Vol 32 | Issue 2 | July – Sep 2017 | page:17-23 | P Ahmed, Y Usmani, Apoorv Mohan Garg.
Authors: P Ahmed , Y Usmani, Apoorv Mohan Garg .
Department of Orthopaedics, LLRM Medical College, Meerut, Uttar Pradesh, India,
Department of Radio-diagnosis, LLRM Medical College, Meerut, Uttar Pradesh, India.
Address of Correspondence
P-16 Medical College Campus, LLRM Medical College, Meerut, U.P.(PIN-250004)
Introduction: Chronic rupture of Achilles tendon causes marked functional impairment. The recommended treatment for this is surgery and various techniques have been reported in the literature.
Materials and Methods: From 2008 to 2016, 30 patients (20 men and 10 women) operated with Bosworth Technique (23 patients) or peroneus brevis (PB) tendon transfer (7 patients) were included for the study. At 12-month follow-up, all patients were assessed with regard to post-operative complications, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot score, and ankle range of motion.
Result: AOFAS scores increased from an average 61.57/100 (range, 58-80) pre-operatively to 95.91 (range, 90-98) post-operatively for Bosworth technique. AOFAS scores increased from an average 61.14/100 (range, 58-64) pre-operatively to 96.71 (range, 94-98) post-operatively for PB tendon transfer technique. All patients were able to perform their daily activity unrestrictedly at last follow-up. Two patient experienced wound dehiscence and 1 patient had hypertrophic scar in Bosworth technique while 1 patient experienced wound dehiscence in PB Tendon transfer technique.
Conclusion: Both the techniques have near similar functional outcome and complication rate. However, Bosworth technique has limitations in the form of requirement of the distal stump and imparting of bulky consistency to the tendoachilles which are not present with PB tendon transfer technique. Either of the technique can be used as per the surgeon’s preference and expertise as well as patients profile and choice.
Keywords: Bosworth technique, chronic Achilles tendon rupture, peroneus brevis tendon transfer.
The Achilles tendon is the strongest, largest, and thickest tendon in the body,1 yet it is the most frequently ruptured tendon,2 with most ruptures occurring at the watershed area approximately 2 to 6 cm proximal to insertion of the tendon.1 Achilles tendon ruptures and incidences in general have increased substantially during the last few decades and are most commonly seen in middle aged males, 30-50 years old, who participate intermittently in recreational athletic with 75% of all ruptures occurring during sporting activities1, 2. Ruptures additionally can occur in the older patient, usually in those with underlying tendenosis, and may be asymptomatic or subclinical. They usually do not feel the classical sensation of being kicked or hit in the calf nor hear an audible snap, and ruptures tend to occur during low-energy activities. As such, these ruptures may be more difficult to recognize and may be more frequently missed on initial evaluation. Although there is debate of what may be considered a chronic injury, 4 to 10 weeks have been used by various authors1, 2, since 4 weeks is the earliest time point that has demonstrated histological evidence of chronic healing.3 Patients initially present with swelling, complaints of weakness, difficulty in climbing up and down stairs, loss of balance, and a tendency to fall forward. Loss of Achilles function leads to loss of plantar flexion strength, weakness, fatigue, limp, inability to run, heel rise and play sports1, 2. There is wasting in calf muscle and often a palpable gap between the ends of the Achilles tendon. In chronic Tendo-Achilles rupture, there is 20% less endurance of the muscle and the treatment becomes more difficult.2 If the tendon is not repaired or immobilized, retraction of the muscle fibers leads to decreased muscle tension until it becomes zero at about 60% of the fibers’ resting length.4 The delay in treatment result from decreased pain after the initial injury, as well as misdiagnosis by the first evaluator, in up to 20-36% of patients.4 These delays in treatment, whether operative or non-operative, can have detrimental effects on the final outcomes. In the management for Chronic Tendoachilles rupture conservative treatment has now been entirely abandoned because of better results and less functional morbidity by operative methods. Moreover, clinical evaluations of non-operative treatment have demonstrated a re-rupture rate of 10–30%. Other drawbacks of non-operative treatment include decreased plantar flexion and decreased endurance when compared to surgically repaired tendons. Moreover, several current studies favour operative repair via open or percutaneous techniques in younger, active patients who wish to return to pre-injury activities. Definitive advantage of surgical repair includes lower Re-rupture rate in surgically repaired Achilles tendon however the complications of operative repair include infection and poor wound healing at the surgical site which is more deliberated. The primary goal of any surgical treatment is to restore the function and strength of the gastrocnemius-soleus complex by recreating the optimal length-tension relationship by many surgical techniques described for the management of neglected Achilles ruptures which include end to end repair of the tendon as in V-Y plasty; gastrocnemius soleus complex “turn-down” of proximal Achilles Tendon tissue described by Bosworth5 and others like Coughlin; local tendon transfer Techniques like that of peroneus brevis (PB)6 or flexor hallucis longus (FHL) tendon or by use of synthetic grafts including carbon fiber composites, polyglycol threads, and polyester mesh. Any of these techniques each with their own pros and cons can be used by the surgeon depending in the patients demand and surgeon’s expertise.
