|Year : 2021 | Volume
| Issue : 6 | Page : 242-246
Tendo-Achilles injury: An observational study in a tertiary care hospital
Parvesh Malik1, Shalendra Singh2, Onkar Singh3, Mannu Tiwari3, Nipun Gupta2, Munish Sood4
1 Department of Plastic Surgery, Command Hospital, Pune 411040, India
2 Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040, India
3 Department of Plastic Surgery, Command Hospital, Kolkata 700027, India
4 Department of Orthopedics, INHS Asvini, Mumbai 400005, India
|Date of Submission||17-Jun-2021|
|Date of Decision||27-Oct-2021|
|Date of Acceptance||29-Oct-2021|
|Date of Web Publication||30-Nov-2021|
Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune 411040
Source of Support: None, Conflict of Interest: None
Objective: To report demographic and injury characteristics of tendo-Achilles (TA) injury, and determine its association with the use of Indian style commode seat (ISCS), the clinical and functional outcomes.
Methods: This observational study was conducted between 1 January 2016 and 31 December 2019, and a total of 44 patients with TA injury were included in the study. Their demographic profile, etiology, operative details, and functional outcomes were studied. All patients underwent primary repair followed by standard postoperative management and follow-up for 6 months.
Results: Out of 44 patients, 7 (15.9%) sustained closed injuries while 37 (84.1%) sustained open injuries. In open injury cases, 30 (81%) patients suffered an injury due to slipping in ISCS, 4 (11%) from road traffic accidents, and 3 (8%) due to falling of a heavy object. Besides, 20.45% of cases of ISCS injury had associated neurovascular injury. Twenty (45%) patients took more than 90 days to start independent ambulation. At 6 months follow-up, no one could reach pre-injury fitness status.
Conclusions: Open TA injury by ISCS is an important, under-reported, and preventable cause of loss of physically active manpower in institutional setups.
Keywords: Tendo-Achilles; Open injuries; Indian style commode; Preventable morbidity
|How to cite this article:|
Malik P, Singh S, Singh O, Tiwari M, Gupta N, Sood M. Tendo-Achilles injury: An observational study in a tertiary care hospital. J Acute Dis 2021;10:242-6
|How to cite this URL:|
Malik P, Singh S, Singh O, Tiwari M, Gupta N, Sood M. Tendo-Achilles injury: An observational study in a tertiary care hospital. J Acute Dis [serial online] 2021 [cited 2022 Jan 19];10:242-6. Available from: http://www.jadweb.org/text.asp?2021/10/6/242/330742
| 1. Introduction|| |
Tendo-Achilles (TA) is one of the strongest tendons in the human body, and an intact TA is essential for a normal gait. Injury to TA can be open or closed, and irrespective of type it has a profound effect on both the personal and professional lives of the affected individual. Closed TA injuries are generally documented in people of a sedentary lifestyle as compared to the open type. Open TA injuries are not frequent though their incidences are on the rise. Even after recovering from an injury, it is very difficult for these individuals to reach pre-injury physical activity levels. This is vital in defense personnel who lead a highly active physical life.
A variety of mechanisms have been reported for open injuries, including cut injury by Indian style commode seat (ISCS) which has been described as one of the causes in few reports,,. This prospective observational study aims to report demographic and injury characteristics of TA injury and its association with the use of ISCS, clinical and functional outcomes.
| 2. Patients and methods|| |
2.1. Study design
This single-center observational study was conducted in a tertiary care hospital from 1 January 2016 to 31 December 2019.
A total of 46 patients with acute injuries around the ankle due to any activity or sports events were referred to the plastic surgery department during the period. Two patients were excluded from the study, of which one patient was lost to follow up and other found to have haematoma around ankle joint. Thus, the remaining 44 patients with open as well as closed TA injuries were included in this study. The diagnosis of TA injury was made on basis of history and standard clinical examination.
2.3. Ethical consideration
Informed consent was obtained from all patients, and this study was approved by the Ethical Committee of Command Hospital Kolkata (0039A dt 15 Nov 2017).
