Long-Term Outcomes of Gastrocnemius V–Y Plasty Gastrosoleus Fascial Turndown Flap for Chronic Tendo-achilles Injuries with Complex Gap (Kuwada Type IV Injuries) (2024)

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Abstract

Keywords: Chronic tendoachilles tears, Defect over 8cm, Combined surgical technique, Gastrosoleus turn down with V–Y plasty, Functional outcome

Introduction

The Achilles tendon is the largest and strongest tendon in the human body formed by two heads of gastrocnemius and soleus muscles [1]. It is subjected to extensive static and dynamic loads, 2–3 times the body weight while walking and up to 10 times during athletic activities [2]. It is one of the most common tendons to rupture spontaneously. When untreated it heals with fibrous elongation or gap nonunion [3]. TA rupture causes a significant loss in plantar flexion strength, which in turn can lead to inability to run, sporting activities and difficult stair climbing.

Various repair techniques have been described for chronic tears. This includes end-to end anastomosis, gastrocnemius flap turn down augmentation, gastrocnemius recession, V–Y plasty or free tendon autograft using peroneus brevis, flexor halluces longus (FHL) or hamstring tendons and allograft if available. Other techniques used are synthetic mesh or carbon fibers to help augmentation at repair site [4].

For chronic achilles tendon tear with severe defects of over 8cm is challenging and needs combination defects. We repaired such tears with combined gastrosoleus turndown flap with V–Y plasty, and assessed the results, patient satisfaction and complications.

Materials and Methods

We retrospectively analyzed all tendoachilles injury from 2013 to 2018 after obtaining Institutional review board approval, along with patient consent obtained for research and publication in local language. A total of 56 cases were identified, but included only 12 cases with chronic tendoachilles tears, with at least 6-weeks-old injury with a tendon gap of over 8cm. The others were excluded, as they were acute or open injury, chronic tears with defect less than 8cm, peripheral dysvascular limb and noncompliant patient.

Demographic details, history, mechanism of injury, clinical findings (Clinically gait observation, tiptoe stance, calf circumference of limbs, palpable defect, Thompson test and Matles test were noted to achieve the diagnosis) Radiological findings and associated comorbidities were collected from hospital database and case sheets. Anteroposterior and lateral radiographs excluded associated bony injuries and also noted presence of calcified mass over proximal migrated tendon end (Fig.1), which represented degenerative tears. We used MRI to confirm the tear and the extent of gap (Fig.2). Most of the patients had rupture due to trivial injury, none of them realized it to be a serious concern and so never consulted a specialist and became disabled over the time. Six were diabetic and one was on oral steroid medications.

The study included 12 patients, eight male and four female. The mean age was 47years, three-quarter of patients were beyond 40years of age. Right and left side were affected equally, average tendon retraction was 8.8cm. All patients underwent combined gastrosoleus turndown flap augmentation repair with V–Y plasty, three patients had insertional repair (Fig.3), rest end-to-end repair (Fig.4), with an average follow-up of 34months.

Results

All patients were evaluated with objective and subjective parameters. The average follow-up period was 34months. (21–55months). In objective assessment, Average regain of calf diameters was 2.2cm, which was statistically significant using paired T test. Pre-op loss of calf diameter of mean 3.4cm on affected side as compared to normal side, which was statistically significant using unpaired T test. Each patient regained average 10° of dorsiflexion. Two patients had terminal 10° restriction of plantar flexion. All patients were able to do heel raise and single leg stance for at least 30s.

Subjective assessments done using modified Rupp score, five patients had excellent and seven patients had good outcome. Mean VAS for pain was 1.5 (1–3) and VAS for satisfaction was 7.5 (6–9).

All patients returned to their pre-injury functional status, and were able to do their activities with no or minimal restrictions. Post healing MRI was done in a standalone case, which showed good healing of the repaired tendon (Fig.6). We had no complications such as re-rupture, deep infection, sural nerve injury, skin necrosis, chronic fistula, deep vein thrombosis, or persistent equinus. Two patients had wound dehiscence, one treated with secondary suturing and another by local flap with split skin grafting.

