Total Achilles tendon rupture. A review

Results of surgical versus non-surgical treatment of Achilles tendon rupture

Between 1990 and 2001, 292 patients with acute Achilles tendon rupture were admitted to our institution. Depending on the day of admission patients were allocated either to the Department of Trauma Surgery or to the Department of Orthopaedics. Two hundred and twelve patients (mean age 37+/-9.4 years) were treated with surgical suture followed by plaster for 6 weeks. Eighty patients were treated non-surgically with splinting for 12 weeks. For both groups mean follow-up was 6+/-3 years. There were 14 re-ruptures, ten after surgical repair and four after non-surgical treatment. In the surgical group there were seven major wound problems, 11 minor wound complications and six patients with complaints from the sural nerve. In the non-surgical group one patient suffered a pulmonary embolism after a re-rupture, 3 months after the initial rupture. There was no difference in mean ankle score and patient-satisfaction score between groups. Only 52% regained their original sports activity level, slightly better in the surgically treated group. With a non-significant difference in re-rupture rate but relatively more complications after surgical repair, non-surgical treatment is preferred. With a slightly better recovery of sports activity after surgical repair, this might be used as an argument for surgical treatment in young athletes.

Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [< or = 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).

Traumatic Achilles Tendon Rupture in a Female College Basketball Player

Objective:

To present the case of a Division I female college basketball player with a complete Achilles tendon rupture.

Background:

A 19-year-old, female college basketball player ruptured her right Achilles tendon during preseason conditioning. She had no previous history of heel cord symptoms.

Treatment:

The athlete underwent open surgical repair of Achilles tendon. The athlete successfully progressed through a functional rehabilitation program focused on early mobilization and weight bearing. The rehabilitation program was continually modified to address deficiencies and to keep the athlete actively engaged. She was cleared for full, unrestricted activity 15 weeks and 3 days after surgery and returned to game participation in 16 weeks.

Conclusions:

This case provides evidence that early mobilization and weight bearing can be used while still protecting the repaired tendon.

Restored flexor carpi ulnaris function after mere tenotomy explains the recurrence of spastic wrist deformity

OBJECTIVE

To prove that fibrous restoration of the continuity of a cut tendon may cause recurrence of flexion deformity of the wrist after mere tenotomy of the spastic flexor carpi ulnaris muscle.

BACKGROUND

Mere tenotomy of the flexor carpi ulnaris tendon is insufficient to prevent recurrence of acquired spastic flexion deformity of the wrist. Subsequent restoration of the continuity of the tendon by fibrous interposition may result in the recurrence. We examined whether a previously tenotomised muscle is strong enough to cause the deformity.

METHODS

Active and passive force-length characteristics of the flexor carpi ulnaris muscle were measured intraoperatively in a patient with recurrent spastic flexion wrist deformity. The observed characteristics were compared with the average in vivo force-length characteristics of 14 spastic flexor carpi ulnaris muscles that had not previously been operated.

RESULTS

The previously tenotomised flexor carpi ulnaris muscle was able to maximally exert 110 N force. Its active force-length curve and passive force at maximal extension were similar to those of non-operated spastic flexor carpi ulnaris muscles.

CONCLUSIONS

A previously tenotomised flexor carpi ulnaris muscle is strong enough to cause recurrence of spastic flexion deformity of the wrist in case functional fibrous restoration of the tendon occurs after mere tenotomy.

RELEVANCE

The surgical routine of mere tenotomy should probably be modified by including the dissection of the distal muscle belly and the excision of a segment of the tendon to avoid its restoration.

Ankle joint proprioception and passive mechanical properties of the calf muscles after an Achilles tendon rupture: a comparison with matched controls

OBJECTIVE

To examine if ankle joint proprioception, passive stiffness, and torque relaxation responses of the involved and uninvolved limbs of persons with a previous history of an Achilles tendon rupture were different from matched controls.

DESIGN

Quasi-experimental mixed design.