2.4. Treatment and follow-up
A standard treatment protocol was followed for all cases. For open injury cases, the wounds were irrigated with a copious amount of saline, and intravenous antibiotics were started. Both open and closed injury cases were given plaster of paris slab to keep the foot in plantar flexion attitude, and all were taken up for definitive surgery within the next 24 h. The surgery was performed in a prone position under spinal anesthesia. All open wounds were irrigated with a copious amount of saline and were debrided judiciously before tendon repair. Primary repair was done with modified Kessler’s core suture technique and epitenon sutures in all cases [Supplementary Figure 1] [Additional file 1]. Postoperatively, the ankle was immobilized in 20° plantar flexion position for 3 weeks and a neutral position for a further 3 weeks. At 6 weeks cast was removed and non-weight bearing ambulation was started. Full weight-bearing was encouraged after 8 weeks. All patients were assessed at 3 and 6 months for independent ambulation status, range of motion at ankle joint, motor power of repaired TA, and pain status.
2.5. Data collection
The data collected included patients’ demographic and injuries characteristics, surgery details, and clinical and functional outcomes at 3 and 6 months postoperatively. Pain status will be assessed using Visual Analog Scale (VAS) score that was explained to the patient preoperatively (0=no pain and 10=worst possible pain),. Motor power of repaired TA was assessed using 05 grade Medical Research Council (MRC) grade scale (0=no contraction and grade 5=normal power).
2.6. End points
The primary outcome of this observational study was to report severity of TA injury cases caused by ISCS, and secondary outcome was to evaluate the outcome of surgical treatment of these injuries.
2.7. Statistical analysis
The statistical analysis was done using SPSS Version 2.0. Categorical variables were expressed as numbers and percentages and compared across the groups using Fisher’s Exact Test. Continuous variables were expressed as mean and standard deviation and compared across the groups using Student’s t-test and Analysis of Variance. The significant level of this study was set at α=0.05.
| 3. Results|| |
A total of 44 patients reported TA injury during the study period, and the majority among these patients were young males. At 3 months, 29.5% of cases had MRC grade IV while at 6 months 68.2% had MRC grade IV. At 3 months, 72.7% of cases had a VAS score<2 while at 6 months 95.5% of cases had a score<2 [Table 1].
|Table 1: Demographic profile and characteristics of the study population.|
Click here to view
Out of 44 patients, 37 (84.1%) sustained open injuries. In 37 open injury cases, 30 (81.1%) gave a history of slipping of the foot into ISCS, 4 (10.8%) had road traffic accidents, and 3 (8.1%) were injured by a fall of the heavy object. Among 7 closed injury cases, 4 (57%) sustained an injury when playing sports; while the rest 3 (43%) got injured due to stumbling when running. Thirty patients (68.2%) presented within 48 h after injury, and 6 cases (13.6%) had pre-existing co-morbidities, out of which 4 had diabetes mellitus and 2 had hypertensive.
Out of 35 cases of the complete cut of the TA, 27 (77%) showed a history of injury from ISCS, and the difference in severity among 5 modes were significant (P=0.001). Out of 44 cases, 20 (45.4%) took more than 90 d to start independent ambulation, and in these 20 cases, 19 had ISCS injury (P=0.002) [Table 2].
|Table 2: Mode of injury of TA injury, management, and rehabilitation time.|
Click here to view
There were 9 (20.5%) cases of associated neurovascular injury, and all these cases had a history of slipping of the foot into ISCS [Table 2]. Post-operative wound complications were also more frequently observed in cases of injury caused by ISCS. There were 4 cases with wound healing problems (3 had skin margin necrosis and 1 had wound dehiscence). Among these, 3 patients had a history of a slip in ISCS while 1 had a road traffic accident.