AIMS AND OBJECTIVES
The purpose of this article is to evaluate and compare the clinical and functional outcomes of 30 patients presenting with Chronic tendoachilles rupture who were treated either by Bosworth Technique or Peroneus Brevis Tendon Transfer technique and to determine the advantage disadvantage of each technique over the other. The patients functional outcome were assessed in post operative period by active plantar flexion at the ankle and by the ankle—hind foot scale developed by the American Orthopaedic Foot and Ankle Society (AOFAS Score) 7 and were compared statistically from the active plantar flexion at the ankle and AOFAS Score taken pre-operatively. Boyden Clinical Score was taken only in post-operative period after patient resume their normal unrestricted activity.
MATERIAL AND METHODS
The study was conducted at the department of orthopaedics in L.L.R.M. medical college and associated hospital, Meerut during period of 2015-2016. A series of 30 patients (20 men, 10 women) were included for the study. All patients were admitted through OPD and operated with either Bosworth Technique or Peroneus Brevis Tendon transfer from 2008 to 2015 were included and reviewed retrospectively and case operated from 2015 to 2016 were included and followed up prospectively. Patient with associated Severe co morbidities like uncontrolled diabetes, poor skin condition, compound Tendo-Achilles rupture were excluded from the study. MRI of the affected Leg was done on each patient to assess the severity of rupture, partial rupture or complete tear.
Anaesthesia was given in the form of spinal anaesthesia/General anaesthesia. The patient was placed prone on the operating table with body supported on bolster one each at just below the level of shoulder supporting the body at the anterior wall of chest and other bolster at the level of level of pubic symphysis. Pneumatic tourniquet was applied to the lower extremity at the thigh. The whole extremity was then painted and draped under aseptic precautions. A posterior longitudinal midline incision, extending from the calcaneus to the proximal one third of the calf was given and the ruptured tendon was exposed. The scar tissue formed between the ends of the ruptured tendon was then excised with sharp dissection. From the median raphe of the gastrocnemius muscle a strip of tendon approx 1.5 cm wide and 17.5 to 22.5 cm long was freed and left attached just proximal to the site of rupture. Strip was then turned distally and passed transversely through the proximal tendon and anchored there with absorbable suture. The strip was then passed distally and then transversely through the distal end of the tendon and passed again through this end from anterior to posterior.While holding the knee at 90 degrees and the ankle in plantar flexion, the fascia strip was drawn tight and anchored with absorbable suture. The strip was then brought proximally and passed transversely throught the proximal end of the tendon, and then was carried distally and sutured on itself. Wound was closed and above knee cast was applied with ankle in maximum equinus.
PERONEUS BREVIS TENDON TRANSFER TECHNIQUE
Anaesthesia was given in the form of spinal anaesthesia/General anaesthesia. The patient was placed prone on the operating table with body supported on bolster one each at just below the level of shoulder supporting the body at the anterior wall of chest and other bolster at the level of level of pubic symphysis. Pneumatic tourniquet was applied to the lower extremity at the thigh. The whole extremity was then painted and draped under aseptic precautions. A posterior longitudinal midline incision, extending from the calcaneus to the proximal one third of the calf was given and the ruptured tendon was exposed. A 2 cm longitudinal incision was then made at the base of 5th metatarsal. Both distal and proximal stump of the ruptured tendon were mobilized by removing peritendinous adhesions and resecting the ruptured tendon back to the healthy tendon. Soft tissue anterior to the soleus and gastroicnemius were realeased to allow max excrusion and minimizing gap between the tendon stumps. The peroneus brevis tendon was then identified and exposed through the incision at the foot and was released from its base after placing a locking suture with absorbable suture. Through the posterior longitudinal midline incision over the Achilles tendon, the deep fascia overlying the peronei muscles was incised identifying the peroneus brevis tendon and withdrawing through the midline incision. The peroneus brevis muscle was then mobilized and a longitudinal tenotomy parallel to the tendon fibres was done in both the tendon stumps. A plane was developed in the distal stump of Achilles tendon and peroneus brevis graft was passed through the tenotomy. It will then be sutured to both sides after putting the ankle in full plantar flexion. Peroneus brevis tendon was then passed beneath into the proximal incision and then from medial to the lateral through transverse tenotomy in proximal stump and then it was secured with absorbable sutures. The peroneus brevis was then sutured back on itself on the lateral side of proximal incision. Wound was closed and above knee cast was applied with ankle in maximum equinus.
