The purpose of this case study is to investigate the post-operative outcomes of acellular dermal regenerative tissue matrix and allogeneic decellularized particular human placental connective tissue matrix as augmentation grafts during open Achilles tendon repair. In this case, a 47-year-old diabetic African American male presented to clinic eleven days status post near complete rupture of the Achilles tendon, proximal to the insertion on the calcaneus, that occurred while playing soccer. One week after presenting to the clinic, the patient underwent open Achilles tendon repair with augmentation fusing both regenerative tissue matrix and allogenic decellularized particular human placental connective tissue matrix. The patient’s pain (0-10), edema, and erythema were all recorded post-operatively on days 3, 10, 17, 24, and 38 in an outpatient clinical setting. Additionally, post-operatively, the patient was on opioid therapy for a short period of time. Significant improvement was noted in all three categories on post-operative day 17. Such findings indicate that the method of combining acellular dermal matrix and decellularized particulate human placental during an open Achilles tendon repair can possibly accelerate the post-operative course by leading to a quicker participation in physical therapy; consequently, leading to rapid return to daily activity and consuming less opioid pain medication post-operatively.

The Achilles tendon is the strongest tendon in the human body; however, it is the most frequently injured tendon as well. As the main contributor to ankle plantarflexion, approximately a third of sport-related injuries affect the Achilles tendon occurring mostly during high-level activities such as, football, soccer, and tennis. The Achilles tendon is comprised of fibers originating from the medial and lateral heads of the gastrocnemius muscle, the plantaris muscle, and the soleus muscle and inserts onto the posterior middle aspect of the calcaneus [1, 2, 3] . Roughly 5-7 cm proximal to the calcaneal insertion lays the watershed area, which has the smallest cross-section area; thus, is the most common site for Achilles injury [3].

Achilles tendon rupture is a significant and debilitating injury that often results from sporting activities in patients younger than 55 years of age [4]. Achilles tendon ruptures may be partial or complete and are misdiagnosed in 20% to 25% of patients [1]. The mechanism of Achilles injury often involves a noncontact process described as a forceful dorsiflexion of a plantarflexed or aggressive push-off with an extended knee [1]. Many patients describe an Achilles tendon injury as a sensation of getting hit in the area of the tendon as they experience a sudden snap or audible “pop” along with a shooting pain. Appropriate managements of Achilles ruptures relies on both conservative and operative treatment; although historically, operative treatments has been associated with lower re-rupture rates and decreased recovered time with restored functional outcomes compared with conservative treatment modalities [1, 5].  A meta-analysis conducted in 2010 analyzed 14 various studies and noted a 12.6% re-injury rate with conservative therapy in comparison to a 3.5% re-injury rate following surgical treatment of acute Achilles tendon rupture, and all groups benefitted from accelerated rehabilitations [1, 4]. 

Conservative treatment may include orthotics, offloading the injury, physical therapy, and the concomitant use of Non-Steroidal Anti-Inflammatories (NSAIDs) [6]. Furthermore, there is a wide variety of surgical techniques for Achilles tendon ruptures, including percutaneous repair, end-end anastomosis, variable anchors, and the use of pliable biological tissue matrix and graft techniques [7]. The latter have been associated with decreased pain and increased recovery time, alongside improved rehabilitation [8,9]. In addition, the ease of application during operative technique to the site of injury and the ability to incorporate and remodel with host tissue supports the use of the technique.

The human placenta is an absolute rich source of biological tissue, comprising the placenta, amniotic membranes, amniotic fluid, umbilical cord, and umbilical cord blood [6,10]. Additionally, it is noted that placental tissues elicit little/no immune response in the patient; therefore, reducing the risk of rejection and graft failure following implantation. Lullove, E demonstrated the use of flowable tissue matrix allograft, derived from human placental connective tissue, for acute posterior tibial tendon injury using percutaneous injection [6]. In all 10 patients, pain was resolved by week 5 and based on the VAS pain scores reported, the 10 patients showed a strong correlation for using amniotic tissue allograft injection to resolve acute tendon injuries rapidly [6].