The mean hospital stay was (18.07±8.46) d [Table 3]. The patients with ISCS injury had statistically significant longer mean hospital stay (20.60±8.39) d in comparison to cases of other etiologies (12.64+2.65) d (t=-2.47, P=0.017) [Table 3].
|Table 3: Comparison of length of hospital stay and range of motion at the ankle joint in various modes of TA injury cases.|
Click here to view
The mean range of motion at the ankle joint was (18.70±3.90) degrees at 3 months and (56.59±5.98) degrees at 6 months. Though all cases showed improvement, none of them reached to normal level at 6 months. Besides, the range of motion at the ankle joint, motor power of TA, and pain status in cases of different etiologies remained comparable (P>0.05).
| 4. Discussion|| |
In this observational study over 3 years, the most common cause of TA injury reporting to hospitals was injury due to ISCS, accounting for 81.1% of total cases of TA injury. ISCS is embedded in the ground at the same level as of surrounding floor. Because of the high user to commode ratio, there is a high turnover of individuals in a limited period. Due to which floor remains wet and chances of slipping off the foot into the lavatory pan increases. All these factors contribute to high chances of TA injury due to ISCS. Once the foot slips into the commode, the individual gets frightened and he tries to remove it reflexly, thereby the taut TA gets injured by a sharp rim of the undersurface of the posterior edge of the commode seat [Supplementary Figure 2] [Additional file 2],,,. The majority of our cases also gave this explanation when they described the events leading to injury caused by ISCS.
In our study, most cases were in the age bracket of 21-30 years. This profile of our study matches with the study reported by Chatterjee et al.. The number of females sustaining open injuries of TA is very less reported and even rare in the group of open TA injuries due to ISCS. The reason for this may be the cautious approach of females.
The patients are usually in remote locations where specialized medical facilities are required to treat TA injury are not available. So, these patients need to be transferred to the higher medical center for definitive treatment. In our study, 31.8% of cases took more than 48 h to reach our center from peripheral hospitals. The late presentation of these cases can affect wound condition and healing. In our study, it was observed that TA injury caused by ISCS is more severe. Around 77% of cases of the complete cut of TA and all cases with associated neurovascular injury in our study were because of ISCS. It may be explained by the mechanism of this injury.
The primary repair of the cut tendon and supervised physiotherapy with early passive mobilization produce satisfactory outcomes. We also followed this standard practice, and all the tendons were repaired primarily. The main complications of TA open surgery are skin edge necrosis, superficial wound infections, seroma, and hematoma formation, re-rupture, deep vein thrombosis, and rheumatoid arthritis,. We had minor skin edge necrosis in 3 patients, wound dehiscence in 1 patient. The wound dehiscence case came to our center after 72 h of injury which further emphasizes the role of the timely evacuation of the injured patient to the center having the facility of definitive surgery.
Duration of hospital stay is one of the known parameters to assess morbidity of an injury. The average hospital stay in our prospective observational study was around 18 d while earlier published studies had a hospital stay of around 7 d. We also noticed that ISCS injury cases had longer hospital stays as compared to other cases of TA injury. This difference in length of hospital stay observed in our study as compared to previously published study may be because of a great share of ISCS injury cases in our study. Moreover, most of our cases belonged to far areas of the country and no immediate family support was available to them.
The time taken to return to independent ambulation is an important parameter for outcome evaluation in cases of TA injury. In our study, 45.45% of cases took more than 90 d to start independent ambulation. In a study by Jallageas et al. where half of their cases were treated by percutaneous surgery and half by open surgery, the average time taken for independent ambulation was 70 d. In our study, all the cases were treated by open surgery.
At our 6 monthly follow-up, all the cases were able to do normal daily activities but none of them reached the pre-injury physical fitness level. In a study published by Lansdall et al., only 77% of patients returned to sports and 23% of their cases abandoned all physical activity after minimally invasive surgery for a rupture of TA after a one-year follow-up. There is no consensus on how many patients will return to play outdoor games after TA injury, and there is no universally applicable cut-off time for the start of active physical life after TA injury. A longer follow-up and further research are required to comment on the time taken to reach the pre-injury fitness level in cases of TA injury.
Among all the causes of TA injury, injury due to ISCS is avoidable. Institutions, where ISCS is still in common use, need to increase awareness among its users. The user to commode ratio must be limited, which will help decrease the turnover rate and will help in keeping the floor dry. All broken commodes and footrest should be replaced. Replacement by a western-style commode seat can be another viable solution. All these measures will reduce the chances of slipping off the foot and consequently reduce TA injury and morbidity associated with it.
