Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon

Minimally invasive reconstruction of chronic achilles tendon ruptures using the ipsilateral free semitendinosus tendon graft and interference screw fixation

BACKGROUND

Achilles tendon ruptures represent more than 40% of all tendon ruptures requiring surgical management. About 20% of acute Achilles tendon tears are not diagnosed at the time of injury and become chronic, necessitating more complicated management than fresh injuries. Several techniques for the reconstruction of chronic tears of the Achilles tendon have been described, but the superiority of one technique over the others has not been demonstrated.

HYPOTHESIS

Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft will result in improvement of the overall function with a low rate of complications.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2008 and 2010, the authors prospectively enrolled 28 consecutive patients (21 men and 7 women; median age, 46 years) with chronic closed ruptures of the Achilles tendon who had undergone reconstruction with a free semitendinosus tendon graft. They assessed the Achilles tendon Total Rupture Score (ATRS), maximum calf circumference, and isometric plantarflexion strength before surgery and at the last follow-up. Outcome of surgery and rate of complications were also recorded. The median follow-up after surgery was 31.4 months.

RESULTS

The overall result of surgery was excellent/good in 26 (93%) of 28 patients. The ATRS improved from 42 (range, 29-55) to 86 (range, 78-95) (P < .0001). In the operated leg, the maximum calf circumference and isometric plantarflexion strength were significantly improved after surgery (P < .0001); however, their values remained significantly lower than those of the opposite side (P < .0001). All patients were able to walk on tiptoes and returned to their preinjury working occupation. No infections were recorded.

CONCLUSION

Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft provides a significant improvement of symptoms and function, although calf circumference and ankle plantarflexion strength do not recover fully.

Less-invasive semitendinosus tendon graft augmentation for the reconstruction of chronic tears of the Achilles tendon

BACKGROUND

Less-extensive and gentler exposure and dissection of deep soft tissues could reduce the times of recovery and rehabilitation after Achilles tendon reconstruction.

HYPOTHESIS

A minimally invasive semitendinosus autologous graft reconstruction of the Achilles tendon preserves skin integrity and reduces wound breakdown.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 26 patients underwent minimally invasive semitendinosus autologous graft reconstruction for chronic ruptures to the Achilles tendon. Patients underwent a comparison of preoperative versus postoperative maximum calf circumference and isometric plantarflexion strength and evaluation of postoperative complications. The Achilles Tendon Total Rupture Score (ATRS) was administered at the final follow-up appointment.

RESULTS

All patients were reviewed at an average of 8.2 years (range, 7-10 years) from surgery. No patient was lost to follow-up. At final follow-up, the maximum calf circumference was significantly higher than preoperatively but significantly lower than the contralateral side. The isometric plantarflexion strength in the operated leg was lower than in the uninjured one. The mean ATRS was 88. Two patients developed a superficial wound infection, both healing within 2 months from the index surgery after systemic antibiotics and local dressings. One patient developed scar adhesion to the distal wound. All patients returned to their preinjury working occupation; 22 patients returned to their preinjury level of activity at a mean of 6.7 months after surgery.

CONCLUSION

This technique is minimally invasive, is safe, and allows most of the patients to return to preinjury daily and sport activities within 9 months from surgery.

The ruptured Achilles tendon: a current overview from biology of rupture to treatment

The Achilles tendon (AT) is the most frequently ruptured tendon in the human body yet the aetiology remains poorly understood. Despite the extensively published literature, controversy still surrounds the optimum treatment of complete rupture. Both non-operative management and percutaneous repair are attractive alternatives to open surgery, which carries the highest complication and cost profile. However, the lack of a universally accepted scoring system has limited any evaluation of treatment options. A typical UK district general hospital treats approximately 3 cases of AT rupture a month. It is therefore important for orthopaedic surgeons to correctly diagnose and treat these injuries with respect to the best current evidence-based practice. In this review article, we discuss the relevant pathophysiology and diagnosis of the ruptured AT and summarize the current evidence for treatment.

Primary gene response to mechanical loading in healing rat Achilles tendons

Loading can stimulate tendon healing. In healing rat Achilles tendons, we have found more than 150 genes upregulated or downregulated 3 h after one loading episode. We hypothesized that these changes were preceded by a smaller number of regulatory genes and thus performed a microarray 15 min after a short loading episode, to capture the primary response to loading. We transected the Achilles tendon of 54 rats and allowed them to heal. The hind limbs were unloaded by tail-suspension during the entire experiment, except during the loading episode. The healing tendon tissue was analyzed by mechanical testing, microarray, and quantitative real-time polymerase chain reaction (qRT-PCR). Mechanical testing showed that 5 min of loading each day for 4 days created stronger tissue. The microarray analysis after one loading episode identified 15 regulated genes. Ten genes were analyzed in a repeat experiment with new rats using qRT-PCR. This confirmed the increased expression of four genes: early growth response 2 (Egr2), c-Fos, FosB, and regulation of G protein signaling 1 (Rgs1). The other genes were unaltered. We also analyzed the expression of early growth response 1 (Egr1), which is often co-regulated with c-Fos or Egr2, and found that this was also increased after loading. Egr1, Egr2, c-Fos, and FosB are transcription factors that can be triggered by numerous stimuli. However, Egr1 and Egr2 are necessary for normal tendon development, and can induce ectopic expression of tendon markers. The five regulated genes appear to constitute a general activation machinery. The further development of gene regulation might depend on the tissue context.

Platelet-rich plasma in tendon models: a systematic review of basic science literature

PURPOSE

To perform a systematic review of the basic science literature on the use of platelet-rich plasma (PRP) in tendon models.

METHODS

We searched the PubMed/Medline and Embase databases in June 2012 using the following parameters: ((tenocytes OR tendon OR tendinitis OR tendinosis OR tendinopathy) AND (platelet rich plasma OR PRP OR autologous conditioned plasma OR ACP)). The inclusion criteria for full-text review were in vivo and in vitro studies examining the effects of PRP on tendons and/or tenocytes. Clinical studies were excluded. Only studies published in peer-reviewed journals that compared PRP directly with a control were included. Data were extracted based on a predefined data sheet, which included information on PRP preparation, study methods, and results. Studies were analyzed for trends, comparing and contrasting the reported effects of PRP.

RESULTS

The search yielded 31 articles for inclusion in our review. Of the studies, 22 (71%) reported platelet concentrations in the PRP; 6 (19%) reported cytology. Eight in vivo studies found decreased tendon repair time, increased fiber organization, or both with PRP treatment. Eight in vitro studies reported that PRP treatment increased cell proliferation; 7 reported an increase in growth factor expression. Three in vivo studies found increased vascularity, and 4 found increased tensile strength with PRP treatment.

