Tag Archives: tendon rupture

Reconstruction of an Achilles rupture with 12 cm defect utilizing Achilles tendon allograft and calcaneal bone block: A case report

Posted on December 31, 2020 | Comments Off on Reconstruction of an Achilles rupture with 12 cm defect utilizing Achilles tendon allograft and calcaneal bone block: A case report

by Isaiah Song1*, DPM; Alvin Ngan2, DPM, FACFAS

The Foot and Ankle Online Journal 13 (4): 11

Chronic Achilles tendon ruptures, especially with extensive defects, are challenging to repair, and options are limited. We present a case of a neglected Achilles tendon rupture with a 12 cm defect, treated with an Achilles tendon allograft with a calcaneal bone block. The repair was augmented with a flexor hallucis longus (FHL) tendon transfer as well as human acellular dermal matrix. At 1-year follow-up the patient had no pain and was able to walk 2 miles at a time. There was no re-rupture of the affected limb, infection or allograft morbidity.

Keywords: Achilles tendon, chronic, tendon allograft, tendon rupture, surgical technique, FHL tendon transfer

ISSN 1941-6806
doi: 10.3827/faoj.2020.1304.0011

1 – Resident, Swedish Foot & Ankle Residency Program, Swedish Medical Center, Seattle, WA
2 – Attending Physician, Swedish Foot & Ankle Residency Program, Swedish Medical Center, Seattle, WA
* – Corresponding author: isaiahsong@gmail.com

A chronically ruptured or neglected Achilles tendon is defined as a rupture with 4-6 weeks between the time of injury and treatment [1,2]. An estimated 20-35% of Achilles ruptures have a delayed diagnosis due to unrecognized injury, misdiagnosis or late presentation [1,2]. Between injury and treatment, granulation tissue between tendon ends prevents apposition and fibrous tissue develops in the rupture site [3-5]. The triceps surae muscle continues to contract and the proximal tendon stump retracts and adheres to the surrounding fascia [6, 7]. Unrecognized injury and retraction of the tendon stump may result in large defects.

Various techniques have been described for surgical repair of the neglected Achilles tendon rupture including gastrocnemius tendon advancement, turndown flaps, autografts, allografts and tendon transfers [8-12]. Which technique provides the best outcome is unknown, and some techniques are limited to smaller defects.

We present a case of a chronic Achilles rupture with a 12 cm defect reconstructed with an Achilles tendon allograft with calcaneal bone block, augmented with a flexor hallucis longus (FHL) tendon transfer and human acellular dermal matrix.

Case Study

A healthy, very active, 71-year-old male initially presented with ankle weakness and difficulty with gait. He was treated by an outside provider for one year with presumed Achilles tendonitis. However, at presentation at the current attendings clinic, he had a palpable defect with a positive Thompson’s test for an Achilles rupture. There was minimal calf atrophy compared to the contralateral side. His gait was antalgic and apropulsive with poor balance. MRI demonstrated an Achilles rupture with approximately 9 cm retraction. The patient was initially offered permanent bracing because of his age. However, due to his good health, and very active lifestyle, he elected for surgical repair understanding the potential limitations of achieving a full recovery given the longstanding misdiagnosis. The patient was counseled on the probable use of allograft and tendon transfer because of the extensive defect.

Figure 1 Intraoperative appearance of the chronic rupture site, interposed with fatty and mucoid diseased tissue or “pseudotendon”.

Figure 2 The proximal excised portion of the diseased Achilles.

Surgical technique

The patient was placed prone on the operative table under general anesthesia with a thigh tourniquet. A linear incision was made just medial to the midline of the Achilles tendon and deepened to expose the tendon. The rupture site was identified. The defect had filled with interposed scar tissue, with fibrofatty and mucoid consistency. This non-viable tissue was excised proximally to the level of the gastrocnemius aponeurosis which was noted to be healthy. The degenerated tissue extended distally to the Achilles insertion, with minimal healthy tendon attachment to the calcaneus. Following debridement and excision of diseased tissue, the defect measured 12 cm with the ankle in near maximal plantarflexion.

Figure 3 Additional excision of nonviable, calcified degenerated tissue at the distal Achilles stump.

