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

Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial

BACKGROUND

Surgical repair of acute Achilles tendon ruptures is considered superior to nonoperative treatment, but complications other than rerupture range up to 34%. Nonoperative treatment by functional bracing seems a promising alternative.

HYPOTHESIS

Nonoperative treatment of acute Achilles tendon rupture with functional bracing reduces the number of complications compared with surgical treatment with a minimally invasive technique.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHOD

Using concealed random allocation, 83 patients with acute Achilles tendon rupture were assigned to nonoperative treatment by functional bracing or minimally invasive surgical treatment followed by tape bandage. Patients were allowed full weightbearing, and follow-up was 1 year.

RESULTS

Complications risk other than rerupture by intention-to-treat basis was 9 in 42 patients (21%) for surgical treatment and 15 in 41 patients (36%) for nonoperative treatment (risk ratio, 0.59; 95% confidence interval, 0.29-1.19). Reruptures risk was 5 in 41 patients after nonoperative treatment and 3 in 42 patients for surgical treatment (risk ratio, 0.59; 95% confidence interval, 0.15-2.29). The mean time to work was 59 days (SD, 82) after surgical treatment and 108 days (SD, 115) after nonoperative treatment (difference, 49 days; 95% confidence interval, 4-94; P < .05). The difference between treatments for return to sports (risk ratio, 0.55; 95% confidence interval, 0.23-1.29), pain, and treatment satisfaction did not reach statistical significance.

CONCLUSION

There appears to be a clinically important difference in the risk of complications between minimally invasive surgical treatment and nonoperative treatment for acute Achilles tendon ruptures, but this was not statistically significant.

The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon

BACKGROUND

The optimal rehabilitation protocol after surgical repair of an Achilles tendon rupture has not been well defined. The objective of this randomized study was to compare the effect of early weight-bearing with that of non-weight-bearing on early postoperative recovery following repair of an acutely ruptured Achilles tendon.

METHODS

Between October 2003 and May 2006, 110 patients with a surgically repaired Achilles tendon rupture were enrolled from one of two major trauma-care tertiary hospitals. All patients were non-weight-bearing for the first two weeks postoperatively. At the two-week postoperative visit, patients were randomized to either weight-bearing or non-weight-bearing for an additional four weeks. Compliance was measured with a pressure sensor in the fixed-hinge ankle-foot orthosis given to each patient. Follow-up assessments were performed at six weeks, three months, and six months postoperatively. The primary outcome was health-related quality of life assessed with use of the RAND 36-Item Health Survey (RAND-36). Secondary outcomes were activity level, calf strength, ankle range of motion, return to sports and work, and complications.

RESULTS

Ninety-eight patients (89%) completed the six-month follow-up. At six weeks, the weight-bearing group had significantly better scores than the non-weight-bearing group in the RAND-36 domains of physical functioning, social functioning, role-emotional, and vitality scores (p < 0.05). Patients in the weight-bearing group also reported fewer limitations of daily activities at six weeks postoperatively (p < 0.001). At six months, no significant differences between the groups were seen in any outcome, although both groups had poor endurance of the calf musculature. No rerupture occurred in either group.

CONCLUSIONS

Early weight-bearing after surgical repair of an acute Achilles tendon rupture improves health-related quality of life in the early postoperative period and has no detrimental effect on recovery.

The Achillon achilles tendon repair: is it strong enough?

BACKGROUND

Open repair of the Achilles tendon is associated with wound breakdown, infection and percutaneous methods risk sural nerve injury. The Achillon mini-incision technique can reduce these risks and may provide the opportunity for early active rehabilitation. The aim of this study was to compare the strength of the Achillon method with the commonly used Kessler method and to assess whether the strength of the repair was related to tendon diameter.

MATERIALS AND METHODS

Simulated ruptures in sheep Achilles tendons were repaired using either the Achillon method or a two-strand Kessler technique with a No. 2 Ticron suture (Tyco Healthcare, UK). Each tendon diameter was measured, and matched for both groups. Specimens were loaded to failure using an Instron tensile testing machine (Instron Limited, UK).

RESULTS

Mean load to failure for the Achillon repair was 153 N+/-60 (range, 65 to 270), and the mean load to failure for the Kessler Repair was 123 N+/-24 (range, 75 to 150). This difference was not statistically significant (p=0.21). There was a statistically significant higher mean load to failure for wider tendons repaired by the Achillon method (p=0.05), however mean load to failure was not related to tendon width in Kessler repairs (p=0.23).