CONCLUSIONS

In the basic science studies evaluated, it appears that PRP confers several potential effects on tendon models compared with a control. However, the literature is inconsistent with regard to reporting the methods of preparation of PRP and in reporting platelet concentrations and cytology.

CLINICAL RELEVANCE

Establishing proof of concept for PRP may lead to further high-quality clinical studies in which the appropriate indications can be defined.

Retrospective analysis of mini-open repair versus open repair for acute Achilles tendon ruptures

PURPOSE

Debate exists over optimal treatment for acute Achilles tendon ruptures. Recent literature suggests the mini-open technique may provide the reliability of the open repair with the decreased complication rate of non-operative treatment. This retrospective review compares acute tendon ruptures treated with one of two techniques: open repair (TO) or mini-open repair (MOA).

METHODS & RESULTS

Records were reviewed and 34 patients were found to meet the inclusion criteria for open or mini-open repair of an acute Achilles tendon rupture with follow up of at least 12 months. TO (n=16) and MOA (n=18) had no statistically significant differences in age at time of injury [TO: 41 + 2.5 years (range 20 - 68); MOA: 46 + 2.5 years (range 33 - 73)] or time between injury and surgical repair [TO: 15 + 2 days (range 2 - 30); MOA: 15 + 2 days (range 2 - 30)]. Post-operative VISA-A scores were 82 + 10 (range 42 - 98) and 92 + 5 (range 66 - 100) for TO and MOA, respectively. Significant differences were found in the time between surgical intervention and beginning of rehabilitation [TO: Post op day 37 + 5 (range 21 - 46); MOA: Post op day 19 + 2 (range 7 - 32)] and the time between surgical intervention and full return to activity [TO: Post op month 7 + 1 (range 4 - 11); MOA: Post op month 5 + 0.6 (range 4 - 11)].

CONCLUSION

These results suggest that the mini-open repair provides acceptable surgical outcomes while optimizing patient function after Achilles tendon repair.

Efficacy and complications of open and minimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study--preliminary report

PURPOSE

Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results.

METHOD

We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon(®) device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months.

RESULTS

No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports.

CONCLUSION

After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.

Long-term functional outcome of bilateral spontaneous and simultaneous Achilles tendon ruptures

Bilateral simultaneous ruptures are rare comprising less than 1% of all Achilles tendon ruptures. Risk factors for bilateral ruptures include chronic diseases and medications such as corticosteroids and fluoroquinolones. There is little in the literature on the long-term functional outcome of bilateral Achilles tendon ruptures. This article present a series of 3 cases of simultaneous and spontaneous bilateral Achilles tendon ruptures with a minimum of 5-year follow up suggesting a good functional outcome.

Electromyographic analysis of the triceps surae muscle complex during achilles tendon rehabilitation program exercises

BACKGROUND

Specific guidelines for therapeutic exercises following an Achilles tendon repair are lacking.

HYPOTHESIS

A hierarchical progression of triceps surae exercises can be determined on the basis of electromyographic (EMG) activity.

STUDY DESIGN

Randomized laboratory trial.

METHODS

Bipolar surface electrodes were applied over the medial and lateral heads of the gastrocnemius as well as the soleus on 20 healthy lower extremities (10 participants, 27 ± 5 years old). Muscle activity was recorded during 8 therapeutic exercises commonly used following an Achilles repair. Maximal voluntary isometric contractions (MVICs) were also performed on an isokinetic device. The effect of exercise on EMG activity (% MVIC) was assessed using repeated measures analysis of variance with Bonferroni corrections for planned pairwise comparisons.

RESULTS

Seated toe raises (11% MVIC) had the least amount of activity compared with all other exercises (P < 0.01), followed by single-leg balance on wobble board (25% MVIC), prone ankle pumps (38% MVIC), supine plantarflexion with red elastic resistance (45% MVIC), normal gait (47% MVIC), lateral step-ups (60% MVIC), single-leg heel raises (112% MVIC), and single-leg jumping (129% MVIC).

CONCLUSION

There is an increasing progression of EMG activity for exercises that target the triceps surae muscle complex during common exercises prescribed in an Achilles tendon rehabilitation program. Seated toe raises offer relatively low EMG activity and can be utilized as an early rehabilitative exercise. In contrast, the single-leg heel raise and single-leg jumping should be utilized only during later-stage rehabilitation.

CLINICAL RELEVANCE

EMG activity in the triceps surae is variable with common rehab exercises.

Operative versus nonoperative management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials

BACKGROUND

Despite several randomized controlled trials comparing operative to nonoperative management of Achilles tendon ruptures, the optimal management of this condition remains the subject of significant debate. Rerupture is a known complication, but most level I studies have not shown a significant difference in the incidence of reruptures when comparing operative to nonoperative management.

PURPOSE

The goal of this systematic review was to identify all randomized controlled trials comparing operative and nonoperative management of Achilles tendon ruptures and to meta-analyze the data with reruptures being the primary outcome. Secondary outcomes including strength, time to return to work, and other complications were analyzed as well.

STUDY DESIGN

Meta-analysis.

METHODS

We searched multiple online databases to identify English-language, prospective randomized controlled trials comparing open surgical repair of acute Achilles tendon ruptures to nonoperative management. Rerupture was our primary outcome. Secondary outcomes included strength, time to return to work, deep infections, sural nerve sensory disturbances, noncosmetic scar complaints, and deep venous thrombosis. Coleman methodology scores were calculated for each included study. Data were extracted from all qualifying articles and, when appropriate, pooled and meta-analyzed.

RESULTS

Seven level I trials involving 677 patients met inclusion criteria. Coleman scores were 95, 95, 95, 89, 78, 97, and 92. Open repair was associated with a significantly lower rerupture rate compared with nonoperative treatment (3.6% vs 8.8%; odds ratio, 0.425; 95% confidence interval, 0.222-0.815). The incidence of deep infections was significantly higher for patients treated with surgery (P = .0113). The incidences of noncosmetic scar complaints and sural nerve sensory disturbances were also significantly higher in patients treated with surgery (P < .001 for each). Strength measurements were not standardized and therefore could not be meta-analyzed.

CONCLUSION

Open surgical repair of acute Achilles tendon ruptures significantly reduces the risk of reruptures when compared with nonoperative management. Several other complications, which are clearly avoided with nonoperative treatment, occur with a significantly higher incidence when surgical repair is performed. The available literature makes it difficult to compare the return of strength in the involved lower extremity after operative or nonoperative management. Future studies may focus on testing strength in a more functional and reproducible manner than isokinetic testing.

