SLR - September 2016 - Syed A. Ahmed

Direct Repair of Chronic Achilles Tendon Ruptures Using Scar Tissue Located Between the Tendon Stumps

Reference: Yasuda T, Shima H, Mori K, Kizawa M, Neo M. Direct Repair of Chronic Achilles Tendon Ruptures Using Scar Tissue Located Between the Tendon Stumps. J Bone Joint Surg Am, 2016 Jul 20; 98 (14): 1168–1175

Scientific Literature Review

Reviewed By: Syed A. Ahmed, DPM
Residency Program: New York Presbyterian – Queens, Flushing, NY

Podiatric Relevance: Several surgical procedures have been described for reconstruction of chronic Achilles tendon ruptures that involve resection of the interposed scar tissue and reconstruction using normal autologous tissue. Although such procedures have good clinical outcomes, they are associated with donor site morbidity, are time-consuming and are difficult to perform as compared to primary repair of the Achilles tendon. The authors of this publication describe their surgical procedure and prospectively review its outcomes. They posit a direct repair procedure using interposed scar tissue that can be effectively used to reconstruct chronic Achilles tendon ruptures.

Methods: Thirty patients (average age 52.7, 16 male and 14 female) with Achilles tendon ruptures and delayed diagnosis of >4 weeks underwent resection of scar and healing tissue with direct primary repair without the use of autografts or allografts with mean follow of 33 months. All patients were evaluated preoperatively and postoperatively for clinical outcomes measured with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the Achilles Tendon Total Rupture Score (ATRS). Patients also were assessed preoperatively and postoperatively on functional outcomes and MRI findings. Histological specimens of the interposed scar tissue located between the tendon stumps were also evaluated for each patient. Surgery was performed by one of the authors from 2001–2012. The authors describe the procedure with the patient in a prone position, longitudinal posteromedial incision along the Achilles tendon and deepened through the paratenon and the interposed scar about 2 to 3mm deep. The mean gap between healthy tendon stumps was 43.4mm. The scar tissue between the tendon stumps was resected allowing for reapproximation of the proximal and distal ends with the ankle in 20º to 30º of plantar flexion. The tendon stumps with the interposed scar tissue were repaired using Krackow suture technique with the ankle in 20º to 30º of plantar flexion. Finally, the paratenon, subcutaneous tissue and skin were closed.

Results: At the latest follow-up, no patients had tendon reruptures, difficulty walking or climbing stairs, and all except for 2 patients could perform a single heel rise. All athletes returned to their pre-injury level of sports participation. The mean AOFAS scores were 82.8 points preoperatively and 98.1 points postoperatively. The mean postoperative ATRS was 92.0 points. Preoperative MRI revealed 22 Achilles tendons were thickened with diffuse intratendinous high-signal alterations, and 8 Achilles tendons were thinned. Postoperative MRI revealed fusiform-shaped tendon thickening and homogeneous low-signal alterations of the tendons in all patients. Histologically, the interposed scar tissue consisted of dense collagen fibers.

Conclusions: The authors conclude that based on the functional outcomes, AOFAS and ATRS scores, MRI and histological findings, direct repair of proximal and distal tendon stumps by using interposed scar tissue can be used to reconstruct chronic Achilles tendon ruptures. The clinical outcomes of this operative method were comparable and showed a lower rate of postoperative complications with previously reported outcomes and complications. The study claims that shortening of the elongated scar tissue restored the length of the Achilles tendon; however, no measurable value is given to qualify the assertion. 

Educational Opportunities