Reconstruction of bilateral tendoachilles with fascia lata graft
A 19 year old male presented to outpatient department with slow and progressive enlargement of tendinous nodule on the posterior aspect of ankle for last 2 years. The disease had progressively worsened in last 3 months with difficulty in walking. The patient was mentally retarded (intelligence quotient 55). Clinical examination did not reveal nodule or mass anywhere else in the body. The patient's blood lipid profile showed hypercholesterolemia (serum cholesterol level 331.7 mg/dl) while serum uric acid level was normal. There was no history of prolonged medication or antecedent trauma. There was no similar history in any of his siblings. Karyotyping of the patient and his parents was normal.\nThe radiographs of the lower legs and ankles demonstrated bilateral soft tissue shadows on the posterior ankle region []. The masses on both sides extended from the ankle to the lower calf and were located along the expected course of the tendoachilles []. No associated calcification or osseous abnormalities were seen. Magnetic resonance imaging of the brain showed diffuse cerebral and cerebellar atrophy.\nFine needle aspiration cytology showed giant cell rich lesion both side. The patient was taken for bilateral wide local excision of tendoachilles and reconstruction of the tendon with fascia lata graft.\nThe curvilinear lazy S incisions were made on the posterior aspect of the lower calf till tendoachilles insertion in prone position. Tendoachilles exposed which revealed large grayish white rounded mass involving 3/4th of length on the right side and full length of tendoachilles on the left side []. Abnormal tendoachilles tendons were excised almost completely creating a large gap which was not possible to reconstruct by primary repair. The defect in each limb was almost from musculotendinous junction to insertion on calcaneum. The thigh was prepared for fascia harvesting. A 25 cm skin incision was made 6 cm proximal to the lateral femoral condyle at the lateral border of patella, extending towards the anterior border of the greater trochanter. The skin flaps were sharply elevated above the fascia lata and reflected apart. The sheath was outlined 3-4 cm anterior to the lateral intermuscular septum, that is, anterior to the iliotibial tract. The deep fascia of thigh was separated from the underlying muscle. A transverse incision was made through the fascia distally while two tissue forceps were used to hold and fasten the fascia. The fascial sheet of 30 cm × 10 cm was procured and divided into two halves of 30 cm × 5 cm each. Each sheet layered onto itself 4 times with width of one cm and secured by interrupted suture with 4-0 proline. One end of prepared deep fascia was sutured to the cut end of muscles with proline 3-0 then it was tunneled through a drill hole in the calcaneum. During the repair, the foot was kept in equinus to reduce the gap and produce repair under adequate tension []. Other end of fascia graft was sutured back to the muscle end of the gastrocnemius and soleus with proline 3-0. The closure was done in layers. Thompson's test was done prior to dressing to check the integrity of reconstruction. The procedure was repeated in other limb in the same sitting. The excised specimen was sent for histopathological examination.\nGross specimen showed large cylindrical grayish white soft tissue mass that involved the tendoachilles completely on the left side and almost 3/4th of tendon on the right side. Specimen was measuring 12 cm × 3 cm × 3 cm on the right and 13 cm × 4 cm × 4 cm on the left side in craniocaudal, transverse and anteroposterior dimension [].\nMicroscopic examination showed a large number of granuloma composed of giant cells with foamy cytoplasm and lymphocytes in subepithelial tissue. Giant cell were mostly langhans type []. Adjacent tissue was with a smaller number of granuloma.\nPostoperatively, the ankle was immobilized in nonweight bearing plaster at 15° of plantar flexion for first 6 weeks and then in plantigrade cast for another 4 weeks. Stitch removal was done at 3 weeks postop and showed no evidence of wound dehiscence, infection or discharging sinus.\nAfter removal of plaster cast the patient was allowed to begin active physiotherapy. Weight bearing was delayed as this was a bilateral case. After 3 months, patient was allowed to increase weight bearing progressively within the limits of comfort. At 5 months followup the patient was able to walk without crutches. At 1 year followup, range of motion in both ankle joints was 15° of plantar flexion and 10° of dorsiflexion. The patient was able to stand and walk on toes, which he was able to since 6 months postsurgery []. Despite low intelligence quotient, at 1 year followup, the patient was independently mobile without pain with good cosmetic outcome. The functional outcome was satisfactory in all aspect except moderate limitation of sagittal and hindfoot motion with an American Orthopedic Foot and Ankle Society ankle hind foot score of 93/100.