A photoactivated nanofiber graft material for augmented Achilles tendon repair

BACKGROUND AND OBJECTIVE

Suture repair of Achilles tendon rupture can cause infection, inflammation and scarring, while prolonged immobilization promotes adhesions to surrounding tissues and joint stiffness. Early mobilization can reduce complications provided the repair is strong enough to resist re-rupture. We have developed a biocompatible, photoactivated tendon wrap from electrospun silk (ES) to provide additional strength to the repair that could permit early mobilization, and act as a barrier to adhesion formation.

STUDY DESIGN/MATERIAL AND METHODS

ES nanofiber mats were prepared by electrospinning. New Zealand white rabbits underwent surgical transection of the Achilles tendon and repair by: (a) SR: standard Kessler suture + epitendinous suture (5-0 vicryl). (b) ES/PTB: a single stay suture and a section of ES mat, stained with 0.1% Rose Bengal (RB), wrapped around the tendon and bonded with 532 nm light (0.3 W/cm(2) , 125 J/cm(2) ). (c) SR + ES/PTB: a combination of (a) and (b). Gross appearance, extent of adhesion formation and biomechanical properties of the repaired tendon were evaluated at Days 7, 14, or 28 post-operatively (n = 8 per group at each time point).

RESULTS

Ultimate stress (US) and Young's modulus (E) in the SR group were not significantly different from the ES/PTB group at Days 7 (US, P = 0.85; E, P = 1), 14 (US, P = 0.054; E, P = 1), and 28 (US, P = 0.198; E, P = 0.12) post-operatively. Adhesions were considerably greater in the SR group compared to the ES/PTB group at Days 7 (P = 0.002), 14 (P < 0.0001), and 28 (P < 0.0001). The combination approach of SR + ES/PTB gave the best outcomes in terms of E at 7 (P < 0.016) and 14 days (P < 0.016) and reduced adhesions compared to SR at 7 (P < 0.0001) and 14 days (P < 0.0001), the latter suggesting a barrier function for the photobonded ES wrap.

CONCLUSION

Photochemical sealing of a ES mat around the tendon repair site provides considerable benefit in Achilles tendon repair. Lasers Surg. Med. 44: 645-652, 2012. © 2012 Wiley Periodicals, Inc.

Z-shortening of healed, elongated Achilles tendon rupture

PURPOSE

A rupture of the Achilles tendon may heal in continuity, resulting in a lengthened Achilles tendon. The elongated structure must be shortened to restore effective push off. We report the results of a longitudinal study using Z-shortening of ruptured Achilles tendons that healed in continuity but were elongated.

METHODS

Nine patients underwent surgery for elongation of a healed Achilles tendon rupture. All participants were prospectively followed up for two to five years, and final review was performed at 32 ± 14 months from operation. Clinical and functional assessment (anthropometric measurements, isometric strength, postoperative total rupture score) was performed.

RESULTS

All patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp. No patient developed clinically evident deep-vein thrombosis or sustained a rerupture. Two patients were managed conservatively following a superficial surgical wound infection. At final review, maximum calf circumference remained significantly decreased in the operated leg. The operated limb was significantly weaker than the nonoperated one.

CONCLUSIONS

Managing a healed Achilles tendon rupture using Z-shortening is safe and effective, providing good recovery and early weight bearing and active ankle mobilisation. Such patients should be warned that they are at risk for postoperative complications and that their ankle-plantar flexion strength is likely to be permanently reduced.

Acute Achilles tendon rupture: a questionnaire follow-up of 487 patients

BACKGROUND

The optimum treatment of acute total Achilles tendon rupture remains controversial. In the present study, the outcomes of surgical and nonsurgical treatment in a large number of patients were compared on the basis of patient age and sex.

METHODS

The records of all 487 patients with an acute total Achilles tendon rupture that had occurred between 2002 and 2006 and had been treated at one of two university hospitals in Sweden were manually reviewed. Surgical treatment was primarily used at Hospital 1, whereas nonoperative functional treatment was primarily used at Hospital 2. At one to seven years after the rupture, the majority of the patients were evaluated for complications, the Achilles Tendon Total Rupture Score was calculated, a heel-raise test was performed, and calf circumference was measured. The outcomes of surgical and nonsurgical treatment were compared on the basis of patient age and sex.

RESULTS

The mean age at the time of the injury was forty-five years. In the surgical treatment group at Hospital 1, six (3%) of 201 patients had a re-rupture and three (1.5%) had an infection. In the nonsurgical treatment group at Hospital 2, the rate of re-rupture rate was 6.6% (fifteen of 227). When the results for the surgical treatment group at Hospital 1 were compared with those for the nonsurgical treatment group at Hospital 2, there was no significant difference in terms of the mean Achilles Tendon Total Rupture Score (81.7 compared with 78.9; p = 0.1), but both the difference in the heel-raise test (p = 0.01) and the difference in calf circumference (1.4 compared with 2.0 cm; p = 0.01) reached significance in favor of surgery. Nonsurgically managed female patients showed significant worsening of the Achilles Tendon Total Rupture Score and heel-raise test with increasing age at the time of injury.

CONCLUSIONS

The good Achilles Tendon Total Rupture Score in the nonsurgically managed group, together with the relatively low rate of re-ruptures and other complications in these patients, makes this treatment a preferable option for most patients. However, the tendency for a lower re-rupture rate and better performance on the heel-raise test in surgically treated patients suggest surgery may be beneficial in selected patients.

A biomechanical comparison of the primary stability of two minimally invasive techniques for repair of ruptured Achilles tendon

PURPOSE

To compare the primary stability of two minimally invasive procedures of Achilles tendon (AT) repair, namely a modified percutaneous repair of ruptured AT and the Achillon suture configuration.

METHODS

Eighteen (nine matched pairs) frozen ovine ATs were tenotomized 5 cm from the calcaneal insertion. In each pair, one tendon was randomly allocated to one of the two techniques: a modified percutaneous repair group and the Achillon device suture configuration. Specimens were tested performing an unidirectional tensile load to failure using a servo-hydraulic testing device (MTS Systems, Eden Prairie, MN, USA), controlled by an electropulse e3000 INSTRON machine (Instron Ltd, Buckinghamshire, UK). The tendons were then loaded to failure at a rate of 10 mm/s.

RESULTS

Two of the nine pairs of specimens were discarded because one specimen for each of the pair pulled out of the pneumatic clamp during mechanical testing. The remaining seven matched pairs were successfully tested. There were no differences in mean strength, mean maximum load, mean failure elongation, tension, stiffness and mode of failure between the two groups.

