SLR - September 2023 - Ferbet
Title: Allograft and Autologous Reconstruction Techniques for Neglected Achilles Tendon Rupture: A Mid-Long-Term Follow-Up AnalysisReference: Jiménez-Carrasco C, Ammari-Sánchez-Villanueva F, Prada-Chamorro E, García-Guirao AJ, Tejero S. Allograft and Autologous Reconstruction Techniques for Neglected Achilles Tendon Rupture: A Mid-Long-Term Follow-Up Analysis. Journal of Clinical Medicine. 2023; 12(3):1135.
Level of Evidence: III
Scientific Literature Review:
Reviewed by: Aleksander Ferbet, DPM
Residency Program: SSM Health DePaul Hospital, St. Louis, MO
Podiatric Relevance: The Achilles tendon is one of the most commonly ruptured tendons, particularly in middle-aged men, that podiatrists will encounter. Ample research has been completed on the acute Achilles tendon rupture, whether it is conservative treatment or surgical repair. The treatment strategies change, however, when these acute injuries are misdiagnosed, or present in a chronic manner. Due to the retraction of the tendon ends and formation of scar tissue, alternative techniques may be required for surgical repair. There are numerous surgical options for these chronic tendon ruptures including V-Y tendon plasty, tendon transfers, allograft and autograft reconstructions, amongst others. This study aims to describe and compare the clinical and functional outcomes, as well as complications at long-term follow-up in chronic ruptures using either autologous techniques or Achilles allograft reconstruction.
Methods: This was a retrospective comparative observational study with an 11 year study period. Inclusion criteria consisted of the patient having had an Achilles tendon rupture diagnosed more than 6 weeks after injury, the inability to perform a single heel rise, a gap length greater than 2cm diagnosed by MRI and having at least 2 years of adequate post-operative follow up. The surgical technique performed was based on the length of the gap intraoperatively. For patients with a gap of 2-4cm, a V-Y Achilles lengthening was performed. The repair of a gap of 4-6cm included a V-Y lengthening, as well as a FHL transfer. If the gap was greater than 6cm, an allograft reconstruction consisting of a bone-tendon full length Achilles allograft. The primary outcome measure in the study was American Orthopedic Foot and Ankle-Society Ankle-Hindfofot Score (AOFASAH) and The Achilles Tendon Total Rupture Score (ATRS).
Results: A total of 17 patients were included in the study, with a mean age of 43 and a mean follow up of 82 months. 9 patients were treated with autologous techniques (6 V-Y and 3 V-Y with FHL transfer), and 8 patients were treated with reconstruction utilizing an Achilles tendon allograft. At a mean of 82 months, all 17 patients were able to complete a single heel rise and no complications were recorded at the end of the follow up. Additionally, there were no instances of recurrent rupture among all of the patients. The median AOFASAH and ATRS scores increased significantly from the pre-operative to the post-operative scores in both groups. There was no significant difference found between the two groups in either of the two scoring mechanisms.
Conclusions: The authors concluded that chronic Achilles tendon ruptures can be treated successfully by selection of the repair method according to the gap length and status of the remaining tissues. In patients with an extensive defect (>6cm), reconstruction with an Achilles tendon allograft should be considered a suitable treatment option as it does not present more complications than autologous techniques, with comparable functional and patient satisfaction outcomes. This study presents a viable pathway in determining the treatment strategy for these difficult injuries, while basing the decision making on patient specific, intraoperative findings.