A frozen Achilles tendon allograft with calcaneal bone block was thawed and pre-tensioned to minimize viscoelastic creep. The calcaneal block portion of the allograft was fixated first, by creating a rectangular cut-out for insertion in the superior aspect of the patient’s calcaneus. The calcaneal bone block was tamped into place and fixated with 2 crossed 3.5 cortical screws with washers.

Before attachment of the allograft proximally, the ankle was placed in 30 degrees of plantarflexion to create a tensioned repair. The proximal portion of the Achilles allograft was then sutured to the gastrocnemius aponeurosis with approximately 3 inches of overlap utilizing a combination of simple interrupted and Krackow suturing, with #2, and #2-0 fiberwire.

In order to improve strength and vascularity to the repair, an FHL transfer was also performed. The FHL tendon was harvested by releasing at the level of the posterior talus, sewn alongside the medial aspect of the Achilles at anatomic tension. The musculotendinous portion of the FHL was also sutured to the undersurface of the proximal repair site with the intent to bring vascularity closer to the repair.

Finally, a human acellular dermal matrix product was sewn over the proximal repair with 3-0 Vicryl, to provide reinforcement, and scaffolding for host tissue ingrowth. The incision was irrigated, the tourniquet was released and the patient was placed into a non-weight bearing compression splint with anterior and posterior slabs.

Figure 4 Planning of graft placement following excision of the chronic rupture.

Figure 5 The proximal Achilles allograft was sutured into the gastrocnemius aponeurosis after securing the distal calcaneal block with 2 crossed screws.

Figure 6 A human cellular dermal matrix was overlaid as the final step.

Figure 7 Patient demonstrating ability to perform partial heel rise on the reconstructed side.

Figure 8 Patient demonstrating ability to perform heel rise on the contralateral side for comparison.

Post-operative protocol

The patient was splinted for 14 days and remained non-weight bearing. Following suture removal, the patient was casted in plantarflexion, remaining non-weight bearing for the next 4 weeks. At 6 weeks, the patient was referred to physical therapy and was also transitioned to weight bearing in a walking boot with heel lifts and progressed gradually to neutral by decreasing the heel lifts. At 12 weeks, he was transitioned out of a boot to a shoe.

Results

The patient had no complications during follow-up. At 1 year follow-up, the patient reported no pain and was able to return to normal daily activities, and walk 2 miles. His range of motion was symmetrical to the contralateral side, and manual muscle testing revealed only slight weakness. He was able to perform heel rise symmetrical to his contralateral side. X-rays showed incorporation of the calcaneal block graft. He was overall pleased with the surgery.

Figure 9 Postoperative x-ray showing incorporation of the calcaneal bone block portion of allograft.

Interestingly, he was more bothered by contralateral Achilles pain. Initially this was presumed to be compensatory tendonitis. After failing conservative care, he had ultrasound evaluation, as MRI was contraindicated due to interval placement of a pacemaker. His contralateral Achilles showed findings consistent with tendinosis or chronic tearing. During this ultrasound, his reconstructed Achilles was also examined and it showed expected findings of stable appearing heterogeneous texture of the Achilles allograft with no rupture.

While the patient was satisfied with his reconstructed Achilles, he felt he was more limited by his contralateral Achilles tendinosis and eventually elected for surgery on that side as well.

Discussion

Large defects following Achilles ruptures are challenging. Delay in diagnosis may lead to retraction of the tendon stump, and atrophy of the gastrocnemius muscle. Furthermore, if significant tendinosis was present prior to rupture, the actual defect may be larger than presumed following debridement. Ofili in 2016 reported that MRI underestimates the true extent of Achilles tendinosis [18]. Indeed, our patient had a 12 cm defect following debridement despite MRI initially predicting a 9cm defect.

While smaller defects may be typically treated by gastrocnemius advancement or flap, there is no consensus on how to manage larger Achilles defects. In the author’s experience, gastrocnemius advancement techniques allow repair of only up to 6-8 cm defects. Our patient had a 12 cm defect and therefore, with limited repair options, it was felt appropriate to utilize Achilles tendon allograft. Additionally, given the significant disease in the distal stump at the insertion, there was no viable tissue to suture the Achilles allograft, and therefore the calcaneal bone block proved useful for distal reattachment. One risk of a calcaneal bone block would be delayed or non-union. Deese in 2015 and Ofili in 2016 have reported delayed union with incorporation at the calcaneus. [12,19] Our patient showed radiographic healing at 6 weeks post-op.