CONCLUSION

The Achillon-like configuration and the modified percutaneous repair of ruptured AT provided similar biomechanical performance.

Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture

This study evaluated the short-term recovery of function after an acute Achilles tendon rupture, measured by a single-legged heel-rise test, with main emphasis on the relation to the patient-reported outcomes and fear of physical activity and movement (kinesiophobia). Eighty-one patients treated surgically or non-surgically with early active rehabilitation after Achilles tendon rupture were included in the study. Patient's ability to perform a single-legged heel-rise, physical activity level, patient-reported symptoms, general health, and kinesiophobia was evaluated 12 weeks after the injury. The heel-rise test showed that 40 out of 81 (49%) patients were unable to perform a single heel-rise 12 weeks after the injury. We found that patients who were able to perform a heel-rise were significantly younger, more often of male gender, reported a lesser degree of symptoms, and also had a higher degree of physical activity at 12 weeks. There was also a significant negative correlation between kinesiophobia and all the patient-reported outcomes and the physical activity level. The heel-rise ability appears to be an important early achievement and reflects the general level of healing, which influences patient-reported outcome and physical activity. Future treatment protocols focusing on regaining strength early after the injury therefore seem to be of great importance. Kinesiophobia needs to be addressed early during the rehabilitation process.

Biomechanical comparison of four methods of repair of the Achilles tendon

We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p <  0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot.

The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.

Current concepts in the rehabilitation of an acute rupture of the tendo Achillis

Rupture of the tendo Achillis is a common injury with a rising incidence. Traditionally the key question following this injury has been whether or not to operate. However a contemporary Cochrane review highlighted that the method of rehabilitation may also have an important contribution to the outcome. Since this review, various early weight-bearing rehabilitation protocols have been described. Currently evidence points to the use of early functional rehabilitation, regardless of operative or non-operative management. However, there is no consensus on which exact functional rehabilitation protocol should be used. Future research should be directed towards improving our understanding of how the different rehabilitative components interact in the tendo Achillis as it heals.

Percutaneous repair of acute ruptures of the tendo Achillis

Minimally invasive repair of acute traumatic ruptures of the tendo Achillis may produce lower complications compared to open repair. Twenty-three active patients underwent percutaneous repair of an acute rupture of the tendo Achillis. Post-operatively, the ATRS score was administered to assess the functional status. The maximum calf circumference, isometric plantar flexion strength of the gastrocsoleus muscle complex, ankle dorsiflexion, and return to sport activity were assessed in all patients at an average post-operative follow-up of 25.7 months. At the last follow-up, the mean Achilles tendon total rupture score (ATRS) score was 84 (range: 53-99). Ankle dorsiflexion and maximum calf circumference on the operated limb were not significantly different compared to the uninjured side. The isometric strength on the operated limb was significantly lower (P=0.04) compared to the contralateral side. Of the 21 (90%) patients participating in sports activities, 16 (80%) had returned to their pre-operative sport, 2 changed to lower activity, and 1 increased his performance. This percutaneous technique provides satisfactory outcome in terms of strength and return to pre-operative level of sport activity.

Clinical and biomechanical outcome of minimal invasive and open repair of the Achilles tendon

Introduction

With evolutions in surgical techniques, minimally invasive surgical (MIS) repair with Achillon applicator has been introduced. However, there is still a lack of literature to investigate into the clinical merits of MIS over open surgery. This study aims to investigate the correlation between clinical outcome, gait analysis and biomechanical properties comparing both surgical methods.

Materials and methods

A single centre retrospective review on all the consecutive operated patients between January 2004 and December 2008 was performed. Twenty-six patients (19 male and 7 female; age 40.4 ± 9.2 years) had experienced a complete Achilles tendon rupture with operative repair. Nineteen of the patients, 10 MIS versus 9 open repairs (13 men with a mean age of 40.54 ± 10.43 (range 23-62 yrs) and 6 women with a mean age of 45.33 ± 7.71 (range 35-57 yrs) were further invited to attend a thorough clinical assessment using Holz's scale and biomechanical evaluation at a mean of 25.3 months after operation. This study utilized the Cybex II isokinetic dynamometer to assess the isokinetic peak force of plantar-flexion and dorsiflexion of both ankles. The patients were also invited to return to our Gait Laboratory for analysis. The eight-infrared camera motion capture system (VICON, UK) was utilized for the acquisition of kinematic variables. Their anthropometric data was measured according to the Davis and coworkers' standard.

Results

The mean operative time and length of hospital stay were shorter in the MIS group. The operative time was 54.55 ± 15.15 minutes versus 68.80 ± 18.23 minutes of the MIS group and Open group respectively (p = 0.045), whereas length of stay was 3.36 ± 1.21 days versus 6.40 ± 3.70 days respectively (p = 0.039). There is statistically significant decrease (p = 0.005) in incision length in MIS group than the open surgery group, 3.23 ± 1.10 cm versus 9.64 ± 2.55 cm respectively. Both groups attained similar Holz's scores, 11.70 ± 0.95 versus 12.0 ± 1.50 respectively (p = 0.262). The mean percentage stance time of the injured leg for MIS patient was 58.44% while the mean percentage stance time of the injured leg for patients with open repair was 56.57%. T-test has shown there were no significance differences between the results of the two groups of patients. The loss of peak torque and total work done with respect to the injured side were similar between the MIS and open group.

Discussion and conclusion

MIS using Achillon method can achieve smaller incisions, shorter operative time and hospital stay. There is no statistical significance difference in clinical outcome, the stance time to strike time ratio and biomechanical properties on the leg receiving Achilles tendon repair using MIS method and open surgery.

Results of accelerated postoperative rehabilitation using novel "suture frame" repair of Achilles tendon rupture

The management of Achilles tendon rupture is a much-debated subject. In recent years, there has been much interest in early postoperative mobilization. We present the results of our Achilles tendon repair technique and accelerated rehabilitation program. The technique we propose uses the strength of a 1-loop polydioxanone "suture frame" to enable restoration of the tendon length, immediate positioning of the foot in a near-plantigrade position, and an accelerated rehabilitation program. We followed up 15 cases of Achilles tendon rupture treated with this technique. The initial follow-up was a review of case notes and a telephone questionnaire. All patients were subsequently invited for a clinical follow-up visit, and 11 patients (68.75%) attended. No cases of infection or repeat rupture occurred. The return to work (mean 5.6 weeks) and return to sport (mean 4.8 months) were relatively rapid. Regarding overall satisfaction on a scale of 0 to 10, the median was 9 (range 8 to 10). Of the 11 patients who attended the clinical follow-up visit, the mean American Orthopaedic Foot and Ankle Surgery ankle-hindfoot score was 94.5 points (range 83 to 100). The Achilles rupture repair scores (including isokinetic muscle strength) were good or excellent in all but 1 patient, whose result was fair. Of the 11 patients, 10 reported complete satisfaction with their outcome. Our technique with accelerated rehabilitation is safe and effective in the management of acute Achilles tendon rupture. It facilitates an early return to work and recreational sports, with excellent overall patient satisfaction.

