Bilateral Achilles Tendon Rupture: A Case Report and Review of the Literature

Round 1

Reviewer 1 Report

The work shows an interesting case, rarely found in medicine. However, the applied methods of treatment are not innovative, they only apply to both limbs at once.

 

A very short review of the literature (especially that the article is title: (...) Review of the Literature) - only 8 references (all older than the last 5 years). Please extend References.

 

The Case Presentation chapter should be split into the Materials and Methods chapters and the Results. The description should be extended in both target chapters.

Additionally, MRI results showing the described problems can be added and radiological images confirming proper convalescence.

 

Chapter Conclusion has the same number as chapter 3. Discussion. - please change.
Chapter 3. Discussion should be described in more detail.

 

I recommend that you include a list of abbreviations and their extensions at the end of the article.

 

Recommendation: The article describes an interesting topic. A case report can be interested to the scientific community. However, the article should be expanded.

Author Response

Thank you for your candid review of our case report.  We have made some significant changes based upon your review and the review of others.  I hope that these changes improved the quality of our manuscript, and will allow it to be a good addition to the literature.  Below is an outline of the changes we made according to your suggestions:

-The aim of our paper is to present an interesting case, discuss how we managed it, discuss commonly cited issues in management, and compare with how others have managed similar injuries.  We added statements throughout to try and establish this as our aim.

-We greatly expanded our review of the literature.  We now have 21 references, and we expanded the introduction and discussion considerably. 

-I agree that the case presentation is a bit lengthy and may be more clear if it was split.  However, from my review, it appears that Osteology would like the whole "Case Summary" to be one section.  Please correct me if this is not accurate and I would be happy to change it.  

-We added the 8 month post-operative MRI showing a healed Achilles tendon on the right side.  This is now figure 7.  

-I corrected the conclusion header to be "4. Conclusion"

-I added a list of abbreviations at the end

Thank you again for your review, and please feel free to let me know if you would recommend any further changes before submission.  

Reviewer 2 Report

The title of the article is very ambitious, but the content of the article does not allow meaningful generalizations to make.

Abstract

The relevance and main results of the work should be disclosed. I recommend presenting the aim of the work and expected results.

Introduction.

It is necessary to discuss the primary research conducted on the problem under consideration. It is required to disclose the practical benefits of the study (answer the questions: What are the main studies conducted? How will the authors' study data be applied?). It is necessary to formulate the aim of the work.

Discussion

The discussion is inconsistent. It is not clear what questions the authors seek to answer in this section. What statements by other authors do they agree or disagree with? What insights do the authors have in discussing the case under analysis?

Conclusion

It remained unclear what the study results were relevant to solving the problem. Why is it necessary to continue researching the problem?

Author Response

Thank you for your candid review of our case report.  We hope that the outlined changes below will improve the quality of our manuscript sufficiently.  In addition to the below changes based upon your recommendation, we have lengthened the introduction and discussion.  We have also tripled the number of references to present a more thorough review of the literature.  

-Abstract: we added a statement about the outcome of our treatment.  The goal of this case report is to show what others have done to manage similar injuries, present how we managed this problem, and explore complications/associated injuries.

-Introduction: We lengthened the introduction.  We added a statement about how difficult this constellation of injuries is to treat.  We also expanded on how these injuries typically occur.  

-Discussion: This was expanded and more articles were referenced.  We also drew comparisons between what others did and how we managed the situation.  We hope this will give some insight to readers and draw attention to common issues with the management of this issue: DVT, missing concomitant injuries. 

-Conclusion: We added a statement about our management and outcome.   There is not a consensus on how bilateral AT ruptures should be managed, especially with concomitant injuries. 

Please let me know what you think of the changes and if you have any further suggestions, I am happy to continue editing this paper.  Thank you again for your help with reviewing our paper. 