POST OPERATIVE CARE
Sutures were removed at 2 weeks and above knee cast with ankle at maximum equines continued till 4 weeks. After 4 weeks cast was changed again and below knee cast with foot gradually brought in plantigrade position was applied for next 2 weeks. At 6-8 weeks, full weight bearing was allowed with the application of removable brace with foot in plantigrade position and gentle range of motion exercises for 20min twice a day were begun along with isometric ankle exercises supplemented with knee strengthening exercise. After 3 months, toe raising exercise with progressive resistance exercises and proprioceptive exercises were started. After 6 months, full unrestricted activity was allowed.
Patients were called for 1st follow up at 15 days for stitch removal. 2nd follow up was at 1 month after surgery when below knee cast was applied bringing the foot in plantigrade position from equines. 3rd follow up was at 2 months after surgery when the cast was removed and physiotheraphy started. 4th follow up was at 3 months after surgery at which first AOFAS score and active plantar flexion is measured for outcome. Subsequent follow ups were then at every 3 months interval till 1 year from surgery at which final AOFAS score and active plantar flexion was measured followed by yearly follow-up.
A series of 30 patients (20 males, 10 females) were included for the study out of which 23 patients (16 males, 7 females) were operated by Bosworth technique for tendon repair while 7 patients (4 males, 3 felmales) were operated by Peroneus brevis tendon transfer technique. Out of 30 patients included in the study 20 patients (66.67%) were male and 10 patients (33.33%) were female thus giving a male to female ratio of 2:1. Age of the patients were between 21 years to 48 years with mean age of 41 years with standard deviation of 6.34. Out of 30 patients included in the study 17 patients (56.67%) had Tendo-Achilles rupture at Right side and 13 patients (43.33%) had rupture at Left side. It was found that minimum follow-up duration of the patients were 12 months while maximum was upto 84 months with the median value of 24 months and interquartile range of 6. Out of the 30 patients in our sample size, 14 (46.67%) had a history of Injection at the Tendo-Achilles and 16 (53.33%) didn’t had a history of injection at Tendo-Achilles. In patients operated with Bosworth Technique, pre-operative active plantar flexion of the patients ranged from 10-40 degrees with median value of 25 degrees and mean active plantar flexion of 22.61. The improvement in active plantar flexion was seen at post-operative period of 12 months with range of 40-50 with median value of 50 and mean active plantar flexion of 49.13 degrees. On comparison it is found to highly statistically significant with P-value less than 0.001. Pre-operative AOFAS score of the patients was from 58-80 with median value of 60 and mean value of 61.57. The improvement in AOFAS score was seen during post-operative period of 12 months which was found to be from 90-98 with median value of 97 and mean value of 95.91. On comparison with pre-op AOFAS Score a significant improvement was seen which was found to be highly statistically significant with P-value less than 0.001. In patients operated with Peroneus Brevis Tendon Transfer technique, pre-operative range of motion of the patients was from 20-40 degrees with median value of 30 degrees and mean active plantar flexion of 28.57. The improvement in active plantar flexion was seen during post-operative period of 12 months with range of 40-50 with median value of 50 and mean active plantar flexion of 50 degrees. On comparison it is found to highly statistically significant with P-value less than 0.001. Pre-operative AOFAS score of the patients was from 58-64 with median value of 62 and mean value of 61.14. The improvement in AOFAS score was seen during post-operative period of 12 months which was found to be from 94-98 with median value of 97 and mean value of 96.71. On comparison with pre-op AOFAS Score a significant improvement was seen which was found to be highly statistically significant with P-value less than 0.001. AOFAS score of the patients at 12 month post-op operated by Bosworth Technique ranged from 90-98 with median value of 97 and mean value of 95.91. AOFAS score of the patients at 12 month post-op operated by Peroneus Brevis Tendon Transfer Technique ranged from 94-98 with median value of 97 and mean value of 96.71. On comparison between AOFAS Scores of subjects at 12th month post-op by Bosworth Technique and AOFAS Scores of subjects at 12th month post-op by Peroneus Brevis Tendon Transfer Technique, it was found to be not statistically significant with P-value more than 0.05. In post-operative functional status of the 30 patients included in over study, as measured by Boyden Score, 29 (96.67%) cases were excellent and 1 (3.33%) cases were good at 12 months after the repair of Chronic Tendo-Achilles rupture. In our study out 30 patients operated for Chronic Tendo-Achilles Rupture, it was found that in 3 patients (10%) problem in wound healing occurred in the form of wound dehiscence out which 2 required reverse sural flap for closure. Only 1 patient (3.33%) had complication of hypertrophic scar over the incision site. No post-operative surgical site infection was found out in any of the 30 case subjects. None of the 30 case subjects neither suffered from re-rupture of the Tendo-Achilles