Percutaneous & Mini Invasive Achilles tendon repair

Rupture of the Achilles tendon is a considerable cause of morbidity with reduced function following injury. Recent studies have shown little difference in outcome between the techniques of open and non-operative treatment using an early active rehabilitation programme. Meta-analyses have shown that non-operative management has increased risk of re-rupture whereas surgical intervention has risks of complications related to the wound and iatrogenic nerve injury. Minimally invasive surgery has been adopted as a way of reducing infections rates and wound breakdown however avoiding iatrogenic nerve injury must be considered. We discuss the techniques and outcomes of percutaneous and minimally invasive repairs of the Achilles tendon.

Initial stability of two different adhesives compared to suture repair for acute Achilles tendon rupture--a biomechanical evaluation

PURPOSE

Treatment of acute subcutaneous Achilles tendon rupture remains challenging. Whereas the results of conservative and operative treatment are inconsistent, early mobilisation treatment seems to be beneficial. Besides suture repair, operative treatment using adhesives reveals promising results. Our hypothesis was that a gluing technique provides initial stability comparable to sutures.

METHODS

In a biomechanical study, 18 fresh frozen sheep Achilles tendons were used to compare the biomechanical properties of suture repair using PDS® II and Bunnell's technique to tendon gluing using BioGlue® and Tissucol®. Load to failure testing was performed.

RESULTS

Ultimate failure loads of sutures (146.2 ± 30.8 N) are significantly superior to the techniques using BioGlue® (38.4 ± 18.3 N; p <0.0001) or Tissucol® (4.7 ± 2.5 N; p <0.0001). Interestingly, no significant differences in stiffness were found between the application of BioGlue® and PDS® II.

CONCLUSIONS

Suture repair provides significantly superior biomechanical properties compared to the use of both tested adhesives BioGlue® and Tissucol®. Based on the presented data we recommend the use of suture material for open Achilles tendon repair.

Major functional deficits persist 2 years after acute Achilles tendon rupture

PURPOSE

The purpose of this prospective randomized controlled study was to evaluate the long-term results after an acute Achilles tendon rupture in patients treated surgically or non-surgically. The focus was to evaluate whether any improvements occurred between the one and 2-year evaluation.

METHOD

Eighty-one patients (67 men, 14 women) with a mean (SD) age of 42 (9.1) were included in this study. Forty-two patients were treated surgically, and 39 treated non-surgically otherwise the treatment was identical for the two groups. All patients were evaluated using the Achilles tendon Total Rupture Score (ATRS), the Physical Activity Scale (PAS) and validated functional tests one and 2 years after injury.

RESULTS

There were significant functional deficits on the injured side compared with the contralateral side 2 years after Achilles tendon rupture, regardless of treatment. Only minor improvements, even though statistically significant, occurred between the 1- and 2-year evaluations. The physical activity level remained significantly reduced as compared with prior to injury, but the ATRS mean was relatively high in both groups (89 and 90).

CONCLUSION

This long-term follow-up indicates that the majority of patients with an Achilles tendon rupture have not fully recovered (in regards to symptoms, physical activity level and function) 2 years after injury regardless of surgical or non-surgical treatment. Furthermore, only minor improvements occur between the 1- and 2-year evaluations. This indicates that to enhance the final outcome the focus should be on improvements in treatment within the first year. The patients appear to have adjusted to their impairments since the patient-reported outcome is relatively high in spite of functional deficits and lower activity level compared with pre-injury.

LEVEL OF EVIDENCE

Prospective randomized study, Level I.

Use of an anti-gravity treadmill in the rehabilitation of the operated achilles tendon: a pilot study

Achilles surgical patients were evaluated using an "anti-gravity" Alter-G (AG) treadmill that allows for reduction of weightbearing pressure on the lower extremity. We studied our hypothesis, which was based on our prior clinical findings, that being able to run on the AG treadmill at 85% of body weight is sufficient to clear patients to run with full body weight outside. Patients undergoing Achilles tendon rupture or insertional repair surgery were prospectively studied. They were compared with a control group that had similar surgeries and a similar rehabilitation program during the same time period: the variable was not using the AG treadmill. The criteria for the study group to be allowed to run outside was being able to run for at least 10 minutes on the AG at 85% of body weight. Each group had 8 patients who underwent surgery for 2 complete tendon ruptures and 6 insertional repairs. There was no significant difference between the AG and control group as to age and postoperative follow-up. AG patients began their initial run on the treadmill at 70% of their body weight at 13.9 ± 3.4 weeks, 85% at 17.6 ± 3.9 weeks, and outside running at 18.1 ± 3.9 weeks. The control group's return to running outside time was 20.4 ± 4.1 weeks. This was not significantly different (p = .27). We confirmed our hypothesis that being able to run at 85% of body weight after Achilles surgery was sufficient to clear patients to run outside.

Achilles tendon ruptures in diabetic patients

AIM

The aim of this study is to evaluate the results of percutaneous repair of an acute AT rupture in diabetic patients.

METHOD

The study included 39 subjects who were operated at our institution. We performed pre-operative evaluations the day of surgery, and report the results of post-operative evaluation at the final follow-up.

RESULTS

The Achilles tendon total rupture score had a post-operative average rating of 70.4 ± 13 (range 55-92). All patients were able to fully weight bear on the operated limb by the end of the eighth post-operative week. Eight patients suffered from a superficial infection of the surgical wound.

CONCLUSION

In conclusion, percutaneous repair of the AT is a viable option for diabetic patients.

Achilles tendon ruptures in elite athletes

BACKGROUND

The management of Achilles tendon (AT) ruptures in elite athletes can be challenging. We performed a retrospective review of prospectively collected data study to evaluate the results of percutaneous repair of an acute AT rupture in elite athletes.

MATERIALS AND METHODS

Seventeen elite athletes with prodromal tendinous problems sustained an acute tear of the AT and underwent percutaneous surgical repair. We performed preoperative evaluations the day of surgery, and report the results of postoperative evaluation at a final followup at an average of 72 months from the procedure. Each patient was evaluated for limb dominance, trauma history, duration and type of preoperative symptoms, and postoperative AT Total Rupture Score (ATRS).