Discussion

The tendoachilles is the strongest, largest and most often ruptured tendon in the human body. It has a unique shape and vascularity pattern. It is predominantly supplied by posterior tibial artery at extreme ends and peroneal artery in the midsection (Fig.7) which has implications on tear pattern [5]. Microscopic examination of the deep fascia in lower limbs of cadavers has revealed four clinically important sources of supply to the deep fascia. Non-axial fasciocutaneous perforators were found to be one of them, highlighting the potential use of non-axial fascial flaps, explains survival of these combination facial flaps.

Scheller et al. [6] and Nesterson et al. [7] reported missed injury on the initial evaluation up to 25% in their patients following trivial trauma and remain asymptomatic. So these chronic tendon ruptures heal with elongated scar tissue and defect non-union and surgical treatment remains the mainstay of management.

Various treatment options for TA ruptures with gap of < 2cm direct end-to-end repair +/− augmentation, for gap 2–6cm fascial advancement like gastroc-soleol release, V–Y lengthening, gastroc-soleol turndown flap local and distant tendon transfers—FHL, FDL, peroneal, plantaris, hamstrings and for complex gaps over 6cm combination procedures are described.

Arner and Lindholm, Bosworth, Barnes and Hardy have reported satisfactory outcome with turndown procedure for defects up to 5cm [4]. Yih-shiunn Lee et al. have used a modified Bosworth technique using a strip of turndown tendon waived into proximal and distal stump with good results [8]. Christensen et al. reported satisfactory results using two 10-cm flaps that were raised from the proximal tendon fragment and turned down to cover the defect [9]. Rush showed inverted U-shaped turndown flap with satisfactory outcome, good vascularity and tendon healing. Maffulli and Leadbetter showed decreased muscle strength, as well as adherence of the raw surface of the turndown flap to the superficial skin [10], tubularising it can avoid this so we adopted this technique.

Abraham et al. [11] described the use of V–Y plasty for a gap of 5–6cm where three out of four patients regained full strength. Us et al. reported on six patients treated with this technique were able to perform a single leg heel raise, walk on their toes, and return to preinjury activities. Myerson, Leitner, Parker and Repinecz [12] demonstrated satisfied results and showed that the V–Y advancement allows intrinsic healing resulting in a tendon with enhanced elasticity, strength, and mobility and additionally avoided the sacrifice of other significant lower limb tendons [13].

Tendon transfers using peroneus brevis has been done both in acute and chronic situations with smaller defects, though Perez-Teuffer had demonstrated satisfactory results in acute tears [14], Pintore et al. showed more complications and dissatisfied results in chronic tears [15]. Loss of eversion was a concern though not subjective but was demonstrable on isokinetic strength testing. FHL is another tendon most commonly used in chronic tears as a standalone graft or in combination with turndown flap. Several authors have shown satisfactory outcome but has donor site morbidity affecting the toe push off, flexion of great toe at interphalangeal level. But for defects of more than 8cm tendon transfers alone has not been successful. Free transfer of several folds of fascia lata by Tobin et al. [15] and hamstring tendons by Maffulli et al. [16] has also been tried but had issues with vascularization of graft and its incorporation, along with higher rates of infection and reruptures were noted [17]. Similarly, availability of allograft and synthetic graft is questionable universally [18].

