SLR - September 2013 - Emily Quinn
Reference: Pavan Kumar A, Shashikiran R, and Raghuram C. A novel modification of Bosworth’s technique to repair zone I Achilles tendon ruptures. J Orthopaed Traumatol Volume 14: 59-65 (2013).
Scientific Literature Review
Reviewed by: Emily Quinn, DPM
Residency Program: Grant Medical Center, Columbus, Ohio
Podiatric Relevance: Achilles tendon pathology is a common clinical etiology associated with pain in the podiatric profession. The neglected Achilles tendon rupture comes with multiple complications including repair of large tendon defects and wound healing. This article presents a new approach to treating neglected Achilles tendon ruptures for tendon deficits greater than six centimeters when the rupture occurs within two centimeters of the insertion of the Achilles tendon.
Methods: A technique paper reviewing the clinical results of 78 patients who underwent the modified Bosworth’s technique for repair of Achilles tendon ruptures is presented. Seventy-two ruptures occurred in zone I (two centimeters from insertion of the Achilles tendon) and six patients were in zone II (two to six centimeters from the insertion of the Achilles tendon). Ultrasound and plain radiographs were obtained preoperatively.
Operative Technique: A midline incision was performed, starting 10-12 cm distal from the knee extending distally with a slight curve lateral to the insertion of the Achilles tendon. A 1.5 to two-centimeter-wide strip of the central portion of the raphe of the aponeurosis is reflected along with aponeurosis freed from the underlying gastrocnemius muscle was utilized for the repair. The raphe remained intact 1.5 cm proximal to the ruptured tendon. The raphe strip was folded upon itself and sutured into a tubularized thickened structure simulating a tendon. The raphe tendinous structure was then passed through the proximal Achilles stump and then distally from medial to lateral through a drill hole in the calcaneus. The raphe was then sutured back to itself at the proximal Achilles tendon site.
Results: Clinical outcomes were evaluated at 12 weeks, six months and one year follow-up. Sixty-two patients had excellent results, eight good results and four fair results. Two patients had poor results and two were lost to follow-up. There was noted to be an equal range of motion of the bilateral lower extremity ankles in 62/76 patients at one year follow-up. Complications were related to scar hypertrophy (two patients), superficial infection (two patients), deep infection (one patient) and delayed wound healing (three patients).
Conclusion: The original Bosworth technique requires a distal Achilles rupture stump to attach the aponeurosis. Utilizing this modification, neglected ruptures with greater than a six centimeter gap can be repaired with one incision and good postoperative function. This technique did not compromise other tendon function as it does not require autogenous tendon transfers. This technique also does not require the use of synthetic grafts which can increase inflammation and delay healing.