Augmentation adds collagen to the repair site and gives more
biomechanical stability to the repair
24. In defective Achilles
tendon ruptures, different surgical procedures have been
described to attempt to restore continuity of the tendon by
bridging the defect with grafts
3-5,8-12,14,16,19-22,24. The
conventional grafts of fascia lata, plantaris, turned-down
aponeurosis of gastrocnemius are avascular and tend to
produce adhesions
3,14.
Tendon adhesion to the skin is especially seen after the
open surgical repairs 6,7,17,18. In primary end to end repair
techniques, tendon adhesion rate was found as 2.6% to 45%
6,7,17,18. Augmented repair with different flap techniques in
2347 cases, adhesion rate was found to be 3.1% 6. Tendon
adhesion is an important minor complication and it may need
reoperation 6,13,15.
Different surgical techniques were defined for prevention
of tendon adhesion 1,2,7,8. Cetti et al compared the mobile
cast group (which leaves the ankle motion in early
postoperative period) and rigid cast group. Adhesion rate were
3.3% in mobile cast group and 13.3% in rigid cast group. They
pointed that the granulation that forms the scar tissue between
the ends of the rupture does cause scar tissue bridges to the
surrounding tissue if immobilization is prolonged, resulting in
a decreased of the mobility of the tendon 7.
Lindholm devised a method of repairing ruptures of the
tendo calcaneus that reinforces the sutures with living fascia
and prevents adhesion of the repaired tendon to the overlying
skin. He fashioned two flaps from the proximal tendon and
gastrocnemius aponeurosis and twist each flap 180 degrees on
itself so that its smooth external surface lies next to the skin
2.
Aldam made a 3 to 4 cm transverse incision in the skin
just distal to the palpable gap in the tendon and adhesion
between the skin and the tendon are avoided because they lie at
different levels after the operation 1.
Esemenli et al used a new open surgical repair technique
in three cases without opening the rupture site and none of
them had tendon adhesion to the skin 8.
Some principles are important for prevention of tendon
adhesion in open surgical methods;
1. Making paramedian (posterolateral or posteromedial)
incision 2.
2. Making incision away from the rupture site 1,8.
3. Closing the paratenon and deep fascia 21.
4. Closing the rupture site with flap and make a smooth
surface in repair area 2.
5. Early postoperative ankle motion 7.
We used 1st, 3rd and 4th principles in our technique. Our
flap technique is a combination of classical median
gastrocnemius aponeurosis flap turned down for augmentation
of repair 24 and Lindholm’s two flaps techniques 2. In
classical flap, rough surface lies next to the skin and tendon
adhesion to the skin may be expected. In our technique,
smooth surface lies next to the skin like Lindholm’s technique
and tendon adhesion to the skin is prevented.
According to us, our technique is strong than Lindholm’s
technique, because we used only one large flap and augment
the repair site with plantaris tendon. Our technique can be used
easily by any Orthopaedic surgeon.
Turn-down fascial grafts are avascular and theoretically
must be revascularized to be incorporated in to the repair
3,14. So, flap base folding in our technique is not important
problem for revascularization of flap.
In conclusion, if augmented repair of Achilles tendon
rupture is preferred, this technique can be used satisfactorily
and tendon adhesion to the skin is prevented.
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