Acellular dermal graft that is derived from human tissue that has been processed to remove the living cells and preserve an intact matrix that can be revascularized and re-populated by the recipient following transplantation [11]. Skedros et al. described a case of a latissimus dorsi tendon transfer with the use of acellular dermal matrix augmentation to increase tendon length for an irreparable rotator cuff tear in a 50 year-old male (both supraspinatus and infraspinatus tear).  [12] used two 4x 7cm patches of acellular dermal matrix were used to extend the LDT, with each patch thickness of 2.0mm, and reported that the patient had marked improvement in his shoulder range of motion after LDTT with acellular dermal matrix extension of the LDT. Thus the use of  acellular dermal matrix to increase LDT length may be indicated in LDTT cases where sufficient length is non-attainable [12].

Repair of an acute Achilles tendon rupture with augmentation of a common acellular dermal matrix and a flowable decellularized human tissue matrix to accelerate tendon healing, to our knowledge, has not been reported in the literature. We report a case of a 47 year-old diabetic male who presented to clinic 11 days status post near complete rupture of the Achilles tendon. The main objective of our study is to demonstrate the combine use of acellular dermal matrix and particular human placental connective tissue matrix to augment the post-operative course with decrease in pain and increase in return to activity. 

​

A 47 year-old well controlled Type II Diabetic African American male presented to office 11 days status post near complete Achilles tendon rupture, left lower extremity that occurred while playing soccer.  Patient is an athletic adult male that admits to experiencing and hearing a “snap” to the left heel while playing soccer on January 26, 2017. Patient reported to outpatient office on February 6, 2017 and states that he utilized RICE therapy at home to alleviate symptoms to the left heel without much success. Upon initial clinical presentation, patient displayed a mild antalgic gait to the left lower extremity with guarding upon push-off.  Tenderness to palpation noted at the insertion of the Achilles tendon along the posterior aspect of the calcaneus with a noted palpable “dell” defect approximately 4cm proximal to the insertion with surrounding erythema with moderate, +2, pitting edema.  Muscle strength was diminished to the left with resistant plantarflexion compared to contralateral with a positive Thompson Test, the inability for ankle plantarflexion with calf squeeze.  Pedal pulses were palpable to bilateral lower extremities, gross and protective sensations were intact. An MRI of the left ankle without contrast was performed with a multiplanar multisequence technique at an outpatient setting [Figure 1].

Figure 1: A sagittal T2 MRI image demonstrating the Achilles tendon rupture approximately 4cm proximal to the Achilles tendon insertion

On impression, there was noted to be an obliquely oriented longitudinal tear throughout the Achilles tendon involving the lateral fibers of the tendon at its insertion onto the calcaneus. The pattern of the tear was noted transverse obliquely from lateral to medial.  Surgery was scheduled and performed for open repair of the left Achilles tendon with augmentation using acellular dermal matrix tissue and decellularized particulate human placental connective tissue matrix two weeks following the initial reported date of injury.

Open repair of the near-complete rupture Achilles tendon was performed under at Aventura Hospital and Medical Center Surgical Unit. The patient was placed on the operating room table in a prone position under general anesthesia with no tourniquet utilized and a marking pen was utilized to map vital anatomical structures. A posterior longitudinal incision about four inches long was performed to expose the ruptured tendon. Intra-operative repair of the near complete tear consisted of sharp dissection of the zone of injury with distal and proximal muscle fibers well approximated with knee flexion and ankle dorsiflexion and plantarflexion. Number 2-0 vicryl suture was than utilized for tubularization of the proximal and distal ends of the tendon and adequate re-approximation was performed using a Krakow type stitch with number 2-0 vicryl. At this time, 1.5mL of flowable human connective tissue matrix was injected into the mid-substance of the Achilles tendon at the area of the rupture, as well as along the course of the tendon [Figure 2 A-C].