CONCLUSION

This is the first study to compare these two methods of repair. The Achillon repair has comparable tensile strength to the Kessler Repair.

CLINICAL RELEVANCE

The Achillon repair appears to be a biomechanically sound method of repair for the acutely ruptured Achilles tendon.

Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon

Background

Many techniques have been developed for the reconstruction of the Achilles tendon in chronic tears. In presence of a large gap (greater than 6 centimetres), tendon augmentation is required.

Methods

We present our method of minimally invasive semitendinosus reconstruction for the Achilles tendon using one para-midline and one midline incision.

Results

The first incision is a 5 cm longitudinal incision, made 2 cm proximal and just medial to the palpable end of the residual tendon. The second incision is 3 cm long and is also longitudinal but is 2 cm distal and in the midline to the distal end of the tendon rupture. The distal and proximal Achilles tendon stumps are mobilised. After trying to reduce the gap of the ruptured Achilles tendon, if the gap produced is greater than 6 cm despite maximal plantar flexion of the ankle and traction on the Achilles tendon stumps, the ipsilateral semitendinosus tendon is harvested. The semitendinosus tendon is passed through small incisions in the substance of the proximal stump of the Achilles tendon, and it is sutured to the Achilles tendon. It is then passed beneath the intact skin bridge into the distal incision, and passed from medial to lateral through a transverse tenotomy in the distal stump. With the ankle in maximal plantar flexion, the semitendinosus tendon is sutured to the Achilles tendon at each entry and exit point

Conclusion

This minimally invasive technique allows reconstruction of the Achilles tendon using the tendon of semitendinosus preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of large gap (greater than 6 centimetres).

Management of chronic ruptures of the Achilles tendon

Chronic ruptures of Achilles tendons are those that present four to six weeks after the original injury. They have become more common as acute Achilles tendon injuries have become more frequent, and they are associated with considerable functional morbidity. Most surgeons agree that chronic ruptures should be managed operatively. Diagnosis is based predominantly on history and clinical examination. Real-time, high-resolution ultrasound and magnetic resonance imaging are helpful in preoperative planning or as a diagnostic aid. Local tissue, local tendons, and allografts can be used to reconstruct the tendon, and end-to-end repair is possible if the gap is <2.5 cm. Compared with acute injuries, chronic injuries are associated with a higher rate of postoperative infection and more prolonged recovery.

Optimizing Achilles tendon repair: effect of epitendinous suture augmentation on the strength of achilles tendon repairs

BACKGROUND

Epitendinous suture augmentation has been shown to increase gap resistance and overall strength in flexor tendon repairs of the hand. The purpose of this study was to evaluate the effect of various suture augmentation techniques in Achilles tendon repair.

MATERIALS AND METHODS

Eighteen fresh-frozen cadaveric Achilles tendons were transected and repaired with a 4-strand Krackow core stitch. Suture augmentation was performed with 3 figure-of-eight stitches in 6 specimens and a running cross-stitch weave in 6 specimens. The other 6 specimens were not augmented. Each tendon was loaded to failure on an MTS. Force to failure (defined as peak force or force at 5 mm gapping), gapping resistance, stiffness, and elongation were compared.

RESULTS

Force to failure (p < 0.001), stiffness (p < 0.01) and gapping resistance (p < 0.05) were increased by suture augmentation. Additionally failure force and gapping resistance for the cross-stitch augmentation was higher than the figure-of-eight augmentation (p < 0.05).

CONCLUSION

Cross-stitch augmentation of Achilles tendon repair yields a stronger and stiffer repair with greater resistance to gapping.

CLINICAL RELEVANCE

Achilles tendon repairs augmented with a cross stitch weave will be able to withstand substantially higher forces than non-augmented repairs.

Effect of knee flexion angle on Achilles tendon force and ankle joint plantarflexion moment during passive dorsiflexion

