SLR - September 2016 - Timothy Karthas

Reconstruction of Neglected Achilles Tendon Ruptures with Gastrocnemius Flaps: Excellent Results in Long-Term Follow-Up

Reference: Seker A, Kara A, Armagan R, Oc Y, Varol A, Sezer HB. Reconstruction of Neglected Achilles Tendon Ruptures with Gastrocnemius Flaps: Excellent Results in Long-Term Follow-Up. Arch Orthop Trauma Surg. 2016 Jul 11

Scientific Literature Review

Reviewed By: Timothy Karthas, DPM
Residency Program: Mount Auburn Hospital, Cambridge, MA

Podiatric Relevance: Ten to 25 percent of all Achilles tendon ruptures are not appreciated, either because they are misdiagnosed or because they have late presenting symptoms, such as weakness, pain, atrophy or swelling. When this occurs, surgical intervention becomes much more difficult and demanding due to tendon retraction and scar tissue management. While there are numerous techniques described for repairing chronic tendon ruptures, such as allograft, autografts, FHL transfers and more, there are very few studies with long-term outcomes reported and very few comparative studies. This study's primary aim was to present long-term functional outcomes of repairing neglected Achilles tendon ruptures with a gastrocnemius fascial turn-down flap.

Methods: A retrospective review of all patients who underwent repair of neglected Achilles tendon rupture with a two gastrocnemius fascial flap technique were included in the study. Only those patients with at least 10 years of follow-up were included. Each of the included patients were then evaluated clinically at final follow-up, and ROM, calf circumference and heel raise strength were all tested on the affected and contralateral side. VAS, AOFAS and FADI scores were also recorded.  

Results: Twenty-one patients out of 46 neglected Achilles tendon ruptures treated between 1995 and 2010 met inclusion criteria. Of these, all were male, with a mean age of 32.1, and all were participating in recreational sports at the time of injury. The average gap distance was 6.4cm, and the mean follow-up was 145.3 months. There were no reruptures and only one superficial dehiscence in the immediate postoperative period. There was no statistical difference in calf diameter, plantarflexion strength on dynamometer or ROM between the operative and contralateral side at final follow-up. The mean AOFAS score and FADI scores were 98.5 and 98.9 respectively, and VAS was zero for all patients. In fact, all patients returned to their prerupture activities in a mean of 14.1 months after surgery.  

Conclusions: The authors demonstrate that a two fascial gastrocnemius turn-down flap technique is a viable option for neglected Achilles tendon ruptures. Of note, there were no statistical differences by final follow-up in any of their measures. This is an acceptable option for these types of injuries in part because it does not sacrifice other tendons in the process or require allograft material. There are some limitations of this article, primarily the relatively small sample size and the inclusion only of a healthy athletic population. Perhaps the results may not have been as good in a different population, but this article still provides a unique long-term review of surgically repaired neglected Achilles tendon ruptures.

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