This study analyzes two methods for treating a ruptured calcaneal tendon (Achilles tendon). Various procedures, some more invasive than others, are currently used by doctors in treating acute and chronic ruptures of this tendon, but there is no consensus on which technique is ideal. This paper focuses on comparing traditional open tendon reconstruction with semitendinous (part of hamstring) grafting and less invasive tendon reinforcement.
The calcaneal, or Achilles, tendon is the strongest in the human body but is very prone to injury, especially in athletes. Injury can occur on a spectrum, from acute rupture with easy diagnosis to chronic degeneration with more difficult diagnosis. Options for tendon repair can be conservative or surgical, with varying recovery times and possibilities for injury recurrence. Surgical options include: primary repair, V-Y slip, bonding, fascia folding, etc. Other methods include transferring short fibular tendon or long flexor hallucis longus for chronic injuries. Such donor tendons cannot, however, be used if tendon loss is greater than 6cm. Without listing the overwhelming list of options, the main idea is that very common Achilles tendon problems can be addressed with many different approaches. Some of these approaches involve reinforcement that is less invasive, some involve using grafts from other parts of the body, and others involve more traditional reconstruction.
A retrospective study was performed on 43 patients with calcaneal tendon rupture. Operations performed between 2008 and 2016 were analyzed (all done by the same surgeon). Patients with diabetes mellitus were excluded and follow up time was two years on average. 16 of the 43 cases used a minimally invasive technique (short fibula tendon graft) while 27 used a conventional, open semitendinous (using part of hamstring) graft. “Age, sex, smoking, injury mechanism, affected side and bilateral cases, local skin complications, and neuromas” and other complications were all reviewed using the available records. Follow up information was analyzed, including American Orthopedic Foot and Ankle Society questionnaires about pain, ankle mobility, and other outcomes. The paper also shares a detailed explanation of “open surgical technique with semitendineous tendon reinforcement” and the following rehabilitation protocol. The procedure involves suture anchors using short fibular tendon and calcaneal tendon with nylon.
37 patients were male and 9 were female, with an average age of 45. 24 had injuries on the left side, while 19 had injuries on the right. 8 patients were smokers, with four undergoing the minimally invasive technique and four undergoing the open technique. 31 of the injuries were traumatic in nature, 12 being due to chronic degeneration. 15 injuries were related to playing soccer, 7 related to stepping on holes, and the others from miscellaneous sources. 12 males and 4 females (7 right and 9 left sided injuries) underwent the minimally invasive technique. 25 men and 2 women (12 right and 15 left sided injuries) underwent the open technique procedure.
With an average follow up time of 2 years, the average score of the AOFAS questionnaire was 92. Complications were found in 6 of the open technique patients, with complaints in both the donor and recipient areas (necrosis, suture separation, pain, etc). One case of deep skin necrosis resulted in long term complications, ultimately leading to skin grafts. Complications were found in 3 of the minimally invasive technique patients (pinched nerve and hyper elongation due to a patient not following rehab instructions).
Discussion This paper clearly promotes tendinous reinforcement surgery, which is less invasive and strives to reduce morbidity. The data discussed promotes this tendon repair technique, even in patients with lesions exceeding 6cm (where semitendineous tendon should be used). The less invasive method (compared to open surgery) results in fewer skin complications and lower morbidity.