The ultrasonographic appearance of the ruptured Achilles tendon during healing: a longitudinal evaluation of surgical and nonsurgical treatment, with comparisons to MRI appearance

Percutaneous suturing of the ruptured Achilles tendon with endoscopic control

INTRODUCTION

A prospective study of modified percutaneous Achilles tendon repair performed between 1999 and 2005 under local infiltration anesthesia is presented; the study evaluated the results of percutaneous repair technique by visualization of the synovia under endoscopic control, followed by early functional postoperative treatment for surgical intervention of acute Achilles tendon ruptures.

PATIENTS

Sixty-two patients (58 males, 4 females, mean age 32) were treated by percutaneous suturing with modified Bunnel technique under endoscopic control within 10 days after acute total rupture. Physiotherapy was initiated immediately after the operation and patients were encouraged to weight-bearing ambulation with a walking brace-moon boot as tolerated. Full weight-bearing was allowed minimum after 3 weeks postoperatively without brace.

RESULTS

The procedure was tolerated in all patients. There were no significant ROM limitation was observed. Two patients experienced transient hypoesthesia in the region of sural nerve that spontaneously resolved in 6 months. Fifty-nine patients (95%) including professional athletes returned to their previous sportive activities, while 18 of them (29%) had some minor complaints. The interval from injury to return to regular work and rehabilitation training was 11.7 weeks (10-13 weeks). At the latest follow-up (mean: 46 months; range: 12-78 months), all the patients had satisfactory results with a mean American Orthopedic Foot and Ankle Society's ankle-hindfoot score of 94.6. No re-ruptures, deep venous thrombosis or wound problems occurred.

CONCLUSION

The proposed method offers a reasonable treatment option for acute total Achilles tendon rupture with a low number of complications. The rerupture rate and return to preinjury activities are comparable to open and percutaneous without endoscopic control procedures.

WITHDRAWN: Interventions for treating acute Achilles tendon ruptures

BACKGROUND

There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace.

OBJECTIVES

To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures.

SEARCH STRATEGY

We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries.

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures.

DATA COLLECTION AND ANALYSIS

Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale.

MAIN RESULTS

Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes.Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28).Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved.Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76).Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients).

AUTHORS' CONCLUSIONS

Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

Repair of achilles tendon rupture under endoscopic control

PURPOSE

To evaluate the functional outcomes and complications after endoscopically assisted percutaneous repair of Achilles tendon rupture.

METHODS

An arthroscopically assisted percutaneous repair was performed in 20 patients between the ages of 28 and 47 years. Two patients were suffering from a long-standing rupture. Follow-up was 2.5 years. Evaluation entailed Merkel's scale for pain, functional load (weight) bearing capacity, and the heel raise test. For statistical analysis, a random effects Poisson regression model was used.

RESULTS

All patients achieved good to excellent outcomes. The median score on Merkel's scale was 600. All patients were able to stand on the tiptoe of the operated leg and none had limitations placed on their daily activities. A 12% decrease in maximum torque and 16.5% decrease in work performance of the injured side were noted. There was no statistical significant difference in the heel raise test between the operated and non-operated leg. No wound problems, re-ruptures, or infections were reported. Two patients (10%) had sural neuralgia; in 1 case, it subsided without further treatment.

CONCLUSIONS

Endoscopy in percutaneous Achilles tendon repair is useful in determining the initial gap and providing adequate apposition of the tendon ends. It is a safe technique with good outcomes and minimal complications. Despite its promising results, potential problems include sural neuralgia and some decrease in strength.

Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study

There is no agreement on the ideal type of surgical management for Achilles tendon rupture. The present randomized prospective study was performed to compare outcome data of open and percutaneous repair in the treatment of Achilles tendon rupture. Forty consecutive patients with acute rupture of Achilles tendon were recruited. Patients were randomized to receive open (group A) or percutaneous repair with Tenolig (group B). All patients followed the same rehabilitation protocol except for slight differences in the duration of immobilization. Follow-up included objective evaluation (at 4 and 12 months), subjective evaluation using the SF-12 questionnaire (at 24 months), and bilateral ultrasound scanning and isokinetic testing (at 12 months). The differences in the parameters evaluated clinically were not significant except for ankle circumference, which was significantly greater in group B. There were two minor complications in the open repair group and one case of failed repair in the percutaneous group. SF-12 questionnaire, ultrasound and isokinetic test data did not show significant differences between the groups. The present study demonstrates that the open and the percutaneous technique are both safe and effective in repairing the ruptured Achilles tendon and that both afford the same degree of restoration of clinical, ultrasound and isokinetic patterns. Medium-term results were substantially comparable. Percutaneous repair is performed on a day-surgery basis, it reduces cutaneous complications and operation times, and enables faster recovery, enhancing overall patient compliance. To us, these characteristics make it preferable to open repair in managing subcutaneous ruptures of Achilles tendon in non-professional sports practicing adults.