Reviewer 3 Report

The authors provided a well-written and structured manuscript whose novelty is however debatable. While the topic is interesting, I have some important reservations. I consider this study has some minor deficiencies. My comments are below:

• Affiliations are unnecessarily duplicated, cases 1 to 3 and 5 to 7. E-mail addresses can be included in other sections. Please correct.
• The topic falls under the journal aims and scope, and, to my knowledge, has followed the submission guidelines. However, the need for this case report is only partially established (in the introduction section). Previous research should be discussed so the desired novelty and singularity of the case can be demonstrated.
• It is not clear whether the fracture component of the case adds some singularity since it is not present neither in the title nor in the keywords. Oppositely, it is widely mentioned throughout the text and intentionally highlighted in the last paragraph of the introduction.
• The Abstract partially summarizes the main aspects of the paper and only partly reflects the content. Please complete.
• Keywords. Reiteration exists in the Keywords section. Please correct and be concise.
• Introduction. I would not strongly support this statement, according to the existing scientific literature^1-6.
• The Case presentation section is generally well-presented and structured. Arrows in Image 1 are absent and would be of help in identifying “bilateral disruption of Kager’s fat pad”. In addition, the mechanism of action should be included in this section as later it is discussed in the text. On the other hand, what does “He had absent plantar […] symmetric Matles test” mean? Please rewrite.
• Figure legends. Specific characteristics of X-ray and MRI studies would be much appreciated and would complement the case presentation. Images should be named as “Figures” both in the legends and in the text. Image 1 should be accompanied by an additional image emphasizing the fracture line.
• Conclusion. I would not consider “great functional outcomes” those including a 1-year-long recovery period, and where a screw removal and an episode of compensatory tendinitis of the posterior tibial tendon have occurred.

 

REFERENCES

1. Barron JL, Yocum LA. Unrecognized Achilles tendon rupture associated with ipsilateral medial malleolar fracture. Am J Sports Med 1993; 21:629–31.
2. Lubin JW, Miller RA, Robinson BJ, Blevins FT. Achilles tendon rupture  associated with ankle fracture. Am J Orthop 2000; 29:707–8.
3. Martin JW, Thompson GH. Achilles tendon rupture: occurrence with a closed ankle fracture. Clin Orthop 1986; 210:216–8.
4. Pieper HG, Radas CB, Quack G, Krahl H. Mediomalleolar fracture combined with Achilles tendon rupture: a rare simultaneous injury of the ankle. Int J Sports Med

1998; 19: 68–70.

5. Assal M, Stem R, Peter R. Fracture of the ankle associated with rupture of the Achilles tendon: case report and review of the literature. J Orthop Trauma 2002;16: 358–61.
6. Maffulli N, Richards PJ. Subcutaneous rupture of the Achilles tendon and ipsilateral fracture of the medial malleolus BMC Musculoskelet Disord 2006; 27; 7:59.

Author Response

Thank you for your feedback, I hope that the corrections outlined below will improve our paper to your satisfaction:

-We removed repeat affiliations

-We established the aim of reporting this case: The treatment of bilateral AT rupture with medial malleolus fracture is challenging given the disability it causes.  We treated with surgical end-to-end repair of the AT and screw fixation of the medial malleolus fracture.  It resulted in good functional outcome by 1 year despite the need for hardware removal.  We expanded the discussion and compared our outcome with that of a few similar cases.  More research is needed on this topic because it is so rare and so disabling.  

-The fracture doesn't provide a singularity because medial malleolus fracture commonly occurs with Achilles tendon rupture.  However, because both AT were ruptured, it made the situation a bit more complicated.  We tried to make this more clear in this version of our paper.   

-The introduction was re-worded to avoid contradiction with up-to-date literature on AT and medial malleolus fracture.

-Case presentation: we added arrows to the imaging, and the mechanism of injury was expanded on. The wording on "symmetric Matles/absent flexion" was changed to improve clarity. 

-Figures/images: we changed the wording from "image" to "figure" and we attached a zoomed image of the fracture line for clarity.  

-Conclusion: we changed the wording to acknowledge the setback of hardware removal in this patients treatment.

 

In addition to the above mentioned edits, we expanded the introduction and the discussion greatly.  We tripled the number of references to better reflect what is currently available in the literature and create a more detailed review.  Please let me know what you think of the changes, and if you have any further suggestions.

Respectfully,

Logan Morin

Round 2

Reviewer 2 Report

Thank the authors for the constructive correction of the manuscript. The submitted manuscript can be published. Sincerely.