One Step Double Augmentation with Human Dermis Allograft and Homologous PRP in Misdiagnosed and or Chronic Achilles Tendon Ruptures

Abstract

Objective: Misdiagnosed/chronic Achilles tendon injuries are rare and disabling for patients. The surgical treatment of these rare injuries aims to ensure the tendon heals mechanically and biologically. This is the prerequisite for a good clinical and functional outcome and reduces recurrences. The main aim of the study is to present a surgical technique that has proven to be original, reproducible, and capable of guaranteeing solid tendon repair and optimal tissue regeneration.

Methods: We treated five patients, four males and one female, with the one-step double augmentation technique. All patients of this study complained of pain, but above all severe functional limitation that Achilles tendon injury had been causing for more than a month. In this study, we widely described the surgical technique, original and not found in the literature, which provides a biological graft (allograft of decellularized dermis) and homologous, thrombin-activated, platelet-rich plasma (H-PRP) in a single step. Surgical approach, always used by the first author, respected predefined steps: careful dissection and preparation of the peritendinous tissues from suture to the end of the procedure, tenorrhaphy, and augmentation with allopatch to obtain a mechanically effective repair to avoid recurrences, and finally "biological" augmentation with a unit of homologous, thrombin activated, PRP. We offered to all patients a regenerative rehabilitation program post-operatively.

Results: All patients were evaluated clinically (functional clinical tests and questionnaires) and instrumentally (elastic-sonography and perfusion MRI). The obtained results have been evaluated at a minimum follow-up of 18 months and a maximum of 24 months. In all patients pain was resolved, and district function and kinetic chains improved with resumption of daily activities, work, and sports.

Conclusion: The present study confirmed the regenerative potential of decellularized dermis allograft and PRP (homologous and thrombin-activated). The same approach can also be exploited in cases of severe tendon destructuring and limited "intrinsic" regenerative potential at any age. The proposed one-step surgical technique of a double augmentation therefore appears useful, safe, reproducible, and applicable in all chronic tendon lesions with low regenerative potential.

Keywords: Achilles tendon; Double augmentation; Homologous platelet-rich plasma (H-PRP); Misdiagnosed chronic rupture; Regenerative medicine; decellularized dermis allograft.

Fig. 1

(A) Skin markers of the lesion site and hatched the incision site. (B) Allopatch of dermis. (C) Dissection and retrieval of the peritenon. D) Quantization of the lesion (adhesions, fibrosis, etc.).

Fig. 2

(A–C) Appearance of the tendon slippage‐type lesion.

Fig. 3

(A) Onlay passage of dermis allopatch. (B) Fully sutured allopatch.

Fig. 4

(A–D) Inlay‐Onlay augmentation in tendon slippage injury.

Fig. 5

(A–C) Suture of the peritenon.

Fig. 6

(A, B) Homologous activated PRP infiltration.

Fig. 7

In the left part of the image: B‐Mode ultrasound study. In the dx part of the image: elastosonographic study with good representation of blue areas demonstrating recovered tendon stiffness.

Fig. 8

(A) Conventional sagittal MRI study with altered Achilles tendon signal. (B) Dynamic perfusion MRI study. Signs of incomplete tendon healing are evident in the left image. Right image healthy side.

Fig. 9

(A) Dynamic‐perfusion MRI at 12 months after surgical treatment. Incomplete and evolving tendon “regeneration.” Green‐red signal. (B) Dynamic‐perfusion MRI at 18 months after surgical treatment. Complete tendon “regeneration.” Blue signal. (C) Conventional MRI in sagittal T1 at 12 months after surgical treatment. Uneven signal of the tendon however continuous. (D) Conventional sagittal T1 MRI at 18 months after surgical treatment. Good restoration of tendon structure.