Early mobilization exercises are advocated following Achilles tendon (AT) repair, but forces on the repair during passive range of motion are unknown. The extent to which these forces change with flexion of the knee is also not known. Estimated AT forces were measured using 3 models: cadaveric, uninjured subjects, and in both legs of subjects 6 weeks following unilateral AT repair. For cadaveric testing, estimated AT force was recorded using a force transducer while cycling the ankle from 10 degrees plantarflexion to maximum dorsiflexion at 3 different knee flexion angles (0 degrees , 45 degrees , and 90 degrees ). For in vivo testing, subjects were seated in an isokinetic dynamometer, and their ankles passively cycled from plantarflexion to dorsiflexion with the knee extended and flexed 50 degrees . Passive plantarflexion moment recorded by the dynamometer was converted to AT force by estimating the AT moment arm. In the cadaveric model, knee flexion reduced estimated AT forces during dorsiflexion by more than 40% (P < .036). In vivo testing showed that estimated AT force was reduced in knee flexion in healthy subjects (P < .001) and in the uninvolved leg AT repair subjects (P = .021), but not in the AT repaired leg (P = .387). Normal AT showed a marked reduction in estimated AT force with knee flexion which was not present in repaired AT. This could be because of elongation of the repair, causing more slack in the tendon that would need to be taken up before force transmission occurs. ACFAS Level of Clinical Evidence: 4.

Percutaneous and mini-open repair of acute Achilles tendon rupture

Treatment of acute Achilles tendon rupture is slowly evolving, but a lack of prospective, randomized trials leaves insufficient evidence for a definitive recommendation as to the best treatment. Percutaneous and mini-open techniques certainly have roles in treating the acutely ruptured Achilles tendon, and some trials suggest that these techniques can give results equivalent to or better than those of an open repair, with the added benefit of fewer complications. These findings have been backed up by a recent meta-analysis.

Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial

Background

We present the design of an open randomized multi-centre study on surgical versus conservative treatment of acute Achilles tendon ruptures. The study is designed to evaluate the effectiveness of conservative treatment in reducing complications when treating acute Achilles tendon rupture.

Methods/Design

At least 72 patients with acute Achilles tendon rupture will be randomized to minimally invasive surgical repair followed by functional rehabilitation using tape bandage or conservative treatment followed by functional rehabilitation with use of a functional bracing system. Both treatment arms use a 7 weeks post-rupture rehabilitation protocol. Four hospitals in the Netherlands will participate. Primary end-point will be reduction in complications other than re-rupture. Secondary end-point will be re-rupturing, time off work, sporting activity post rupture, functional outcome by Leppilahti score and patient satisfaction. Patient follow-up will be 12 month.

Discussion

By making this design study we wish to contribute to more profound research on AT rupture treatment and prevent publication bias for this open-labelled randomized trial.

Trial registration

ISRCTN50141196

A preliminary study on the effects of acellular tissue graft augmentation in acute Achilles tendon ruptures

Acute Achilles tendon rupture injuries present surgical challenges because of the mechanical forces placed on this tendon. The purpose of this study was to evaluate the effectiveness of an acellular human dermal tissue matrix, GraftJacket Matrix (Wright Medical Technology, Inc., Arlington, TN), as an augmentation material in acute Achilles tendon repair. Eleven consecutive patients with acute tendon ruptures were evaluated and followed up (20-31 months). Primary repair was followed by augmentation with the graft sutured circumferentially around the tendon. Patients were placed in an early functional rehabilitation program with postoperative evaluation at 3, 6, and 12 months. Outcome scores were calculated based on the American Orthopaedic Foot and Ankle Society ankle-hindfoot scoring system. At 20-month postoperative follow-up, there have been no cases of rerupture or recurrent pain. The average return-to-activity time was 11.8 +/- 0.75 weeks. These retrospective clinical results suggest that with an acellular human dermal tissue matrix to augment acute Achilles tendon, primary repair offers a desirable return-to-activity time without any rerupture or complications. ACFAS Level of Clinical Evidence: 2c.

A modified operation for Achilles tendon ruptures

BACKGROUND

Treatment of Achilles tendon rupture has long been at the center of debate.

HYPOTHESIS

A new technique in surgical Achilles tendon repair allows for more stability and earlier rehabilitation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

One hundred Achilles tendon rupture patients (70 men, 30 women; age range, 16-54 years; mean age, 32 years) were treated by a newly modified method of repair. Twenty-one of these patients were high-level athletes, and 79 were recreational-level athletes. The average length of follow-up was 2.4 years (range, 1-6.3 years), and none of the ruptures included avulsion fractures. After adjusting the tendon to an adequate length using a Tsuge suture, each fibrous bundle was gathered in a longitudinal direction and fixed with a Bunnell-type suture. The same postoperative physical therapy protocol was applied to all patients: at 1 week, early full weightbearing with a walking cast was initiated, and at 2 weeks, patients began range of motion (ROM) exercises and were instructed to wear a hinged ankle-foot orthosis that permitted full plantar flexion but limited full dorsiflexion. From 6 weeks, patients started practicing double-legged heel raises.