This study was conducted during 2015-16 on 30 patients who presented with Chronic Tendo-Achilles rupture and were treated with either Bosworth Technique of Tendo-achilles repair or by Peroneus Brevis Tendon Transfer technique in the department of orthopaedic surgery of L.L.R.M Medical College and associated S.V.B.P Hospital, Meerut from 2008-2016. In this study the age of the patients were between 21 years to 48 years with mean age of 41 years. Male patients (66.67%) were affected more than female patients (33.33%) with ratio M:F = 2:1. This can probably be attributed to Sports participation which has undergone an increase in recent decades and therefore there has been subsequent rise in Injuries due to sporting activity. The Achilles tendon has been one of the most common sports-related injuries. Schepsis et al8 observed in 2002 that Tendo-Achilles rupture is observed in men in the fourth to fifth decades of life with male to female injury ratios range from 2:1 to 12:1. Running, sprinting, jumping, and agility activities involving explosive plyometric contractions are usual mechanisms. In this study all of our subjects suffered trauma at their ankle which lead to rupture of Tendo-Achilles which has been consistent with the study conducted by Suchak AA et al9 in 2005. In our study 14 patients (46.67%) had history of corticosteroid injection at their Achilles Tendon while 16 patients (53.33%) had no history of steroid injection. Studies conductied by Maffulli et al10 in 1998 and White et al11 in 2007 implicated Two drugs that have been associated with delayed healing and tendon necrosis which were fluoroquinolone antibiotics and corticosteroids. Fluoroquinolone antibiotics have been observed to weaken the Achilles tendon extracellular matrix, resulting in less tensile tendon strength. Corticosteroids, used to decrease tissue inflammation, also cause collagen to weaken and decrease blood supply to an already avascular structure. The duration of presentation of patient to us with the chronic tendoachilles rupture ranged from 3 months to 36 months. In many patients the initial symptoms after an Achilles tendon rupture diminish quickly. In a study conducted by Christensen et al12 in 1953, out of 57 patients with acute Achilles rupture, 19 of them reported to be painless. Patients with Achilles tendon ruptures frequently are unable to stand on the toes of the involved side, however, active plantarflexion maybe intact due to partial ruptures, recruitment of plantar flexors, and an intact plantaris muscle. The lack of pain and no obvious loss of plantarflexion can be misleading and up to 20-25% of cases the diagnosis is missed initially13,14. The failure to establish the diagnosis at the initial presentation is the most common reason for delayed treatment. Hence, patient is unable to get the required treatment in time and thus showing a wide range of presentation. The follow up duration of our study ranged from minimum 12 months to maximum of 84 months with average duration of follow up being 23.6 months which is consistent with the literature. In our study, out 30 patients who underwent operative intervention for Chronic Tendo-Achilles rupture, 23 of them underwent repair by Bosworth Technique while Peroneus brevis tendon transfer was done on the 7 patients. For patients who underwent repair by Bosworth Technique, We observed that pre-operative functional score AOFAS score of the patients ranged from 58 to 80 with mean AOFAS Score of 61.57. Active plantar flexion of these patients averaged at 22.61o ranging from 10o-40o. For patients who underwent repair by Peroneus Brevis tendon transfer, We observed that pre-operative functional score AOFAS score of the patients ranged from 58 to 64 with mean AOFAS Score of 61.14 and they had range of active plantar flexion from 20o-40o with average flexion of 28.57o in preoperative period. The average AOFAS score of the patients who underwent repair by Bosworth Technique significantly increased to 95.91 with a range from minimum 90 to a maximum of 98. Active plantar flexion of these patients averaged at 49.13o ranging from 40o-50o. The average AOFAS score of patients whose Tendo-Achilles was repaired by Peroneus brevis tendon significantly increased to 96.71 with a range from minimum 94 to a maximum of 98. Active plantar flexion of these patients averaged at 48.57o ranging from 40o-50o Out of 30 patients, 5 (16.67%) patients gave a poor score on Boyden scale in pre-operative period to their condition while rest 25 (83.33%) patients had a fair score in Boyden Scale. However in post-operative period, only 1 (3.33%) patient gad a good score on Boyden scale while rest (96.67%) had