Reconstruction using an Achilles tendon allograft with a calcaneal bone block has previously been demonstrated to have good results [18,19]. These studies did not include an FHL transfer. The FHL transfer is a relatively simple, in-phase transfer with the potential benefits of increasing strength of the repair and providing additional plantarflexion power. Additionally, the FHL transfer theoretically may provide additional vascularity from the flexor hallucis muscle belly to the repaired Achilles. The FHL transfer has been shown to have high patient satisfaction and minimal donor morbidity has been noted with this procedure [21-24]. From a technical standpoint, the use of a calcaneal bone block with screw fixation may limit the ability to secure an FHL transfer with biotenodesis as creating an additional bone tunnel adjacent to the screws may create stress risers. Therefore in the current case the FHL tendon was sutured side by side instead.

Disadvantages with allograft procedures are the risk of disease transmission, longer allograft incorporation time, and increased cost. There is also a potential amount of creep in allograft tendons. In addition, Hanna in 2014 reported that 4 of 6 patients with an Achilles allograft with calcaneal bone block ambulated with a limp and complained of weakness at 16-32 months [18]. It is important to counsel patients with longstanding neglected ruptures, that recovery of full strength may not be possible. Our patient, however, appeared to be able to perform a symmetrical appearing single heel rise on examination.

In our case, we augmented the allograft repair with FHL transfer and human acellular dermal matrix. Human acellular dermal matrix acts as a scaffold for host revascularization and cellular growth. [25] A few studies have described acellular dermal matrix augmentation to strengthen an Achilles tendon rupture site, all with favorable outcomes without any re-ruptures. [26-29] Therefore, the final addition of the dermal matrix in our patient was intended to assist with incorporation of the large allograft.

In conclusion, Achilles tendon reconstruction with tendon-bone block allograft augmented with FHL transfer and a human acellular dermal matrix may successfully repair a severely degenerated and neglected Achilles tendon rupture. We believe this technique can be useful for Achilles tendon ruptures with large deficits up to, and perhaps more than 12 cm.

Acknowledgements

Thank you to the Swedish Medical Center Foot and Ankle Surgery Residency Program for the support. Additional thanks to Drs. Brian Rougeux and Bryn Rowe for early input into this case study.