In our series, we used both V–Y plasty and turndown augmentation technique. V–Y plasty can bring down the tendon by up to 3–4cm without affecting much the vascularity and the strength of the muscle. Further turndown of the inverted U central flap we were able to repair defects over 8cm bring the foot to 30° planter flexion. Plantar flexed foot was gradually brought back to neutral position with gradual weight bearing and full functional recovery. Three patients had insertional tears so tendon was repaired to calcaneum with two swivel lock suture anchors. In rest of patients end-to-end repair was done. Tubularisation of the turndown flap prevented adhesion of the repaired tendon to the overlying skin. Beveling of the stump reduced the bump formation at turndown site; hypertrophied plantaris was thinned out and used as paratenon covering of the repair, which prevented adherence to the skin, which are well described techniques [19]. A degree of decrease in plantar flexion strength secondary to recession of the gastrocnemius muscle could be expected; however, the gastrocnemius muscle retains in significant function because the muscle is not transected. This V-to-Y recession allows for end-to-end anastomosis and anatomical tendon healing. This is at the cost of a measurable decrease in plantar flexion strength, which is of minimal clinical significance.

The clinical results of this combined surgical technique for repair of chronic Achilles tendon ruptures indicate that very satisfactory results can be obtained and that it offers a most acceptable restoration of the gastrocnemius soleus complex.

A two incision mini invasive V–Y plasty technique has been described by Arrondo et al. [19]. Kaul et al. have used this turn down technique with satisfactory outcome [20]. Pradeep Jain et al. have published this novel technique of turndown for defect up to 6cm with satisfactory outcome [21]. The fascia turndown graft functions to augment both length and strength by reinforcing the repair with collagen bulk, and subsequently decreases the re-rupture rate [22–24]. Guclu et al. [25] showed with turndown flap, 50 of 54 patients were able to stand on their tiptoes for 30s, perform repeated toe raises, and hop on the affected limb within a mean follow-up time of 4.8years. Myerson [26] had excellent AOFAS scores averaging 99 points after performing a turndown repair, and patient functionality was observed to approach levels comparable to uninjured levels.

Ponnapula et al. recommend using the V–Y plasty rather than an inverted-V gastrocnemius recession. The V–Y plasty creates a continuous fascial strut to brace the underlying soleus muscle belly. Lengthening under these circ*mstances occurs in a controlled manner without tearing the underlying muscle. Moreover, the technique presently described provides about twice the length by combining two lengthening procedures. Anatomic continuity of the musculotendinous unit and restoration of functional length hold the utmost priority in repair of Achilles tendon ruptures. The maximum length of 4–6cm reported by Us et al. was achieved with gastrocnemius recession alone [23]. More extensive defects require an additional source of length to realize postoperative functionality. The key to performing a combination of the V–Y plasty with the fascia turndown flap is preservation of the broad distal attachment of the triangular flap. The substantial width coupled with a 3-cm length allows the transposed V-flap to act as a stable brace against the underlying soleus belly. The broad myofascial junction also maximizes revascularization of the V-flap [8]. Guclu B et al. provided high patient satisfaction and good long-term results with this technique[25], we completely agree with their results as we had similar outcome. This effective and straightforward technique did not require synthetic materials or allografts for augmentation. Treatment options based on Kuwada classification has been shown in Table ​Table1.1. Comparison of various treatment options for various defects has been discussed in Table ​Table22.

We performed a MRI in one patient, which showed satisfactory healing of the tendon. Repairs of chronic tears with such large defects are always challenging and less common injuries, not many articles describing their management. when compared to similar articles we had satisfactory outcome. So small number of study subjects, inability to do repeat MRI to see healing and unable to perform objective scores for recovery are some of the limitations of this study.

Conclusion

Combined surgical technique of gastrosoleus turndown flap augmentation with V–Y plasty for repairing complex defects in chronic achilles tendon tears is a fair option with satisfactory functional outcome and fewer complications.

Supplementary Information

Acknowledgements

Dr. Somashekar V, Dr. Sudeep kumar, Dr. Vinoth T, Dr.Raghavakumar V.N, Department of Orthopaedics, Preethi Hospitals P Ltd.Master. Pratham Singhi for drawing the line diagram of our technique and blood supply.

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Author contributions

This manuscript has been read and approved by all the authors and represents honest work. This manuscript has not been presented or published anywhere earlier.

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References