excellent score on Boyden scale which a significant improvent as compared to previous non-operative state. No intra-operative complication were encountered in any of our cases. Among the post-operative complications, wound dehiscence were found in 3 (10%) of our patients and in 1 (3.33%) patient hypertrophic scar over the incision site was found. Scar hypertrophy was later managed by triamcenolone acetate injection locally with compression bandage. Out of the 3 patients with wound dehiscence in post-operative period, 1 was managed conservatively and healing occurred with daily cleaning and dressing of wound with normal saline and placental extract while other 2 patients where managed by reverse sural flap surgery for their wound. There was no post-operative instability in any of our patients. No post-operative infection was reported in our group. There was no incidence of re-rupture following the procedure in our group. Although wound healing is usually a general complication for most procedures, it is particularly concerning for an Achilles tendon repair. This is because the tendon itself has relatively little soft-tissue coverage and this area of skin has a notoriously poor blood supply. Therefore, any type of wound healing problem can easily end up involving the tendon itself. For most patients, there is approximately a 2-5% chance of a significant wound healing problem. The risk of a wound healing problem increases significantly in smokers and diabetics. In our study 2 patients showed post-op wound dehiscence for which sural flap was done while 1 was healed conservatively with daily dressing by placental extract. Wound detachment and rerupture are well known complications after open surgical treatment of Achilles tendon ruptures. However, open rerupture after surgical treatment of the Achilles tendon occurs much less frequently as compared to conservative treatment. According to a meta-analysis by Bhandari et al15 the rerupture rate with surgical treatment (3.1%) was significantly lower than with nonsurgical treatment (13%). However, there were wide confidence intervals in his included studies. In a meta-analysis by Khan et al16 the rerupture rates were estimated at 3.5% and 12.6% in surgically and nonsurgically treated patients, respectively. García Germán et al17 reported on 2 cases in which they hypothesized that open rerupture may have been related to incomplete closure of the paratenon. Mellor et al18 reported that the rates of wound break down, infection and rerupture after surgical repair were lower when special care was taken to perform a correct separate repair of the paratenon. Graf et al.19 found that the role of a well vascularized paratenon was of paramount importance in the surgical treatment of a rupture and correct closure could help vascularization and avoid adhesion to superficial layers. We performed a complete suture of the paratenon in all of our cases and we found no rerupture of the tendon although we believe that more cases are needed to comment with certainity about the rerupture rate. Animal studies have shown the importance of mechanical loading in tendon healing. Langberg H et al20 in 1999 and Olesen JL21 in 2007 have stated in their study that tendon strengthening occurs because exercise leads to anabolic responses of tendons such as increase in the formation of type I collagen in peritendinous tissue, as shown by microdialysis measurements. In 2009, Kjaer M, Langberg H22 et al showed in human models, that mechanical load leads to an increase in collagen synthesis and tendon size. The current AAOS guidelines23 recommend early, protected, postoperative weight-bearing. In our study, all our patients were placed on protected weight bearing as early as within 4 weeks of post-operative period. On comparing the clinical and functional outcome between the Bosworth technique of tendon repair and Peroneus brevis tendon transfer technique, it was not found to be of statistical significance as each of the technique independently provided the near to normal result at 12 months after the surgery. The AOFAS score of 95.91 for the Bosworth technique is only marginally lower than the AOFAS score of 96.71 by the Peroneus brevis tendon transfer technique of tendon repair. As fas as active plantar flexion at the ankle is concerned in the post-operative patients, Bosworth technique(49.13o) fared well although marginally when compared to Peroneus brevis tendon transfer(48.57o). As we all know that plantar flexors are the muscles that push off the ground during walking. Harvesting the plantar flexors results in weakening the push-off phase of walking and is distressing, particularly in young persons24. In cadavers, the failure load was significantly higher in Achilles tendons reconstructed with the peroneus brevis tendon25. After peroneus brevis tendon augmentation, the strength of eversion may be mildly weakened but that of plantar flexion can be maintained26. According to a study conducted by Clarke HD et al27 in 1998, the 2 peroneal muscles contribute only 4% of the work capacity