Figure 2: Intra-operative examination of acute Achilles tendon repair using Krackow suture technique and flowable tissue matrix. A) Intra-operative exposure of near-complete rupture of Achilles tendon prior to sharp debridement. B) Intra-operative repair of ruptured Achilles tendon with Krackow stitch utilizing 2-0 Vicryl. C) Intra-substance injection of repaired Achilles Tendon utilizing flowable decellularized particular human placental connective tissue.

Next, a 2cm x 4cm acellular dermal matrix was pulled upward beneath the sutured Achilles tendon at the previously noted rupture site and superiorly across the tendon; therefore, enveloping the tendon. The ends of the acellular dermal matrix remained visible and three pairs of horizontal mattress sutures (number 3-0 vicryl) were passed along the acellular dermal matrix and tendon. Intra-operative Achilles tendon passive range of motion was demonstrated with ankle plantarflexion and dorsiflexion with the knee flexed and extended. Careful dissection was performed throughout the procedure in order to preserve the paratenon which was then closely re-approximated using number 3-0 vicryl suture, enveloping the repaired tendon and acellular dermal matrix. 

The patient was then placed in a well-padded posterior splint with slight plantarflexion applied at the ankle joint for 2 weeks. Gently passive ankle range of motion was allowed only after 2 weeks. Weight bearing exercises with restrictions where allowed at 4 weeks after surgery with close follow-up in office.  The patient’s pain (0-10), edema, and erythema were all recorded post-operatively on days 3, 10, 17, 24, and 38 in an outpatient clinical setting. Significant improvement was noted in all three categories on post-operative day 17. Such findings indicate that the method of combining acellular dermal matrix and during an open Achilles tendon repair can possibly accelerate the post-operative course by leading to a quicker participation in physical therapy; consequently, leading to rapid return to daily activity and consuming less opioid pain medication post-operatively.

​

The Achilles tendon is the strongest tendon in the human body; however, it is the most frequently injured tendon as well. As the main contributor to ankle plantarflexion, approximately a third of sport-related injuries affect the Achilles tendon occurring mostly during high-level activities such as, football, soccer, and tennis. Appropriate management of Achilles tendon ruptures, either conservative or operative, is essential for early rehabilitation and return to physical activity. Although conservative measures are warranted in many cases, operative treatments have been associated with lower re-rupture rates and decreased recovery time with restored function outcomes compared with conservative treatment modalities [1,5]. Hussain et al. conducted a study consisting of two surgical teams in various Military hospitals in Pakistan, level 3 facilities, from June 8 to June 2011. Researchers gathered 10 cases of tendo-Achilles ruptures in middle aged soldiers (28-44 years) with a mean follow-up was 18 months, in order to compare operative technique consisting of the Krackow stitch for complete repair versus conservative, non-operative treatment. They noted that patients returned to professional activities on average 3.5 months following the initial injury and resumed physical activity on average 6.8 months after initial injury [13]. They concluded that open surgical repair of Achilles tendon ruptures leads to decrease chances of re-rupture and decrease complication rates as compared to percutaneous repair or conservative treatment [14]. There is a wide variety of surgical techniques for Achilles tendon ruptures, including percutaneous repair, end-end anastomosis, variable anchors, and the use of pliable biological tissue matrix and graft techniques. The latter have been associated with decreased pain and increased recovery time, alongside improved rehabilitation [8,9]. In addition, the ease of application during operative technique to the site of injury and the ability to incorporate and remodel with host tissue supports the use of the technique.

At the time of surgical repair, it was unknown whether adequate re-approximation of the Achilles tendon utilizing a Krackow stitch alongside tendon augmentation using acellular dermal matrix and a decellularized particulate human placental connective tissue matrix would allow for accelerated post-operative recovery. As demonstrated in our case report, the patient’s post-operative pain (0-10), edema, and erythema were all recorded on post-operative days 3, 10, 17, 24, and 38 in an outpatient setting. Physical and clinical examination revealed significant improvement in all three categories on post-operative day 17 with a faster return to daily activity.

