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TRAUMATOLOGY Table of Contents   
Year : 2006  |  Volume : 40  |  Issue : 4  |  Page : 262-264
Evaluation of surgical repair of neglected cut injury of tendoachilles by muscle slide


Department of Orthopaedics, Burdwan Medical College, Burdwan, India

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   Abstract 

Background : Late presentation of cut injury of tendo achilles is common in our country. Management of these cases poses a problem.
Method : We present 16 patients of different age groups and both sexes with tear of tendo achilles treated by primary anastomosis of the tendon by muscle slide.
Results : In all patients we had excellent to good results.
Conclusion : This method gives excellent physio- anatomical correction of such defects.

Keywords: Old cut injury tendo Achilles; primary suture by muscle slide.

How to cite this article:
De C, Pal A K, Banerji D, Raman R, Biswas D. Evaluation of surgical repair of neglected cut injury of tendoachilles by muscle slide. Indian J Orthop 2006;40:262-4

How to cite this URL:
De C, Pal A K, Banerji D, Raman R, Biswas D. Evaluation of surgical repair of neglected cut injury of tendoachilles by muscle slide. Indian J Orthop [serial online] 2006 [cited 2020 Jan 17];40:262-4. Available from: http://www.ijoonline.com/text.asp?2006/40/4/262/34509

   Introduction Top


Division of muscle and tendon by a sharp object is common in our country and in open injuries infection is a possibility. In fresh injuries primary anastomosis must be done after would debridement, but in cases delayed by more than one week reconstructive operation is required. Garret et all have shown that after repair of a muscle a dense connective tissue develops at site of repair[1]. Therefore power of muscle is expected to be approx ½ and its contractility to 2 / 3 rd that of an uninjured muscles after repair[2].

Tear of tendo-achillis is quite common in our clinical practice. Further more those cases often present with no or improper primary management complicating the management protocol. Different methods are available to bridge the gap between tendon ends in such old tear like turned down strip of the tendon[3], fascia lata reefing, mobilization of proximal stump and muscles bellies to points of entry of neurovascular bundles. Others have recommended transfer of the peroneus brevis[4], the posterior tibial tendon or flexor digitorum longus. None of the above method provided consistent results.

We describe long term outcome of a technique of late repair of cut-injury by muscles slide of gastroenemius and direct anastomois of tendon ends[5].


   Materials and methods Top


From July, 1992 through August 2002, 16 patients who had a long standing cut-injury of the achilles tendon were treated. There were 6 women and 10 men, and the ages ranged from 16 to 60 year. Duration of follow up ranged from 3 to 13 yrs (avg 8.5 yrs.)

Duration of the symptoms ranged from one to seven months. All had history of injury behind the heel by a sharp object which was not properly treated. Three had moderate swelling and oedema about the posterior aspect of the ankle. All had painful limping with major weakness of active plantar flexion. The Thompson test and O'Brien's needle test was positive in all patients.

Operative technique: The procedure was performed with the patient semiprone and under general anaesthesia, with the use of tourniquet control. A 12 to 13 cm long lazy 'S' incision was made from the musculotendious junction of gastrocnemius and distal to the insertion of the tendon. The tendon sheath was opened at the site of the rupture and scar tissue which was identified by rough surfaces and gritty sensation, was excised. The length of tendon defect was measured after scar resection keeping the knee in 30 0 flexion and ankle in 20 0 plantar flexion. In all cases a gap of average 2.5 centimeters was produced. Distal end was mobilized upto bony attachment and proximal end for a length of 5 to 6 cms. An inverted 'V' incision was made through gastrocnemius bellies just above musculotendinous junction with the arms of 'V' being at least 1½ times longer than the defect. After sliding down of proximal cut end the tendon ends were directly sutured by one modified kessler stitch at the core of the tendon and 4 to 5 intermittent simple peripheral stitches using No. 1 'C' maintaining 20 0 plantar flexion of ankle joint and 60 flexion of knee joint. Tendon sheath and muscle bellies were stitched with one zero Vicryl the later in an inverted 'Y' manner. Skin was apposed by simple stitches with nylon. Post operatively, the foot was placed in approximately 20 0 of equinus angulation and knee in 60 0 of flexion in an above knee-long leg plaster for 6 weeks. After 6 weeks, equinus angulation was reduced to approx 10 0 and further immobilization for 4 wks in a below -knee plaster after removal of stitches. After that period weight bearing was allowed using 2 cm raised heel shoes for six months. Range of motion and strengthening exercises were initiated at this time [Figure - 1],[Figure - 2].


   Result Top


The final result was assessed by calf circumference to measure wasting which is almost invariably persistent, range of movement of ankle joint and calf power assessed by standing on tip toes [Table - 1]. Accordingly, the cases were graded as excellent, good, fair and poor. There were excellent results in six and good in nine and one in one patient. Two patients developed post operative sloughing of skin of which one recovered with good results after rotational skin grafting and another showed fair result due to uncontrolled recurrent infection with long standing discharging sinus leading to complaint of slight pain and swelling and limp.


   Discussion Top


The patients who have a chronic rupture or old cut injury need operative intervention in order to obtain an optimum result[7]. In a neglected tendon rupture or injury there is fixed retraction of proximal end and with scarring at the site of rupture which bridges the gap that often results in functional lengthening of the tendon and shortening of triceps surae muscle bellies.

Single most important characteristic of muscle fibers is that its capacity to produce tension depends on its, length at the moment of excitation. Once a fiber shortens to less than its rest length, its ability to produce tension diminishes, if the fiber is 60% of rest length, it produces no tension. When a neglected injury of calceneal tendon heals with lengthing of tendon and shortening of muscle bellies ability of triceps surae to produce tension is altered[8].

The patient tends to walk on the heel without push off hence; physioanatomical correction can be done by V-Y technique of tendon shortening utilizing bridging scar tissue or reconstitution of optimum length of muscle tendon unit by performing repair with proximal stump pulled down. We opted here for second choice with modifications.

 
   References Top

1.Garrel AD, Norris SH. The blood supply of the caledneal tendon. J Bone Joint Surg (Br). 1989; 71:100-102.  Back to cited text no. 1    
2. Garden DC et al. Rupture of the calcaneal tendon. J Bone Joint Surg (Br). 1987; 69: 416-20.  Back to cited text no. 2    
3. Barnes MJ, Hardy AE. Delayed reconstruction of the calcaneal ten­don: J Bone Joint Surg (Br). 1986; 68: 121-24.  Back to cited text no. 3    
4. Juffer AP. Traumatic rupture of the achilies tendon, reconstruction by transplant graft using the peroneus brevis. Orthop Clin North Am. 1974 5: 89.  Back to cited text no. 4    
5. Pankovich AE. Neglected rupture of the achilles tendon, treatment by V-Y tendinous flap. J Bone Joint Surg (Am). 1975; 57: 253-64.  Back to cited text no. 5    
6. Scheller AD et al. Tendon injuries about the ankle. Orthop Clin North Am. 1980; 4: 80.  Back to cited text no. 6    
7. Bosworth DM. Repair of defects in the tendo achilles. J Bone Joint Surg (Am). 1956; 38: 111-4.  Back to cited text no. 7    
8. Inglish AE et al. Rupture of the tendo Achillas of an objective assess­ment surgical and non surgical treatment. J Bone Joint Surg (Am). 1976 58:980.  Back to cited text no. 8    

Top
Correspondence Address:
Chinmay De
112 A, R.C. Das Road, Burdwan – 713101
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.34509

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    Tables

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    Abstract
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    Materials and me...
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