for plantar flexion, but for eversion the peroneus brevis tendon contributes about 28% of the total work strength. Thus, the use of the peroneus brevis tendon may cause a strength deficit in eversion of the ankle but a negligible deficit in planter flexion. Nonetheless, the peroneus longus, which is the major evertor of the hind foot, may take over some of the functions of the peroneus brevis28. Thus, subjective weakness in ankle function after peroneus brevis tendon augmentation is minimal29. This can be cause of slightly less active plantar flexion although insignificant in patient with peroneus brevis tendon transfer. Moreover, it can also be hypothesized that Bosworth technique doesn’t disturb other compartment of the leg. This in theory can cause decrease in movement at the ankle joint due to more dissection around the ankle as well as more involvement of normal functioning tendon for reparative function, which is not done in case of Bosworth technique. Nonetheless, in our patients, ankle movement exercise was performed during rehabilitation as early as 2 months post-operative period and ankle strengthening exercises were started within 3 months post-operative period to reduce the post-operative stiffness of the joint and to achieve near normal range of motion at the ankle.
Chronic Achilles tendon ruptures are not uncommon and potentially debilitating. Many surgical treatments are available for reconstruction of a neglected Tendo-Achilles rupture. The choice of management is partly guided by the type of tendon lesion, with most injuries requiring operative management. Many techniques can be used to repair or reconstruct a tendon with a chronic rupture. Most studies have been retrospective and small and have focused on the results of a single technique. There is no concrete data to support one technique over another; hence, there is no “gold standard”. Most agree, however, in order to achieve the optimal functional outcome surgical reconstruction is required. Regardless of the chosen technique, the ultimate goal of surgical treatment is to restore the length tension relationship such that sufficient plantar flexion power is attained. Bosworth technique is a simple, safe and predictable repair with limitation of requirement of distal stump of atleast minimum 2 cm. This technique combines the benefit of operative procedure with reduced rate of re-rupture and non operative procedure by being technically simple and therefore restoring the tendon length and producing excellent functional improvement as shown by marked improvement in post-op AOFAS Score. Moreover, no separate incision is required apart from exposing the Achilles tendon and it does not disturb the anatomy of the adjacent compartments of the leg gives it the edge over other procedures. Peroneus brevis tendon transfer technique is one of the fewest tendon transfer technique with no limitations as of Bosworth Technique and is not associated with any residual morbidity in the foot when compared with FHL or FDL tendon transfer. Theoretical partial loss of eversion of foot is negligible and well compensated by the Peroneus longus. Although this technique does involve violation of two compartments of leg instead of one as in Bosworth technique, final clinical and functional outcome is marginally higher for Peroneus Brevis technique and is not statistically significant. Both the techniques are simple, safe and none of them have a higher complication rate or residual deformity when compared to each other. However, Bosworth technique have some limitations in the form of requirement of distal stump for the repair of Tendo-Achilles and imparting of bulky consistency to the Tendo-Achilles post repair which seldomly gives discomfort to the patient in post-op rehabilitation period. These limitations are not present with Peroneus Brevis Tendon Transfer technique. Both the techniques have near similar functional and clinical outcome and hence either of the technique can be used as per the surgeon’s preference and expertise as well as patients profile and choice after due consideration of procedure of the technique and possible complications and risks associated with either of them. Further study and critical analysis is needed with a larger sample size and a longer follow up.
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- Reddy SS, Pedowitz DI, Parekh SG, Omar IM, Wapner KL. Surgical treatment for chronic disease and disorders of the achilles tendon. J Am Acad Orthop Surg. 2009;17(1):3-14.
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- White DW, Wenke JC, Mosely DS, Mountcastle SB, Basamania CJ. Incidence of major tendon ruptures and anterior cruciate ligament tears in US Army soldiers. Am J Sports Med. 2007;35:1308-1314.
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|How to Cite this Article: Ahmed P, Usmani Y, Garg AM. Repair of Chronic Tendoachilles Rupture – Bosworth Technique versus Peroneus Brevis Transfer Technique – A Retrospective and Prospective Study. Journal of Bone and Joint Diseases. Jul-Sep 2017;32(2):17-23.|