruptures that underwent surgery. All the patients presented to the clinic with a common complaint of calf pain in the posterior aspect of their lower leg while playing basketball. Intraoperatively, all three had
degenerative tissue and scar formation suggestive of a chronic nature to their pathology. Six months after surgery, all three athletes were able to return to play and played collegiate basketball.