Achilles tendon pain intensity and level of neovascularization in athletes as determined by color Doppler ultrasound

The cause of pain in Achilles tendinopathy is thought to be related to the presence of neovascularization in the tendon as seen on color Doppler ultrasound. Asymptomatic pathology has been observed in patellar tendons of elite athletes. The purpose of this study was to examine the prevalence of Achilles tendon pain and the characteristics of Achilles tendons in a young athletic population. Sixty-four varsity athletes underwent color Doppler ultrasound imaging to determine tendon thickness, presence of degeneration and neovascularization. The presence of swelling and tenderness was determined, and Achilles tendon pain was rated on three visual analogue scales (VAS) (pain during exercise, pain at rest, pain during daily activities) as well as on the VISA-A scale. Tendon symptoms were not related to the presence of neovascularization. There was a low prevalence of Achilles tendinopathy, tenderness, and neovascularization in this population. Neovascularization was seen in both a painful and a non-painful tendon.

Postoperative imaging of the ankle and foot

This article describes the relevant surgical detail and MR imaging appearance of common operations performed in the foot and ankle. To evaluate postsurgical patients critically, it is important to understand the primary clinical diagnosis, surgical treatment undergone, the interval since surgery, and patients' current clinical symptoms. Radiography is the most common imaging modality for evaluation of the postoperative ankle and foot. MR imaging may be useful for evaluating the soft tissues and osseous structures in the postsurgical foot and ankle.

[Post-surgical Achilles tendon and correlation with functional outcome: a review of 40 cases]

OBJECTIVE

To assess the value of MRI in the post operative evaluation of Achilles tendon rupture.

MATERIAL AND METHODS

40 patients treated for acute Achilles tendon rupture at the Pasteur Hospital of Cherbourg between 1994 and 2002 underwent postoperative MRI. The objective was to look for correlations between functional outcome and reproducible measurements from imaging data previously described in the literature.

RESULTS

We obtained only two positive correlations among all the combinations of comparisons: the first one between the perimeter of the calf and the surface area of the posterior muscle compartment, the second between the surface area of the operated tendon and its elongation estimated by the recalculated ratio of ankle dorsiflexion amplitude.

CONCLUSION

MRI plays no role in the routine follow-up of post-surgical Achilles tendons. It should consequently only be used as a specific tool in problem cases, such as evaluation of possible re-tear.

Musculoskeletal imaging in physical therapist practice

This article presents an overview of current concepts of evidence-based diagnosis using a variety of imaging modalities for a broad spectrum of musculoskeletal conditions and syndromes. There is limited but increasing evidence that physical therapists appropriately use diagnostic studies in clinical practice. Pathology revealed by diagnostic studies must be viewed in the context of the complete examination, as pathology is common in the asymptomatic population. Special diagnostic challenges are presented by patients with areas of referred pain, multiple injuries or multiple areas of pathology, neoplasms, and infections. Plain film radiographs have been overused in the clinical management of many conditions, including low back pain. Clinical decision rules provide simple evidence-based guidelines for the appropriate use of imaging studies.

The Webb-Bannister percutaneous technique for acute Achilles' tendon ruptures: a functional and MRI assessment

This was a study of 57 patients treated for Achilles' tendon rupture between 1994 and 2002: 35 with an open repair and 22 with the Webb-Bannister percutaneous technique. The aim of the study was to evaluate this percutaneous method as compared to other percutaneous and open techniques, with respect to functional result and complications. In addition, postoperative MRI was performed on 40 patients in order to determine whether there were any correlations between clinical results and MRI findings. No significant differences were found between the 2 surgical methods with respect to clinical and functional results, and no wound dehiscence or infections were found in the Webb-Bannister group. There was an 8.6% incidence of wound complications in the open repair group. Similarly, return to work times were not significantly different between the groups (4 months for open repair and 3.75 months for percutaneous repair). Two patients experienced re-rupture after open repair and there was 1 re-rupture following the Webb-Bannister technique. Early weight bearing and the use of the percutaneous repair did correlate to increased postoperative tendon lengthening, though this did not appear to have any clinical consequence. MRI did not appear to be of any value in the clinical or functional evaluation, but it demonstrated a relationship between increased tendon diameter and tendon elongation (P=.0038). In those patients with thicker tendon repair sites, the dorsiflexion tended to exceed the uninjured leg. The functional results of the Webb-Bannister technique were comparable to the open repair. This technique is an effective treatment for acute ruptures less wound complications.

The distribution of microvascular response in Achilles tendonopathy assessed by colour and power Doppler

OBJECTIVES

To assess the distribution of microvascular response on colour Doppler (CD) and power Doppler (PD) ultrasound (US) of the tendo Achilles (TA) in tendonopathy, and to look for any relationship between tendon morphology and symptoms.

