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Case Report *Corresponding author Vinayak Sathe, Department of Orthopedics, University of Connecticut 263 Farmington Avenue, Farmington, Unusual Case of Atraumatic Connecticut, 06032, USA, Email: Submitted: 18 April 2017 Bilateral Achilles Tendon Accepted: 28 April 2017 Published: 30 April 2017 ISSN: 2475-9112 Rupture in the Chronic Setting Copyright Cameron Kia, Alim F. Ramji, and Vinayak Sathe* © 2017 Sathe et al. Department of Orthopedics, University of Connecticut, USA OPEN ACCESS
Keywords Abstract • Achilles tendon Bilateral spontaneous rupture of the Achilles tendon is a rare occurrence with few • Rupture case reports in the literature. Despite being one of the strongest tendons in the lower • Ankle limb, it is the most common one ruptured. Majority of Achilles tendon ruptures are • Trauma unilateral. We present a case of surgically treated chronic bilateral Achilles tendon • FHL transfer rupture in a 42-year-old patient without associated risk factors. The patient presented with atraumatic, bilateral Achilles tendon ruptures that were each treated with flexor hallucis longus transfer and V-Y gastrocnemius advancement. Our surgical repair was followed by six weeks of immobilization followed by increased strengthening in range motion with physical therapy. At six months follow-up visit, the patent had returned to his baseline function.
ABBREVIATIONS week later, the patient was neuro vascular intact in both lower extremities, had pain with palpation along his Achilles tendons FHL: Flexor Hallucis Longus bilaterally, and exhibited positive Thompson’s tests bilaterally, INTRODUCTION with a palpable defect on the right. Radiographic views of the
The Achilles tendon, despite being one of the strongest The left calcaneus demonstrated a large Haglund process with tendons in the body is most frequently ruptured lower limb right calcaneus demonstrated large calcific tendinitis (Figure 1A). tendon and compromises roughly 20% of all large tendon demonstrated complete Achilles tendon rupture bilaterally with injuries [1]. Achilles tendon rupture is most often unilateral in posterior calcaneal bone spur (Figure 1B). MRI of both ankles loading with activities [2]. Atraumatic causes of Achilles tendon chronic degenerative changes along the distal tendon (Figure ruptureindividuals are in rare their and fourth are or usually fifth decade associated usually with during risk eccentric factors 2A,B).The patient was a laborer who desired surgical intervention for both sides. After a complete discussion of the risks and The incidence of spontaneous Achilles tendon rupture without suchrisk factors as previous is roughly corticosteroids .02%and less or than fluoroquinolone 1% of all ruptures use [3,4]. are repair. Using a posteromedial approach, dissection was carried benefits, the patient consented to bilateral open Achilles tendon bilateral [5,6]. Bilateral spontaneous Achilles tendon rupture in out on both ankles. The paratenons were divided to expose patients without predisposing factors during normal physiologic the Achilles tendon bilaterally. A Haglund process was noted load is rare, with only minimum number of case reports in the bilaterally and both bony prominences were excised. The left literature [7,8]. We present a case of idiopathicbilateral chronic Achilles tendon rupture. that required excision. Following debridement of both tendons, tendon was torn at its insertion and had a large calcific portion CASE PRESENTATION there was significant gapping bilaterally even while held in interferenceequinus. A flexor screws. halluces Given longus the extensive (FHL) tendon gaps, transfer gastrocnemius to the with increased pain and heel weakness that he noticed during calcaneus was done bilaterally and fixed using Fiber loop and normalA 42 activity year old nine with days a history prior to of presentation. bilateral ankle Patient pain, statespresents he V-Y advancement was also performed bilaterally. Using anchor has had chronic heel pain over the last two years, however denies strong repair was achieved without gapping or tension. Following fixation with the Athrex (Naples, Florida) Speed Bridge device, a week prior that placed bilateral lower leg splints on, made non- closure, both heels were placed into 10 degrees of equinus and weightany specific bearing, trauma. and Herecommended was initially thatseen patientat an outside obtain hospital bilateral a splinted. foot and ankle MRI imaging. On initial exam in our office one Postoperatively, the patient was seen five days later and Cite this article: Kia C, Ramji AF, Sathe V (2017) Unusual Case of Atraumatic Bilateral Achilles Tendon Rupture in the Chronic Setting. JSM Foot Ankle 2(2): 1026. Sathe et al. (2017) Email:
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Figure 1
Lateral view of the left and right ankle respectively demonstrating calcification and Haglund lesions.
Figure 2 Demonstrate sagittal MRI images taken preoperatively demonstrate complete rupture of the Achilles tendon bilaterally with evidence of retraction more chronic in nature. converted to short leg casts, and was to continue ambulating with in a patient with previous chronic Achilles tendinitis, without his wheelchair. At six weeks the patient was transitioned to cam traumatic rupture or extrinsic risk factors. boots and worked with physically therapy on increasing range of motion and gradual weight-bearing with a walker. At three of bilateral Achilles tendon rupture. Meta-analyses generally months the patient was ambulating without walker in bilateral agreeThere that is re-rupture currently rates no standard in patients of care treated regarding non-surgically fixation cam boots. His heel lifts were gradually removed from the cam boots and the patient was transitioned to his normal tennis shoes Those that have been surgically treated are at an increased risk at four months. At the patient’s six month visit, he was ambulating forare complications12.6% as opposed such to as 3.5% infection, in those neurovascular treated surgically injuries, [9,10]. and wound healing [11]. without difficulty with excellent plantar flexion strength Our patient had a history of chronic Achilles tendinopathy showsbilaterally. a functional Figures Achilles(3A & 3B) tendon demonstrate bilaterally clinical with simultaneous photographs the patient’s surgical scars at his six month visit. Figure 3B requiring a thorough debridement followed by gastrocnemius V-Ywith advancement. significant degenerativeThere are currently changes multiple at his treatment tendon options edges plantar flexion at the heel. His active range of motion of the right for chronic Achilles tendon rupture with no current guideline for patient’sankle was incisions from neutral were wellto 30degrees healed and of he plantarflexion. was pleased withThe leftthe management [12]. Gastrocnemius V-Y lengthening is currently recommended for gaps of up to 6cm from the insertion site [12]. resultsankle had of hisa pain surgery. free40-degree arc of active range of motion. The Given the chronicity appearance on MRI and patient history, DISCUSSION the patient was aware that allograft was a possible necessity.