References

  1. Maffulli N. Clinical tests in sports medicine: more on Achilles tendon. Br J Sports Med. 1996;30(3):250.
  2. Maffulli N, Ajis A. Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am. 2008;90(6):1348–1360.
  3. Carden DG, Noble J, Chalmers J, Lunn P, Ellis J. Rupture of the calcaneal tendon. The early and late management. J Bone Joint Surg Br. 1987;69(3):416–420.
  4. Bosworth DM. Repair of defects in the tendo achillis. J Bone Joint Surg Am. 1956;38-A(1):111–114.
  5. Yasuda T, Kinoshita M, Okuda R. Reconstruction of chronic Achilles tendon rupture with the use of interposed tissue between the stumps. Am J Sports Med. 2007;35(4):582–588.
  6. Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon. Treatment by V-Y tendinous flap. J Bone Joint Surg Am. 1975;57(2):253–255.
  7. Zadek I. Repair of old rupture of the tendo Achilles by means of fascia lata: Report of a case. JBJS. 1940;22(4):1070.
  8. Maffulli N, Longo UG, Maffulli GD, Rabitti C, Khanna A, Denaro V. Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon, Knee Surg Sports Traumatol Arthrosc 19, 680–687 (2011). https://doi.org/10.1007/s00167-010-1193-2
  9. Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med. 2002;36(4):239–249.
  10. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73(10):1507–1525.
  11. Aström M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop Relat Res. 1995;(316):151–164.
  12. Ofili KP, Pollard JD, Schuberth JM. The neglected Achilles tendon rupture repaired with allograft: A review of 14 cases. J Foot Ankle Surg. 2016;55(6):1245–1248.
  13. Duhamel P, Mathieu L, Brachet M, Compere S, Rigal S, Bey E. Reconstruction of the Achilles tendon with a composite anterolateral thigh free flap with vascularized fascia lata: a case report. J Bone Joint Surg Am. 2010;92(15):2598–2603.
  14. Nellas ZJ, Loder BG, Wertheimer SJ. Reconstruction of an Achilles tendon defect utilizing an Achilles tendon allograft. J Foot Ankle Surg. 1996;35(2):144–148; discussion 190.
  15. Lepow GM, Green JB. Reconstruction of a neglected Achilles tendon rupture with an Achilles tendon allograft: A case report. J Foot Ankle Surg. 2006;45(5):351–355.
  16. Hansen U, Moniz M, Zubak J, Zambrano J, Bear R. Achilles tendon reconstruction after sural fasciocutaneous flap using Achilles tendon allograft with attached calcaneal bone block. J Foot Ankle Surg. 2010;49(1):86.e5-10.
  17. Beals TC, Severson EP, Kinikini D, Aoki S. Complex Achilles reconstruction for massive soft tissue loss: allograft, autograft, and use of a temporary cement spacer. J Orthop Trauma. 2010;24(8):e78-80.
  18. Hanna T, Dripchak P, Childress T. Chronic Achilles rupture repair by allograft with bone block fixation: technique tip. Foot Ankle Int. 2014;35(2):168–174.
  19. Deese JM, Gratto-Cox G, Clements FD, Brown K. Achilles allograft reconstruction for chronic Achilles tendinopathy. J Surg Orthop Adv. 2015;24(1):75–78.
  20. Den Hartog BD. Flexor hallucis longus transfer for chronic Achilles tendonosis. Foot Ankle Int. 2003;24(3):233–237.
  21. Hahn F, Maiwald C, Horstmann T, Vienne P. Changes in plantar pressure distribution after Achilles tendon augmentation with flexor hallucis longus transfer. Clin Biomech (Bristol, Avon). 2008;23(1):109–116.
  22. Coull R, Flavin R, Stephens MM. Flexor hallucis longus tendon transfer: evaluation of postoperative morbidity. Foot Ankle Int. 2003;24(12):931–934.
  23. Richardson DR, Willers J, Cohen BE, Davis WH, Jones CP, Anderson RB. Evaluation of the hallux morbidity of single-incision flexor hallucis longus tendon transfer. Foot Ankle Int. 2009;30(7):627–630.
  24. Steginsky BD, Van Dyke B, Berlet GC. The missed Achilles tear: Now what? Foot Ankle Clin. 2017;22(4):715–734.
  25. Norton LW, Babensee JE. Innate and adaptive immune responses in tissue engineering. In: Fundamentals of Tissue Engineering and Regenerative Medicine, pp. 721–745, edited by U Meyer, T Meyer, J Handschel, HP Wiesmann, Springer-Verlag, New York, 2009.
  26. Lee DK. Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures. J Foot Ankle Surg 2007;46:451–455.
  27. Lee DK. A preliminary study on the effects of acellular tissue graft augmentation in acute Achilles tendon ruptures. J Foot Ankle Surg 2008;47:8–12.
  28. Branch JP. A tendon graft weave using an acellular dermal matrix for repair of the Achilles tendon and other foot and ankle tendons. J Foot Ankle Surg 2011;50:257–265.
  29. Huang X, Huang G, Ji Y, Ao R, Yu B, Zhu YL. Augmented repair of acute Achilles tendon rupture using an allograft tendon weaving technique. J Foot Ankle Surg 2015;54:1004–1009.

 

Comments Off on Reconstruction of an Achilles rupture with 12 cm defect utilizing Achilles tendon allograft and calcaneal bone block: A case report

Posted in Uncategorized

Tagged , , , , ,

Management of Open Chronic Tendo Achilles Injuries: A case report

Posted on January 1, 2010 | Comments Off on Management of Open Chronic Tendo Achilles Injuries: A case report

by Anil Thomas Oommen MS Orth1 , Pradeep Mathew Poonnoose MS Orth2 ,
Debabrata Padhy MS Orth3 , Ravi Jacob Korula MS Orth4

The Foot and Ankle Online Journal 3 (1): 2

Delayed presentation of an open Tendo Achilles injury with segmental loss of tendon and soft tissue is a challenging problem for the Orthopaedic surgeon. We present a patient who presented with a 4 x 5 cm open wound and a 4cm segmental loss of the tendon 6 months after the injury. To bridge the defect in the tendon, lengthening of the proximal tendon was done using a tongue in groove sliding technique, and a reverse sural artery flap was used to cover the soft tissue defect. At 9 months follow up, the patient was able to perform a single limb toe stance. The technique and the relative merits of this simple procedure are discussed.