DESIGN AND PATIENTS

A retrospective, observational study was carried out on consecutive ambulant US patients with suspected tendonopathy, presenting with pain or an Achilles mass. Exclusion criteria were: use of steroids, and previous or possible rupture or surgery in either tendon or arthropathy. Using a 5-12 MHz linear array probe (ATL HDI 3000) both TAs were scanned. Tendonopathy was defined as tendon swelling and/or hypoechogenicity of the TA. The site, number and distribution of microvascularity, on CD and PD, and the anteroposterior size were recorded, with the analysis masked.

RESULTS

Fifty-two patients presented with TA pain and six also with swelling. There were 34 males and 18 females, aged from 11 to 78 years (mean 45 years). Fifty-five TAs that showed tendonopathy with hypoechogenic areas were all observed to be over 5.9 mm (mean 11.1 mm, range 5.9-20 mm), of which 45 were symptomatic with abnormal PD and 24 with abnormal CD flow. It was observed that the extent and completeness of vessel branching was more extensive on PD than CD. All TAs demonstrating tendonopathy were over 5.9 mm in adults and all TAs that showed PD flow were over 6.5 mm. All microvessels originated towards the TA from the ventral surface usually into tendonopathy, and were 16-fold more frequent around the margins. There were 49 TAs with normal spectral US, and with no PD flow, with a mean size of 4.5 mm (range 3.0-7.4 mm). For the right and left TAs independently analysed and taking the 40 patients with a paired asymptomatic and symptomatic tendon: (1) There was a highly significant difference in size (P<0.00001) using the paired t-test (parametric) between the asymptomatic tendon (mean 5.2+/-1.4 mm (1 SD)), and the contralateral morphologically abnormal and symptomatic side (mean 9.7+/-1.4 mm). (2) There was no linear Pearson correlation (0.25) between TA size and duration of symptoms (P=0.11) for symptomatic tendons. (3) There was a positive Spearman correlation (0.84) between the number of vessels and TA size (P<0.00001). (4) There was a significant difference in the number of PD vessels using the non-parametric Wilcoxon signed test (P<0.00001) between the symptomatic and asymptomatic groups.

CONCLUSIONS

(1) PD shows more tendon microvascularity than CD in TA tendonopathy. (2) All microvessels arise on the ventral side of the TA. (3) There is a non-linear relationship between tendonopathy, TA size and the amount of microvascularity, but not between PD and duration of symptoms. (4) Morphologically abnormal adult TAs were larger than 5.9 mm, and PD flow was only seen in TAs above 6.5 mm.

Imaging of the Achilles tendon

The Achilles tendon is the most commonly injured tendon in the foot and ankle; injuries commonly are related to sports/athletic activities. Imaging modalities that are used most commonly in the diagnostic assessment of the Achilles tendon include conventional radiography, ultrasonography, and MRI. This article reviews the normal and pathologic imaging features of the Achilles tendon, and highlights the potential usefulness and limitations of various imaging techniques in the noninvasive assessment of the tendon and the potential impact of imaging findings on clinical patient care.

Tensile properties and biological response of poly(L-lactic acid) felt graft: an experimental trial for rotator-cuff reconstruction

Poly(L-lactic acid) felt (PLLA felt) was prepared for reconstruction of the rotator cuff in animal models. Small changes were found in the tensile strength of both the cultured PLLA felt and the PLLA felt implanted on the paravertebral muscle of rabbits up to 16 postoperative weeks. The stiffness of the felt implanted on the muscle from 6 to 16 weeks showed a statistically significant increase. When the infraspinatus tendons of beagle dog were reconstructed with the PLLA felt, the ultimate strength of PLLA felt increased threefold, and the stiffness increased fivefold by 16 postoperative weeks compared to that of the initial PLLA felt. They were statistically significant (p < 0.01). All the implanted specimens ruptured at the junction between the bone and the PLLA felt. Histological examination demonstrated infiltration of fibrous tissue into the interstices of the PLLA felt fibers. Connection between the infraspinatus tendon and the PLLA felt was tight with the formed scar tissue, but the connective tissue between the bone and PLLA felt fibers was sparse even at 16 and 32 postoperative weeks. A few deteriorated PLLA felt fibers were observed at 32 postoperative weeks. It was concluded that the degradation rate of PLLA felt was low and the tensile recovery of the PLLA felt graft in beagle dogs was excellent. Thus, PLLA felt might be a useful bioabsorbable material for rotator-cuff reconstruction.

Interventions for treating acute Achilles tendon ruptures

BACKGROUND

There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace.

OBJECTIVES

To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures.

SEARCH STRATEGY

We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries.

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures.

DATA COLLECTION AND ANALYSIS

Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale.

MAIN RESULTS

Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes. Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28). Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved. Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76). Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients).

REVIEWERS' CONCLUSIONS

Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.