Post-Operative Management

Patient was immobilized in a posterior splint and non-weight bearing for two weeks. Sutures were removed from the surgical site at two weeks without incident. At six weeks, patient was transitioned to weight bearing as tolerated in a CAM walker with assistive walking device and began physical therapy. At eleven weeks, patient returned to full weight bearing status and activity without CAM walker or assistive walking device for ambulation [Figure 3].

Figure 3: Patient at 11 weeks

Improvement was noted in all three categories (pain, erythema, and edema) on post-operative day 17. Such findings indicate that the method of combining acellular dermal tissue matrix and decellularized human placental connective tissue matrix during open Achilles tendon repair can possibly accelerate the post-operative course by leading to quicker participation in physical therapy; thus, leading to a rapid return of daily activity and consuming less opioid pain medication post-operatively. To our knowledge, this is the first documented case study that has investigated the use of both acellular dermal tissue matrix and decellularized human placental connective tissue matrix during open Achilles tendon repair to further investigate whether such augmentation aids in accelerated healing of the damaged tendon. Such indication demonstrate that we can possible use a similar treatment course in other lower extremity tendon injuries, such as Tibialis Anterior, Extensor muscle groups, and peroneals.  

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity.  The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities. 

1. Santrock, R.D, Friedman A.J, Hanselman A.E (2017) Acute rupture open repair techniques. Clin Podiatr Med Surg 34: 245-250.

2. Pekala P.A, Henry B.M, Ochala A, Kopacz P, Mlyniec A et.al (2017) The twisted structure of the Achilles tendon unraveled: A detailed quantitative and qualitative anatomical investigation. Scand J Med Sci Sports 1–11.

3. Bussewitz B.W (2017) Repair of neglected Achilles rupture. Clin Podiatr Med Surg 34: 263-274.

4. Devries J.G, Scharer B.M, Summerhays B.J (2017) Acute Achilles rupture percutaneous repair: approach, materials, techniques. Clin Podiatr Med Surg 34: 251-262.

5. Yammine K, Assi C (2017) Efficacy of repair techniques of the Achilles tendon: a meta-analysis of human cadaveric biomechanical studies. The Foot 30: 13-20.

6. Lullove E (2015) A flowable placental tissue matrix allograft in lower extremity injuries: a pilot study. Cureu.

7. Wallace RG, Traynor IE, Kernohan WG, Eames MH (2004) Combined conservative and orthotic management of acute ruptures of the Achilles tendon. J Bone Joint Surg 86: 1198-202.

8. Schneider K.H, Aigner P (2016) Decellularized human placenta chorion matrix as a favorable source of small-diameter vascular grafts. Acta Biomaterialia 29: 125-134.

9. Torregrosa J. (2013) Anterior talofibular ligament rupture/repair and reinforcement using dermaspan acellular dermal matrix: a single patient case study. Biomet Orthopedics.

10. Bhattacharya N, Stubblefield P (2011) Regenerative Medicine Using Pregnancy-Specific Biological Substances. Stubblefield P Springer-Verlag, New York.

11. Brigidio SA (2006) The use of an acellular dermal regenerative tissue matrix in the treatment of lower extremity wounds: a prospective 16-week pilot study. Int Wound J 3: 181-187.

12. Skedros J.G, Henrie T.R (2017) Latissimus dorsi tendon transfer with GraftJacket augmentation to increase tendon length for an irreparable rotator cuff tear. Department of Orthopedic Surgery.

13. Hussain Z, Anwar A (2013) Achilles tendon rupture in middle aged soldiers: an experience of 10 cases. Pakistan Armed Forces Medical Journal.

14. F.Fitoussi, M.Bachy (2015) Tendon Lengthening and Transfer. Orthopaedics and Traumatology 1: 149-157.