RESULTS

All patients were able to fully weightbear on the operated limb by the end of the 8th postoperative week. The average time to return to full sport participation was 4.8±0.9 months. Two of the 15 elite athletes on whom we have full data suffered from a superficial infection of the surgical wound.

CONCLUSION

Our study suggests that percutaneous repair of the AT is a good option for elite athletes, allowing a safe and prompt return to sport activities.

Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation

BACKGROUND

To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In all but one study, the limb was immobilized for six to eight weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of the present study was to compare the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functional rehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone.

METHODS

Patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. All patients underwent an accelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The primary outcome was the rerupture rate as demonstrated by a positive Thompson squeeze test, the presence of a palpable gap, and loss of plantar flexion strength. Secondary outcomes included isokinetic strength, the Leppilahti score, range of motion, and calf circumference measured at three, six, twelve, and twenty-four months after injury.

RESULTS

A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized. There were 118 males and twenty-six females, and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were thirteen complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group.

CONCLUSIONS

This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. All measured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management.

Rehabilitation of the operated achilles tendon: parameters for predicting return to activity

Return to activity (RTA) following Achilles tendon surgery assessment criteria has not been generally adopted. A well-defined postsurgical rehabilitation regimen with 3 distinct criteria, yet easy to measure, can be used to assess the ability of patients undergoing Achilles tendon surgery to return to activity. We studied whether if patients were able to meet all 3 criteria, would this show significance in predicting the ability to RTA within a normal range. A total of 219 patients undergoing surgery on the Achilles tendon from 1990 to 2005 were retrospectively studied to evaluate for the ability to perform 5 sets of 25 single-legged concentric heel raises, along with symmetry of calf girth and ankle range of motion. Time of RTA and the ability to meet all 3 parameters was studied. If patients could meet all 3 criteria, they were allowed to RTA. This time postsurgery was recorded in weeks. Of the 219 surgeries reviewed, 149 were on males and 70 on females. Fourteen patients were unable to meet all 3 parameters evaluated above within the proposed time frames. The inability to meet all 3 criteria resulted in a delay to RTA (P = .03). Eleven females had a delay in RTA as compared with 2 males (P < .0001). RTA was different based on procedure. Meeting all 3 criteria was helpful in assessing if patients were able to RTA in the normal range. Patients who were unable to meet all 3 had a delay in RTA. Females were more likely to have a delay in RTA.

Less-invasive reconstruction of chronic achilles tendon ruptures using a peroneus brevis tendon transfer

BACKGROUND

A less-invasive technique to reconstruct chronic Achilles tendon rupture with transfer of the tendon of peroneus brevis is suitable in patients with a tendon gap less than 6 cm.

PURPOSE

To report the results of a longitudinal study on reconstruction of chronic Achilles tendon rupture using a less-invasive peroneus brevis repair through 2 paramidline incisions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-two patients underwent surgery for chronic Achilles tendon rupture with a tendon gap during surgery less than 6 cm, occurring between 60 days and 9 months preoperatively. All participants were prospectively followed for 5 to 8 years; final review was performed at 48.4 ± 13.5 months from the operation. Clinical and functional assessment (anthropometric measurements, isometric strength, postoperative Achilles tendon total rupture score) was performed.

RESULTS

All patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp. No patient developed a clinically evident deep vein thrombosis or sustained a rerupture. Five patients were managed nonoperatively after a superficial infection of one of the surgical wounds. At final review, the maximum calf circumference remained significantly decreased in the operated leg (39.2 ± 6.2 cm [side with rupture] vs 40.9 ± 7.0 cm [uninjured side]; P = .04). The operated limb was significantly less strong than the nonoperated one (231.2 ± 132.4 N vs 275.3 ± 150.2 N; P = .033). The Achilles tendon total rupture score at final follow-up was 92.5 ± 14.2.

CONCLUSION

The management of chronic Achilles tendon tears by a less-invasive peroneus brevis repair is technically demanding but safe. It allows good recovery, even in patients with a chronic rupture of 9 months' duration. These patients should be warned that they are at risk for postoperative complications and that their ankle plantar flexion strength is likely to be reduced.

Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures

BACKGROUND

There is no consensus regarding the optimal treatment for patients with acute Achilles tendon rupture. Few randomized controlled studies have compared outcomes after surgical or nonsurgical treatment with both groups receiving early mobilization.

PURPOSE

This study was undertaken to compare outcomes of patients with acute Achilles tendon rupture treated with or without surgery using early mobilization and identical rehabilitation protocols.

STUDY DESIGN

Randomized, controlled trial; Level of evidence, 1.

METHODS

Ninety-seven patients (79 men, 18 women; mean age, 41 years) with acute Achilles tendon rupture were treated and followed for 1 year. The primary end point was rerupturing. Patients were evaluated using the Achilles tendon Total Rupture Score (ATRS), functional tests, and clinical examination at 6 and 12 months after injury.

RESULTS

There were 6 (12%) reruptures in the nonsurgical group and 2 (4%) in the surgical group (P = .377). The mean 6- and 12-month ATRS were 72 and 88 points in the surgical group and 71 and 86 points in the nonsurgical group, respectively. Improvements in ATRS between 6 and 12 months were significant for both groups, with no significant between-group differences. At the 6-month evaluation, the surgical group had better results compared with the nonsurgically treated group in some of the muscle function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work test in favor of the surgical group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower than that of the uninjured leg in both groups.

CONCLUSION

The results of this study did not demonstrate any statistically significant difference between surgical and nonsurgical treatment. Furthermore, the study suggests that early mobilization is beneficial for patients with acute Achilles tendon rupture whether they are treated surgically or nonsurgically. The preferred treatment strategy for patients with acute Achilles tendon rupture remains a subject of debate. Although the study met the sample size dictated by the authors' a priori power calculation, the difference in the rerupture rate might be considered clinically important by some.

Diagnosis and treatment of acute Achilles tendon rupture

This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of acute Achilles tendon rupture. None of the 16 recommendations made by the work group was graded as strong; most are graded inconclusive; four are graded weak; two are graded as moderate strength; and two are consensus statements. The two moderate-strength recommendations include the suggestions for early postoperative protective weight bearing and for the use of protective devices that allow for postoperative mobilization.