Key words: Achilles tendon, Sural artery flap, Bakers slide, Tendo Achilles, tendon rupture.

Accepted: December, 2009
Published: January, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0301.0002

Open Tendo Achilles injuries commonly occur following cycle spoke injuries or after a fall into ‘Indian style’ closets. [1] If patients present within 6 to 12 hours of the injury a thorough wash followed by primary or delayed repair of the tendon can be done. Management of delayed presentation of open Tendo Achilles injuries is more complex, as there is a loss of soft tissue cover in addition to the tendon defect.

An effective surgical procedure is required to bridge the defect in the Tendo Achilles, as well as to achieve adequate soft tissue cover. [1,2] A number of procedures have been described for reconstruction of the Tendo Achilles. These include lengthening the aponeurotic tendon either in a ‘tongue in groove’ fashion as described by Baker, or the V-Y technique popularized by Abraham and Pankovich. [1,2] The other methods described for repair of neglected rupture include augmentation with the peronei (Teuffer’s modification of White and Kraynick technique), or with a strip from the median raphe of the proximal tendon (Bosworth’s technique). [2] Management of the defect in an open injury is more complex because of the associated loss of soft tissue cover. The use of vascularised extensor digitorum brevis and various composite free flaps have been described for such defects. [2] These require the expertise of a micro vascular surgeon.

We present the case of a patient who presented with a 4 x 5 cm open wound and a 4 cm segmental loss of the tendon six months following a fall. Following a thorough debridement, we opted to bridge the defect by lengthening the tendon with a Baker’s procedure, and cover the skin defect with a reverse sural artery flap. The technique and relative merits of this simple procedure are discussed.

Surgical Procedure

With the patient in prone position, the wound was debrided and the residual skin defect measured. Swabs taken from the wound confirmed the absence of active infection.

The reverse sural artery flap was elevated before the tendon was lengthened. (Fig 1) The flap was marked proximally on the calf, with the edges 0.5 cm more than the measured recipient area.

Figure 1  Presentation of injury. Elevation of the reverse sural artery flap, with insert (A) showing the skin defect over the ruptured Tendo Achilles. The flap has been cut back to a bleeding edge.

The small saphenous vein, sural artery and nerve were cut at the proximal edge of the flap and raised along with the fascio-cutaneous flap. The deep fascia was anchored to the epidermis prior to elevating the flap, in order to prevent shearing between the deep fascia and the skin. Distally, the incision was extended up to the medial border of the wound. Laterally, the flap was raised to 7.5 cm short of the lateral malleolus, in order to preserve the perforators from the peroneal artery that supply the elevated flap. At this stage, the tourniquet was released, and bleeding from the flap edge was noted. As the bleeding from the leading edge of the flap was inadequate, the flap had to be cut back until a bleeding edge was obtained. (Fig. 1) The flap was then turned over its pedicle, and laid over the defect.

Following the elevation of the flap, the aponeurosis and tendinous portion of the Tendo Achilles was exposed. The proximal edge of the defect was freshened, and a no. 5 ethibond (ETHICON, Inc.) Bunnel suture was passed through the distal end of the tendon. Care was taken not to disturb the mesotenon near the defect. A ‘tongue in groove’ lengthening of the tendon was done at the musculotendinous junction. For the defect of 4 cm, a 9 cm cut was made in the aponeurosis, to ensure adequate overlap after the lengthening. Traction was applied to the tendon with the ethibond suture to lengthen the tendon, and the defect was closed with the ankle in 10 degrees of plantarflexion. (Fig. 2)

Figure 2 Repair of the tendon using a ‘tongue in grove lengthening’ of the aponeurosis.

There was no distal remnant of the Tendo Achilles, and hence the tendon was anchored on to the calcaneum directly. The insertion site on the calcaneum was freshened, and the ethibond suture was threaded through the calcaneum using a Beath pin, and anchored tightly onto the sole of the foot over a button. (Fig. 2) Additional bony sutures were placed between the tendon and the calcaneum.