RESULTS

At an average of 10 weeks, ankle ROM was comparable to that of the nonoperated leg, and double-legged heel raises were achieved at an average of 7.6 weeks. On average, patients were able to do 20 continuous single-legged heel-raising motions (equivalent to manual muscle testing grade 5) at 15.4 weeks, and jogging started at 12.3 weeks. High-level athletes returned to their original sports level at an average of 5 months. Two reruptures (2%) were experienced, but no other complications occurred.

CONCLUSION

This surgical technique allows for strong repair stability and subsequent early weightbearing and ROM exercises.

The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment

BACKGROUND

There is still controversy regarding the optimal surgical technique and post-operative treatment of acute Achilles tendon ruptures. We evaluated a treatment protocol for Achilles tendon ruptures consisting of a minimally invasive Achilles tendon repair combined with early full weight bearing.

METHODS

A consecutive group of 163 patients was prospectively followed during a 6 year period (1998-2004) in one university hospital and five teaching hospitals. Data were collected during the outpatient department visits at 1, 3, 5, and 7 weeks, 4 months and 12 months after the intervention. Outcome parameters were the incidence of re-rupture, other complications, the functional outcome and the period of sick leave concerning work and sport.

RESULTS

The patient group consisted of 128 men (79%) and 35 women (21%). The mean operating time was 41 min. In 9 patients (5.5%) a major complication occurred, necessitating 5 surgical re-interventions (2 for re-ruptures, 2 for infections and 1 for tendon necrosis). Fifteen patients (9.2%) suffered from dysfunction of the sural nerve. The median time of returning to work was 28 days (range 1-368) and the median time of returning to sport was 167 days (range 31-489). The majority of patients (150; 92%) were satisfied with the results.

CONCLUSION

Minimally invasive Achilles tendon repair in combination with a functional rehabilitation program is a safe and quick procedure with a low rate of re-rupture and a high level of patient satisfaction.

Percutaneous and minimally invasive techniques of Achilles tendon repair

Despite the controversy regarding the best treatment for an acute Achilles tendon rupture, percutaneous and minimally invasive techniques seem to offer good results in terms of low risks of rerupture and complications with satisfactory clinical and functional outcomes. A comparison between a percutaneous surgical technique and a minimally invasive one has not been reported in the literature. We consecutively evaluated 12 patients who had a modified Ma and Griffith percutaneous Achilles tendon repair and 12 patients who had a minimally invasive technique. The same semifunctional rehabilitation protocol was used after surgery in both groups. At a minimum followup of 24 months (mean, 33 months; range, 24-42 months), we observed no reruptures or major complications in either group. Both groups had similarly high values for the American Orthopaedic Foot and Ankle Society score. The two techniques allowed equivalent time for return to work and sports. In the group of patients treated with the modified Ma and Griffith suture only, the mean loss of calf circumference in the injured leg was greater, compared with the contralateral leg. The two groups were isokinetically similar. In this study, the percutaneous and minimally invasive techniques of repair of the Achilles tendon yielded essentially identical clinical and functional outcomes.

SURGICAL REPAIR FOLLOWED BY FUNCTIONAL REHABILITATION FOR ACUTE AND CHRONIC ACHILLES TENDON INJURIES: EXCELLENT FUNCTIONAL RESULTS, PATIENT SATISFACTION AND NO RERUPTURES

BACKGROUND

We evaluated 46 patients who underwent surgical repair of the Achilles tendon at our institution during a 4.5-year period, followed by early weight bearing, aiming to assess their return to activities, rerupture rate and satisfaction.

METHODS

A cohort of 46 patients who underwent Achilles tendon repair at our institution during a 4.5-year period, with a modified triple mini-Becker suture technique, for both acute as well as chronic Achilles tendon ruptures were studied. These patients were reviewed at a minimum of 2.5 years follow up (average 4.5 years ranging from 2.5 to 6.5 years), by chart review and questionnaire, to determine the functional outcome as well as patient satisfaction following an active postoperative protocol involving full weight-bearing ambulation in a controlled ankle motion walker and active stretching, followed by a graduated strengthening programme.

RESULTS

We found a very high level of satisfaction, with few minor complications and no reruptures in either the early or the delayed repair groups.

CONCLUSION

We believe that surgical repair using this technique associated with an early return to protected full weight-bearing ambulation and an active early rehabilitation programme provides not only excellent functional results, patient satisfaction and a zero rerupture rate, but also much less morbidity in the first 3 months and a quicker overall recovery compared with non-operative treatment.