Minimally invasive surgery for Achilles tendon pathologies

Minimally invasive trauma and orthopedic surgery is increasingly common, though technically demanding. Its use for pathologies of the Achilles tendon (AT) hold the promise to allow faster recovery times, shorter hospital stays, and improved functional outcomes when compared to traditional open procedures, which can lead to difficulty with wound healing because of the tenuous blood supply and increased chance of wound breakdown and infection. We present the recent advances in the field of minimally invasive AT surgery for tendinopathy, acute ruptures, chronic tears, and chronic avulsions of the AT. In our hands, minimally invasive surgery has provided similar results to those obtained with open surgery, with decreased perioperative morbidity, decreased duration of hospital stay, and reduced costs. So far, the studies on minimally invasive orthopedic techniques are of moderate scientific quality with short follow-up periods. Multicenter studies with longer follow-up are needed to justify the long-term advantages of these techniques over traditional ones.

Desequilíbrios musculares entre flexores dorsais e plantares do tornozelo após tratamento conservador e acelerado da ruptura do tendão calcâneo

A ruptura do tendão calcâneo (TC) reduz a sobrecarga mecânica dos flexores plantares (FP) do tornozelo. Essa alteração muda o equilíbrio natural entre os FP e flexores dorsais (FD) do tornozelo. O objetivo do estudo foi avaliar as razões isocinéticas concêntricas convencionais de torque de pacientes submetidos a tratamento cirúrgico de ruptura aguda do TC após dois protocolos diferentes de reabilitação. Após procedimento cirúrgico para reconstrução do TC, a amostra foi dividida de forma intencional em dois grupos: conservador (GC, 11 homens, 41,3±7,9 anos) e grupo acelerado (GA, 13 homens, 43,5±13,7 anos). O GC permaneceu com imobilização gessada no tornozelo por seis semanas (tratamento tradicional), enquanto o GA usou uma órtese robofoot em posição neutra e, após duas semanas, iniciou mobilização e apoio precoce do tornozelo, com reabilitação por seis semanas. Após 3 meses de pós-operatório, a razão do torque concêntrico máximo dos FD pelos FP do tornozelo foi avaliada por dinamômetro isocinético. As razões de torque do lado operado se mantiveram superiores às do lado saudável mesmo após 3 meses de pós-operatório (p<0,05). Não foi encontrada diferença no equilíbrio muscular entre os grupos. Pode-se concluir que os dois grupos requerem um período mais longo de reabilitação para recuperar o equilíbrio natural do tornozelo no lado operado.

Factors associated with calf muscle endurance recovery 1 year after achilles tendon rupture repair

STUDY DESIGN

Cohort study.

OBJECTIVES

To describe calf muscle endurance recovery and to explore factors predictive of poor calf muscle endurance recovery 1 year after surgical repair of an Achilles tendon rupture (ATR).

BACKGROUND

ATR is a common sports-related injury and is often managed with open surgical repair. After ATR repair most patients return to usual activities 6 months after surgery. However, calf endurance impairment can persist up to 6 years, possibly impacting performance of daily activities and sport.

METHODS

A secondary analysis of a 73-patient cohort from a randomized controlled trial assessing the effects of early weight bearing after surgical repair of an ATR was performed. Calf muscle endurance recovery was measured by single-heel raises using a customized counting device at 6 months and 1 year postoperatively. Descriptive statistics were used to outline recovery of calf muscle endurance. Physical and patient-reported outcomes were examined for their association with calf-muscle endurance recovery. Multiple linear regression analysis was performed to explore variables associated with recovery of calf endurance 1 year postoperatively.

RESULTS

Mean recovery of calf muscle endurance was 76% at 1 year. Multivariate regression analysis showed an association of being female, reporting no resting pain at 3 months, and physical functioning and calf endurance at 6 months, with better recovery of calf endurance at 1 year.

CONCLUSIONS

Calf muscle endurance at 1 year remained impaired in a considerable portion of the sample. Pain, gender, and physical functioning are likely important factors in determining recovery of calf muscle endurance.

LEVEL OF EVIDENCE

Prognosis, level 2b.J Orthop Sports Phys Ther 2010;40(6):345-351, Epub 15 April 2010. doi:10.2519/jospt.2010.3204.

Favorable outcome of percutaneous repair of achilles tendon ruptures in the elderly

Percutaneous repair of Achilles tendon (AT) ruptures reportedly reduces the risk of rerupture compared to nonoperative treatment and reduces the risk of wound infection compared to open surgery. We retrospectively reviewed the postoperative Achilles tendon total rupture score (ATRS), and the maximum calf circumference in 35 patients over 65 years of age who sustained an acute tear of the AT and underwent percutaneous repair of the AT. There were 26 men and nine women with a mean age at operation of 73.4 +/- 8.7 years (range, 65-86 years). Of the 35 recruited patients, we report on 27 patients for whom we have a full data set. The minimum followup was 49 months (mean, 88 months; range, 49-110 months). The ATRS had a postoperative average rating of 69.4 +/- 14 (range, 56-93). All patients were able to bear weight fully on the affected limb by the eighth postoperative week. The data suggest that percutaneous repair of the AT is a suitable option for patients older than 65, producing similar outcomes when compared to percutaneous repair in younger patients of previous reports.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A new conservative-dynamic treatment for the acute ruptured Achilles tendon

INTRODUCTION

There is a trend towards surgical treatment of acute ruptured Achilles tendon. While classical open surgical procedures have been shown to restore good functional capacity, they are potentially associated with significant complications like wound infection and paresthesia. Modern mini-invasive surgical techniques significantly reduce these complications and are also associated with good functional results so that they can be considered as the surgical treatment of choice. Nevertheless, there is still a need for conservative alternative and recent studies report good results with conservative treatment in rigid casts or braces.

PATIENTS/METHOD

We report the use of a dynamic ankle brace in the conservative treatment of Achilles tendon rupture in a prospective non-randomised study of 57 consecutive patients. Patients were evaluated at an average follow-up time of 5 years using the modified Leppilahti Ankle Score, and the first 30 patients additionally underwent a clinical examination and muscular testing with a Cybex isokinetic dynamometer at 6 and 12 months.

RESULTS

We found good and excellent results in most cases. We observed five complete re-ruptures, almost exclusively in case of poor patient's compliance, two partial re-ruptures and one deep venous thrombosis complicated by pulmonary embolism.

CONCLUSION

Although prospective comparison with other modern treatment options is still required, the functional outcome after early ankle mobilisation in a dynamic cast is good enough to ethically propose this method as an alternative to surgical treatment.

Free hamstrings tendon transfer and interference screw fixation for less invasive reconstruction of chronic avulsions of the Achilles tendon

Reconstruction of chronic avulsions of the Achilles tendon can be technically difficult, as the calcaneus can be totally denuded of tendon, or only a small tuft of frayed tissue may have remain attached to the calcaneus, and be inadequate to allow a direct repair. In these patients, if it is not possible to directly reattach the Achilles tendon, a tendon graft can be necessary. We developed a less invasive technique using a free semitendinosus tendon graft with interference screw fixation in the calcaneus through a Cincinnati incision. Using this approach, a wide exposure of the insertion of the Achilles tendon is possible, preserving the integrity of the skin overlying the site most prone to wound breakdown.