One limitation of this study was the observational study restricted to mostly young surgical males within one tertiary care hospitals which prevented significant associations between patient variables and outcomes, and therefore may not represent the general population. Secondary, sample with greater variation of patient basal demographics and injury details would be useful for the identification of predictors of outcome. Thirdly, we only observed patient for six months, which required least 24-month follow-up.
Injury by ISCS is an important, under-reported, and preventable cause of TA injury. It includes financial implications in form of transferring the individual to higher medical centers and longer hospital stays. More importantly, the injury leads to avoidable attrition of manpower. Even after standard treatment and physiotherapy sessions for months, not all cases can reach their pre-injury fitness status.
Conflict of interest statement
The authors report no conflict of interest.
P.M. and M.T. collected and curated the data; P.M. and O.S. guide and concept of Study; S.S., N.G., and M.S. contributed to writing the manuscript; All authors read and approved the final manuscript.
| References|| |
Yin NH, Fromme P, McCarthy I, Birch HL. Individual variation in Achilles tendon morphology and geometry changes susceptibility to injury. Elife
Egger AC, Berkowitz MJ. Achilles tendon injuries. Curr Rev Musculoskelet Med
Soring D, Singh AM, Chishti SN, Nag R, Tada K, Sharmaet KK. Clinical outcome of open TA injuries within 12 hours of primary repair. J Dent Med Sci
Chatterjee SS, Sarkar A, Misra A. Management of acute open tendo-achilles injuries in India lavatory pans. Indian J Plast Surg
Mohsin M, Zargar HR, Bhat TA, Bhat HA, Mir FA, Wani AH. Open tendoachilles injuries due to squatting type of toilet seats: Five-year prospective observational study from a tertiary care center in India. Injury
Dar TA, Sultan A, Dhar SA, Ali MF, Wani MI, Wani SA. Response to ‘Toilet seat injury of the Achilles tendon’. Foot Ankle Surg
McCoy BW, Haddad SL. The strength of achilles tendon repair: a comparison of three suture techniques in human cadaver tendons. Foot Ankle Int
Langley GB, Sheppeard H. The visual analogue scale: its use in pain measurement. Rheumatol Int
Radhakrishna N, Rajagopalan V, Chouhan RS, Singh S, Pandia MP. Effect of preoperative transcutaneous electrical nerve stimulation on intraoperative anesthetic drug consumption and pain scores in patients undergoing lumbar discectomy under general anesthesia. Indian J Pain
Vanhoutte EK, Faber CG, van Nes SI, Jacobs BC, van Doorn PA, van Koningsveld R, et al. Modifying the Medical Research Council grading system through Rasch analyses. Brain
Dar TA, Sultan A, Dhar SA, Ali MF, Wani MI, Wani SA. Toilet seat injury of the Achilles tendon a series of twelve cases. Foot Ankle Surg
Cretnik A, Frank A. Incidence and outcome of rupture of the Achilles tendon. Wien Klin Wochenschr
(Suppl 2): 33-38.
Said MN, Al Ateeq Al Dosari M, Al Subaii N, Kawas A, Al Mas A, Al Ser Y, et al. Open Achilles tendon lacerations. Eur J Orthop Surg Traumatol
Moreira FP, Sousa A, Machado S. Neglected Achilles tendon rupture associated with rheumatoid arthritis: a case report and a brief review of the literature. BMJ Case Rep
Jallageas R, Bordes J, Daviet JC, Mabit C, Coste C. Evaluation of surgical treatment for ruptured Achilles tendon in 31 athletes. Orthop Traumatol Surg Res
Lansdaal JR, Goslings JC, Reichart M, Govaert GA, van Scherpenzeel KM, Haverlag R, et al. The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment. Injury
Zellers JA, Carmont MR, Grävare Silbernagel K. Return to play post- Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Br J Sports Med
[Table 1], [Table 2], [Table 3]