The Achilles tendon Total Rupture Score (ATRS): development and validation

BACKGROUND

There is a need for a patient-relevant instrument to evaluate outcome after treatment in patients with a total Achilles tendon rupture.

PURPOSE

To develop and validate a new patient-reported instrument for measuring outcome after treatment for total Achilles tendon rupture.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

Development of this instrument consisted of item generation and test construction, item reduction, validation, evaluation of structure and internal consistency, test-retest, and test for responsiveness. The final version, the Achilles tendon Total Rupture Score (ATRS), was tested for validity, structure, and internal consistency (Cronbach's alpha) on 82 patients and 52 healthy persons. A correlation analysis was performed of the ATRS with the 2 validated foot/ankle/Achilles tendon scores, the Foot and Ankle Outcome Score (FAOS) and the Swedish version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-S). Structure was evaluated with factor analysis. Test-retest reliability was evaluated on 43 patients. The ATRS responsiveness was tested on 43 patients by calculating the effect size.

RESULTS

The total score for the patients ranged from 17 to 100 with a mean (median) of 77 (85) and a standard deviation (interquartile range) of 21.4 (23). A significantly (P < .0001) higher total score was found for the healthy subjects, ranging from 94 to 100 with a mean (median) of 99.8 (100) and a standard deviation (interquartile range) of 1.1 (0). The ATRS correlated significantly (P < .01) with all subscales of the FAOS (r = 0.60-0.84) and the VISA-A-S (r = 0.78). The factor analysis gave 1 factor of importance. The internal consistency was 0.96 as measured with Cronbach's alpha. The test-retest produced an intraclass correlation coefficient of 0.98. The tests for responsiveness showed an effect size between 0.87 and 2.21.

CONCLUSION

The ATRS is a patient-reported instrument with high reliability, validity, and sensitivity for measuring outcome after treatment in patients with a total Achilles tendon rupture.

CLINICAL RELEVANCE

The ATRS is a self-administered instrument with high clinical utility, and we suggest the score for measuring the outcome, related to symptoms and physical activity, after treatment in patients with a total Achilles tendon rupture.

Relationship between recovery of calf-muscle biomechanical properties and gait pattern following surgery for achilles tendon rupture

BACKGROUND

The relationship between ankle plantar flexor biomechanical properties and gait pattern following surgery for acute rupture of the Achilles tendon has not yet been fully investigated.

METHODS

Forty-nine young adults (27 men and 22 women) who underwent surgical repair of a complete Achilles tendon rupture were evaluated at 3, 6, 12 and 24 months by clinical assessment, biomechanical evaluation and gait analysis.

FINDINGS

Ankle range of motion, plantar flexor passive stiffness and concentric strength were recovered within 12 months. Gait abnormalities related to these factors took longer to disappear owing to the presence of anomalous muscle patterns. At 24 months, a deficit in calf-muscle eccentric strength was still present, determining adaptive changes in gait strategy that involved ankle motion and coordinated muscular activity.

INTERPRETATION

Improvement of gait pattern is slower than recovery of plantar flexor mechanical properties. Persisting mechanical impairment resulting in gait adaptations may be detrimental to the healing structures by increasing stress on the Achilles tendon. Restoration of calf-muscle eccentric strength and coordinated antagonist muscle activity should be key points in postoperative rehabilitation following surgical repair of Achilles tendon rupture.

Management of shoulder hemiarthroplasty in a patient with rheumatoid arthritis

STUDY DESIGN

Case report.

BACKGROUND

Rehabilitation after shoulder hemiarthroplasty for rotator cuff tear arthropathy (RCTA) represents a significant challenge to physical therapists. Limited goals have been defined for this patient population and include no pain or slight pain at rest, moderate pain with vigorous activity, shoulder external rotation active range of motion (AROM) greater than 20 degrees, and shoulder abduction AROM greater than 90 degrees.

CASE DESCRIPTION

The patient was a 60-year-old female elementary school teacher with functional class III adult-onset rheumatoid arthritis, who came to physical therapy 2 weeks after undergoing a hemiarthroplasty for RCTA of the right shoulder. Physical therapy included 33 treatment sessions involving 4 to 11 exercises each session. All sessions were performed under the direct supervision of a physical therapist utilizing specially designed equipment. Physical therapy emphasized early active assisted elevation range of motion (ROM), graded progressive exercise, and functional training. All exercises were performed in a pain-free ROM or a ROM that did not increase shoulder pain.