Novel approach to repair of acute achilles tendon rupture: early recovery without postoperative fixation or orthosis

BACKGROUND

Immobilization or orthosis is required after conventional Achilles tendon surgery. Hypothesis This new Achilles tendon repair approach enables early rehabilitation without any postoperative immobilization or orthosis.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty consecutive patients (14 men and 6 women; mean age, 43.4 years; range, 16-70 years) who had acute subcutaneous Achilles tendon rupture were treated by the new method, with an average follow-up of 2.9 years (range, 2-4.8 years). Among them, 15 injuries were sports-related and 5 were work-related. The authors applied a side-locking loop technique of their own design for the core suture, using braided polyblend suture thread, with peripheral cross-stitches added. The patients started active and passive ankle mobilization from the next day, partial weightbearing walking from 1 week, full-load walking from 4 weeks, and double-legged heel raises from 6 weeks after surgery.

RESULTS

The range of motion recovery equal to the intact side averaged 3.2 weeks. Double-legged heel raises and 20 continuous single-legged heel raise exercises were possible at an average of 6.3 weeks and 9.9 weeks, respectively. T2-weighted magnetic resonance signal intensity recovered to equal that of the intact portion of the same tendon at 12 weeks. The patients resumed sports activities or heavy labor at an average of 14.4 weeks. The Achilles tendon rupture score averaged 98.3 at 24 weeks. There were no complications.

CONCLUSION

This new Achilles tendon repair approach enables early mobilization exercise without costly specialized orthosis or immobilization and allows an early return to normal life and sports activities, reducing the physical and economic burden on patients.

Endoscopic-assisted repair of acute Achilles tendon rupture with Krackow suture: an anatomic study

PURPOSE

To study the feasibility of applying Krackow locking stitches in the endoscopic-assisted repair of acute Achilles tendon rupture and the possible complications encountered.

TYPE OF STUDY

Anatomic study.

METHODS

Twelve Achilles tendons in six cadavers were cut at 6cm from its insertion and endoscopic-assisted repair of Achilles tendon was performed. These legs were then cut open in midline to study (i) the locking stitches formed and (ii) the relation of the sural nerve to the locking stitches.

RESULT

With endoscopic-assisted technique, Krackow-type locking stitches can be formed in eight legs. In four legs, the stitches fell into the ruptured gap and lie deep to the tendon. The tendon rupture end was grasped by the suture rather than forming a Krackow-type locking stitch when the suture was tightened. There was no sural nerve laceration noted. However, in two legs, the sural nerves were found trapped in the sutures at around the proximal portal.

CONCLUSIONS

Krackow locking stitches can be formed by the minimally invasive technique. However, there are risks of stitches falling into the ruptured gap and lie deep to the tendon and risk of sural nerve entrapment at the proximal medial portal. The original technique is not suitable for clinical application. Modification of the technique by grasping the tendon end with Allis tissue forceps before passing the suture may prevent the suture from falling into the ruptured tendon gap.

Complications of the treatment of Achilles tendon ruptures

Since the first reports in the medical literature of treatment of the Achilles tendon, complications have been recognized from both non-operative and operative techniques. These include tendon rerupture, sural nerve morbidity, wound healing problems, changes in tendon morphology, venous thromboembolism, elongation of the tendon, complex regional pain syndrome, and compartment syndrome. This article delineates the incidence for each of these complications, with differing techniques, methods of avoiding these complications and treatment methods if they occur.

Minimally invasive surgery of the achilles tendon

Minimally invasive surgical techniques for pathologies of the Achilles tendon (AT) hold the promise to decrease perioperative morbidity, allow faster recovery times, shorten hospital stays, and improve functional outcomes when compared with open procedures, which can lead to difficulty with wound healing because of the tenuous blood supply and increased chance of wound breakdown and infection. This article presents recent advances in the field of minimally invasive AT surgery for tendinopathy, acute ruptures, and chronic tears. All of the techniques described in this article are inexpensive and do not require highly specialized equipment and training. Future randomized controlled trials are required to address the issue of the comparison between open versus minimally invasive AT surgery.

Acute ruptures of the achilles tendon

The Achilles tendon (AT) is the most frequently ruptured tendon in the human body, but the etiology of AT ruptures is still not completely understood. Percutaneous repair and conservative management are viable alternatives to open surgery, which carries higher complication rates and is the most costly of the 3 management options. Individual patients will have different needs due to their age, occupation, or level of sporting activity. If the studies reporting a rising incidence of AT rupture are accurate, the field of AT surgery will become an increasingly important one for orthopedic surgeons. A major problem in the evaluation of the outcome of management of AT ruptures has been the lack of a universally accepted scoring system for the evaluation of results of management of AT rupture. The AT Total Rupture Score is a self-administered instrument with high clinical utility, and it can be used for measuring the outcome, related to symptoms and physical activity, after treatment in patients with a total AT rupture. Future developments may include the use of adhesives in tendon surgery. An understanding of the role, which cytokines play in tendon healing may also lead to the advent of new treatments, possibly based on gene therapy. However, such novel interventions are unlikely to be in routine clinical use for some time.

Tissue memory in healing tendons: short loading episodes stimulate healing

Intact tendons adapt slowly to changes in mechanical loading, whereas in healing tendons the effect of mechanical loading or its absence is dramatic. The longevity of the response to a single loading episode is, however, unknown. We hypothesized that the tissue has a "memory" of loading episodes and that therefore short loadings are sufficient to elicit improved healing. The Achilles tendon of 70 female rats was transected and unloaded by tail suspension for 12 days (suspension started on day 2 after surgery). Each day, the rats were let down from suspension for short daily training episodes according to different regimes: 15 min of cage activity or treadmill running for 15, 30, 60, or 2x15 min. Rats with transected Achilles tendons and full-time cage activity served as controls. The results demonstrated that full-time cage activity increased the peak force over three times compared with unloading. Short daily loading episodes (treadmill running) increased the peak force about half as much as full-time activity. Prolongation of treadmill running above 15 min or dividing the daily training in two separate episodes had minimal further effect. This mechanical stimulation increased the cross-sectional area but had no effect on the mechanical properties of the repair tissue. The findings indicate that once the tissue had received information from a certain loading type and level, this is "memorized" and leads to a response lasting many hours. This suggests that patients might be allowed early short loading episodes following, e.g., an Achilles tendon rupture for a better outcome.

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.