Bilateral rupture of the Achilles tendon is a rare occurrence have varied throughout the literature as well, usually consisting seen in less than 1% of the population [6]. Achilles tendon tears Postoperative protocols for fixation of Achilles tendon rupture are generally associated with a traumatic injury during eccentric and the additional time out of work, the patient elected to loading [2]. We present a case of bilateral Achilles tendon rupture of bracing for 6-8 weeks [13-15]. Given the lengthy recovery
fix both simultaneously. Our protocol involved six weeks of JSM Foot Ankle 2(2): 1026 (2017) 2/3 Sathe et al. (2017) Email:
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Figure 3 Physical exam at six month follow up demonstrating well healed surgical scars as well as intact Achilles tendon functioning bilaterally. immobilization followed by progressive weight-bearing with 6. removable boots with heel inserts. We monitored his healing Habusta SF. Bilateral simultaneous rupture of the Achilles tendon: a clinically through physical exam; however ultrasound imaging 7. rare traumatic injury. Clin Orthop Relat Res. 1995; 320: 231-234.
Gitto et al., demonstrated in their study that Achilles tendon Taylor TL, Simon D, Feibel R. Idiopathic simultaneous bilateral can be used to confirm physiological progression of healing [16]. 8. Achilles tendon rupture. BMJ Case Rep. 2009; 2009. repair following complete rupture normal healing will show Garneti N, Holton C, Shenolikar A. Bilateral Achilles tendon rupture: a regression of vasculature on ultrasound after 6 months of repair caseHanlon report. DP. Bilateral Accid Emerg Achilles Nurs. tendon 2005; rupture: 13: 220-223. an unusual occurrence. J hypervascularization within 3 months postoperatively and then [16]. 9. 10. Emerg Med. 1992; 10: 559-560. The Achilles tendon is generally at increased risk of rupture versus non operative management of acute Achilles tendon rupture: after the third decade of life due to a decrease in blood supply Kocher MS, Bishop J, Marshall R, Briggs KK, Hawkins RJ. Operative that makes it more susceptible to rupture [17]. The point of 11. expected-valuePajala A, Kangas decision J, Ohtonen analysis. P, Am Leppilahti J Sports Med. J. Rerupture 2002; 30: and 783-790. deep infection following treatment of total Achilles tendon rupture. J Bone corresponds to a watershed area in the blood supply [17]. rupture generally occurs 3-5 cm proximal to its insertion and 12. Malagelada F, Clark C, Dega R. Management of chronic Achilles tendon and can be missed up to 25% of cases by the initial physician [12], Joint Surg Am. 2002; 84: 2016-2021. especiallyAchilles tendon in the rupture atraumatic can often setting. be a difficult Management diagnosis of bilateralto make tendon rupture has only been reported in few case reports, and ruptures-A review. The Foot. 2016; 28: 54-60. and ankle mobilization after open repair of acute midsubstance tears 13. Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing chronic, atraumatic bilateral Achilles tendon rupture requiring FPLwe believe transfer we and present V-Y lengtheningthe first case in of a surgical patient management who is back toof of the Achilles tendon. Am J Sports Med. 2003; 31: 692-700. normal function at six months. comparison of CAM walker and light-weight plaster cast in the 14. Petersen OF, Nielsen MB, Jensen KH, Solgaard S. Randomized REFERENCES treatment of first-time Achilles tendon rupture. 2002; 164: 3852- 1. Haines JF. Bilateral rupture of the Achilles tendon in patients on 15. 3855. controlled early mobilisation after rupture of the calcaneal tendon: a prospective,Saleh M, Marshall randomised PD, Senior comparison R, Mac Farlane with plasterA. The Sheffieldtreatment. splint J Bone for 2. steroid therapy. Ann Rheum Dis. 1983; 42: 652-654.
Schepsis AA, Jones H, Haas AL. Achilles tendon disorders in athletes. 16. Joint Surg Br. 1992; 74: 206-209. Am J Sports Med. 2002; 30: 287-305. Gitto S, Draghi AG, Bortolotto C, Draghi F. Sonography of the Achilles 3. Orava S, Hurme M, Leppilahti J. Bilateral Achilles tendon rupture: a Tendon After Complete Rupture Repair. J Ultrasound Med. 2016; 35: report on two cases. Scand J Med Sci Sports. 1996; 6: 309-312. 17. 2529-2536.Lagergre C, Lindholm A. Vascular distribution in the Achilles tendon: 4. Lee WT, Collins JF. Ciprofloxacin associated bilateral Achilles tendon 5. rupture. Aust N Z J Med. 1992; 22: 500. an angiographic and microangiographic study. Acta Chir Scand. 1959; non-traumatic rupture of the Achilles tendon: a case report. J Med 116: 491-495. Khanzada Z, Rethnam U, Widdowson D, Mirza A. Bilateral spontaneous
Case Rep. 2011; 5: 263. Cite this article Kia C, Ramji AF, Sathe V (2017) Unusual Case of Atraumatic Bilateral Achilles Tendon Rupture in the Chronic Setting. JSM Foot Ankle 2(2): 1026.
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