OUTCOMES

Following physical therapy, subjective pain scale at rest was 0/10 and during vigorous activity 1/10 to 2/10. Shoulder AROM was normal and shoulder rotation and elevation strength was good. There was a significant improvement in shoulder proprioception and the patient demonstrated a negative belly press test for subscapularis muscle integrity. Additionally, the patient's score on the self-report section of the American Shoulder and Elbow Surgeons Assessment Form increased from 0% at the initial examination to 70% at discharge.

DISCUSSION

Despite limited expectations, this patient achieved normal shoulder ROM and near normal shoulder strength after 14 weeks of physical therapy. Overall, an early, aggressive, progressively graded exercise program appears to be a safe and effective form of treatment after shoulder hemiarthroplasty for RCTA.

Subcutaneous rupture of the Achilles tendon and ipsilateral fracture of the medial malleolus

Background

Although ankle fractures and an Achilles tendon rupture are relatively frequent in isolation, their association in the same injury is uncommon.

Case presentation

A 38 year old male tree surgeon fell six meters from a tree, sustaining a subcutaneous rupture of the Achilles tendon and an ipsilateral closed fracture of the medial malleolus. The injuries were diagnosed following clinical examination and imaging.

Conclusion

This injury combination is infrequent, and management of the Achilles tendon rupture should take into account the necessity not to secondarily displace the fracture of the medial malleollus.

Acute rupture of the Achilles tendon

Achilles tendon ruptures are common, and their incidence is increasing. The evidence for best management is controversial, and, in selected patients, conservative management and early mobilization achieves excellent results. Surgery is associated with an increased risk of superficial skin breakdown; however, modern techniques of percutaneous repair that are performed under local anesthesia and followed by early functional rehabilitation are becoming increasingly common, and should be considered when managing such patients.

Achilles tendon rupture and tendinopathy: management of complications

Ailments of the Achilles tendon are on the increase and present in athletic and sedentary patients. The management of tendinopathy and rupture is not codified; Achilles tendon rupture and tendinopathy can be managed conservatively or surgically. Tackling the complications that arise from the management of these conditions provides a formidable challenge to the surgeon. Rupture, rerupture, disordered scarring with potential keloid formation, nerve damage (especially the sural nerve), poor healing, infection, bleeding and hematoma formation, wound dehiscence, deep vein thrombosis (DVT), and loss of function have been reported. This article gives an up-to-date account on our personal views of managing complications following Achilles tendon rupture, tendinopathy, and delayed rupture.

Free gracilis tendon graft in neglected tears of the achilles tendon

OBJECTIVE

To report the results of a longitudinal study on reconstruction of neglected Achilles tendon rupture using a free autologous gracilis tendon graft.

DESIGN

Cohort study.

PARTICIPANTS

Twenty-one patients underwent surgery for a neglected rupture of the Achilles tendon occurring between 65 days and 9 months before the operation.

METHODS

All participants were prospectively followed up for 2 years, and final review was performed at 28.4 +/- 3.5 months from the operation. Functional (anthropometric measurements, isometric strength, return to activities) and clinical assessment was performed.

RESULTS

No patients experienced any problems in the wound used to harvest the tendon of gracilis. Five patients were managed conservatively following a superficial infection of the Achilles tendon surgical wound. No patients developed a deep vein thrombosis or sustained a rerupture. All patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp. The maximum calf circumference remained significantly decreased in the operated leg at final review. The operated limb was significantly less strong than the nonoperated one.

CONCLUSIONS

The management of neglected tears of the Achilles tendon by free gracilis tendon grafting is safe but technically demanding. It affords good recovery, even in patients with a neglected rupture of a duration of 9 months. These patients should be warned that they are at risk for postoperative complications, and that their ankle plantar flexion strength can remain reduced.

Orthopaedics

Orthopaedic surgery is a large and expanding speciality. There are approximately five million clinic attendances each year in this country and musculo-skeletal complaints are the commonest presentation in General Practice. This review examines three key areas within orthopaedics, fracture management, sports medicine and the new subspeciality of minimally invasive orthopaedics and highlights areas of recent advancement, significant research and ongoing debate.

Neglected rupture of the Achilles tendon: Reconstruction with peroneus brevis tendon transfer

The management of acute and neglected subcutaneous tears of the Achilles tendon by peroneus tendon transfer is safe but technically demanding. It affords good recovery, even in patients with a long-term neglected rupture. Patients with a neglected rupture are at a slightly greater risk of post-operative complications and may never fully recover their ankle plantar flexion strength.

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.