After anchoring the tendon, the flap was rotated and sutured over the defect. Multiple corrugated drains were used under the flap to ensure good drainage. The donor site was covered with split thickness skin graft. An anterior plaster splint was applied to keep the ankle in plantarflexion. Once the sutures were removed after 2 weeks, the leg was casted in 20 degrees of flexion at the ankle for 2 months, followed by another 2 months in neutral position. The button used to anchor the ETHIBOND suture was removed at 4 months. He was then allowed to bear weight, though the repair had to be protected with a cast for another 2 months. At 9 months, he was able to perform a single limb toe stance. (Fig. 3)

Figure 3 Nine months following surgery, the patient was able to stand on one leg without support.

Discussion

Delayed presentation of open Tendo Achilles injuries require careful repair of the tendon defect, and adequate soft tissue cover. [1,2] Reconstruction of the defect can be challenging, as the blood supply of the Tendo Achilles at its insertion is extremely poor. [3] The reconstruction of Tendo Achilles injuries require meticulous handling of the remnant segments. The mesotenon of the tendon segment near the defect should be preserved in order to maintain vascularity and achieve healing at the site of reconstruction. [3] Bosworth advocated elevation of a full thickness central strip of the proximal tendon, which is turned over and sutured to the distal end of the defect. The ‘turned over’ section of the graft has poor vascularity, and the healing at the repair site could potentially be compromised.

If the defect is bridged by lengthening the tendon proximally, the dissection of the mesotenon near the defect is less extensive, and hence the vascularity at the repair site is relatively well preserved. The repair is more biological and is more appropriate for reconstruction of the Tendo Achilles. The repair is also less bulky near the insertion site.

For protection of the reconstructed tendon, a full thickness soft tissue cover is necessary, as split thickness skin graft is unlikely to heal over the repair site.

The options for soft tissue cover include free vascularised composite tensor fascia lata flap, medial plantar flap with plantar aponeurosis or a free flap. [1,4] These free flaps often require micro vascular expertise.

The reverse sural artery flap is a neuro-cutaneous flap that has the advantages of having a fairly constant blood supply with associated ease of elevation and preservation of major vascular trunks in the lower extremity. [2,3] This flap is based on the distribution of the sural nerve and the retrograde perfusion is maintained by the anastomoses of the cutaneous perforating branches of the peroneal artery and the median superficial sural artery. [2,3]

This flap remains the workhorse for soft tissue cover over the posterior distal third of the leg and heel. [2,3] It is a relatively simple flap that can be performed by most orthopaedic surgeons. [2,4] The Tendo Achilles slide can be done through the same incision used for elevation of the flap. The resultant flap is however, often quite bulky. Where expertise is available, an adipo-fascial flap can be used to make the repair more aesthetic. [1]

Conclusion

The sliding technique for bridging defects in the Tendo Achilles followed by a reverse sural artery flap is an excellent option for management of delayed presentation of open Tendo Achilles injuries.

Acknowledgements

No benefits in any form have been received or will be received from any commercial party related directly or indirectly to the subject of this article.

References

1. Mohanty A, Jain P: Reconstructing and resurfacing open neglected Achilles tendon injury by distal posterior tibial artery based adipofascial flap. Eur J Plastic Surgery 27: 196 – 199, 2004.
2. Bullocks JM, Hickey RM, Basu CB, Hollier LH, Kim JY: Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap. J Plast Reconstr Aesthet Surg 61(5): 566 – 572 , 2008.
3. Carr AJ, Norris SH: The blood supply of the calcaneal tendon. J Bone Joint Surg 71B (1):100 – 101, 1989.
4. Jeng SF, Wei, FC: Distally based sural island flap for foot and ankle reconstruction. Plastic and Reconstructive Surgery 99 (3): 744 – 750,1997.

Address Correspondence to : Anil Thomas Oommen, Assistant Professor, Unit 2,Department of Orthopaedics,Christian Medical College and Hospital, Vellore, India, 632004 Email : lillyanil@cmcvellore.ac.in

1  Assistant Professor,Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282172.
2  Associate Professor, Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282173.
3  Assistant Professor,Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282081.
4  Professor and Head, Unit 2, Department Of Orthopaedics, Christian Medical College and Hospital, Vellore 632004, India +914162282167.

© The Foot and Ankle Online Journal, 2010

Comments Off on Management of Open Chronic Tendo Achilles Injuries: A case report

Tagged , , , , ,