BACKGROUND

The influence of an Achilles tendon rupture on the proprioceptive and kinetic performance of the involved and uninvolved ankle is not known.

METHODS

Twenty persons (mean age, 44.8 years) with a unilateral rupture and 20 matched controls (mean age, 44.2 years) volunteered. Proprioception was tested with a position-matching protocol from which absolute errors were quantified. A dynamometer was used to measure ankle joint angle and passive torque from which stiffness and torque relaxation were calculated.

RESULTS AND CONCLUSIONS

Proprioception absolute errors for the involved and uninvolved limbs of the experimental group were 27% and 31% greater respectively, than values for the control group. Torque relaxation values were greater in the involved limb versus the uninvolved limb or the control group (P=0.003-0.04). In conclusion, participants with a previous history of an Achilles tendon rupture display proprioception deficits in both limbs and greater torque relaxation in the involved limb in comparison to matched controls.

RELEVANCE

Bilateral deficits in ankle joint proprioception, as reported in this study, suggest the uninvolved limb may not serve as an effective control and because proprioception deficits influence some functional tests, Achilles tendon rupture patients may benefit from proprioception training.

Recent advances in the reconstruction of complex Achilles tendon defects

Large, complex lower-extremity defects in the region of the Achilles tendon occur when tendon loss or disruption is complicated by damage to surrounding structures, including soft tissue, vessels, or bone. The surgical approach to these complex defects has evolved from simple amputation to the recognition that satisfactory reconstruction has three components: functional reconstruction of the tendon, importation of vascularized soft tissue, and skin coverage. Many techniques have been developed to address these difficult reconstructive goals, which often require multiple procedures or complicated single-stage operations. Microsurgical advances have begun to reduce the complexity of Achilles tendon region reconstruction, and excellent results can be obtained which restore function, form, and cosmesis with minimal morbidity.

Strength analysis and comparison of the Teno Fix Tendon Repair System with the two-strand modified Kessler repair in the Achilles tendon

BACKGROUND

Various options exist for repair of Achilles tendon ruptures, yet a method that consistently provides sufficient gap resistance to allow early mobilization remains elusive. This study compares the mechanical performance of a modified Kessler repair with that of the Teno Fix Tendon Repair System (Ortheon Medical, LLC) in matched pairs of cadaver Achilles tendons.

METHODS

The two-strand modified Kessler repair was selected as the control construct on the basis of literature review and physician interviews which identified it among the many options as a popular method for repair of acutely ruptured Achilles tendons. Test specimens were harvested from matched pairs of cadaver ankles. The tendons were transected 3.5 cm proximal to the calcaneal insertion and repaired with either the two-strand modified Kessler suture construct or the Teno Fix Tendon Repair System. Assignment to the modified Kessler or Teno Fix group was done randomly for the first member of each pair. All test and control repairs were performed by the same author to reduce variability. Evaluation of the repairs consisted of tensile strength testing and measurement of the gap formation and peak stresses.

RESULTS

Gap and peak stress for the two-strand modified Kessler repair were 0.30 +/- 0.15 N/mm2 and 1.03 +/- 0.51 N/mm2, respectively. For the Teno Fix repairs the mean gap and peak stress values were 0.80 +/- 0.46 N/mm2 and 1.19 +/- 0.12 N/mm2, respectively. The mean gap formation stress was significantly higher in the Teno Fix repairs than in the control repairs (p < .0005). There was no significant difference in peak strength between the repairs (p < .10).

CONCLUSIONS

The Teno Fix repair was superior to the modified Kessler repair. In the Teno Fix repairs, the gap formation stress was 67% of the peak tensile stress. In comparison, in the modified Kessler repairs, the gap formation stress was 29% of the peak stress. This can be correlated to the elastic property of the modified Kessler suture and the initial tightening of the suture around the tendon fibers. The Teno Fix system is nonelastic and is fully tensioned during installation. This lends to a more gap resistant repair.

Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study

Recent experimental and clinical evidence suggests that early loading and mobilisation for Achilles tendon ruptures may improve functional outcomes. This paper presents the results of a pilot study designed to assess the safety of immediate weight-bearing mobilisation. Twenty-eight operatively repaired patients were randomised to either immediate loading in an orthosis or traditional serial plaster casting. An independent observer, blinded to treatment, assessed the results. Improved clinical, anthropometric, and functional outcomes were noted in the immediate loading group. Ultrasound assessment confirmed no deleterious effects upon the tenodesis. There was one re-rupture of the tendon at a minimum follow-up of 1 year.

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

PURPOSE

To study the effects of early weightbearing and ankle mobilization after acute repair of ruptured Achilles tendon.

STUDY DESIGN

Comparative longitudinal study.

METHODS

Patients in group 1 were postoperatively immobilized with their ankle in gravity equinus, they were encouraged to bear weight on the operated limb as soon as possible to full weightbearing, and they received a single cast change at 2 weeks, with the ankle accommodated in an anterior splint in a plantigrade position, allowing the ankle to be plantar flexed fully but not dorsiflexed above neutral. Patients in group 2 were immobilized with their ankle in full equinus with a cast change at 2 weeks, when the ankle was immobilized in mid equinus, and at 4 weeks, when the ankle was immobilized in a plantigrade position, and they were advised to bear weight.

RESULTS

Patients in group 1 attended fewer outpatient visits, completely discarded their crutches at an average of 2.5 weeks, and more were satisfied with the results of surgery. At ultrasonography, the average thickness of the repaired tendon was 12.1 mm, with no difference in the thickness of the ruptured tendon regardless of postoperative management. There was no significant difference in isometric strength between the two groups.

CONCLUSIONS

Early weightbearing with the ankle plantigrade is not detrimental to the outcome of repair after acute rupture of the Achilles tendon and shortens the time needed for rehabilitation. However, strength deficit and muscle atrophy are not prevented.

Simple end-to-end suture versus augmented repair in acute Achilles tendon ruptures: a retrospective comparison in 98 patients

We retrospectively compared the results in 98 patients with an acute Achilles tendon rupture treated with an augmented tendon repair (n = 59) to patients with an end-to-end suture (n = 39) after an average follow-up of 44 (22-69) months. 7 patients were operated on more than 2 weeks after the rupture, all with augmention. The complication rates in the augmention group were 0.1 and in the end-to-end suture group 0.2. We found no differences in subjective outcome or rerupture rate between the groups. In the augmentation group, the rate of complications was higher in those operated on after 2 weeks than in those operated on before. A simple end-to-end suture seems sufficient.

Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients

60 consecutive patients with spontaneous rupture of the Achilles tendon (AT) underwent surgery. Biopsies were taken at the operations from the site of the rupture, the proximal part, the calcaneal insertion, and the peritendium of the injured tendon. A percutaneous needle biopsy was taken from the contralateral (uninjured) AT. On histological examination, collagen degeneration, tenocyte necrosis, and acute inflammation were found at the rupture site in all cases. In the proximal part and at the insertion, degeneration was present in 56/56 and 51/55 of the cases, necrosis in 55/56 and 50/55, and acute inflammation in 49/56 and 35/55, respectively. The severity of the histological changes decreased from the rupture site to the proximal part to the site of insertion, and showed no relation to the age of the patients or the time from the rupture to the operation. Peritendineal vascular changes were minor. In the contralateral AT, degeneration and necrosis were present in 47/50 and 42/50 of the cases, respectively, but the severity of the changes was less than in the injured tendon. Acute inflammation was present in only 1 case. Spontaneous rupture of AT seems to be preceded by widespread, bilateral damage of the tendon and widespread ipsilateral acute inflammation.

Operative versus nonoperative management of acute Achilles tendon rupture: expected-value decision analysis

BACKGROUND

The optimal management strategy for acute Achilles tendon rupture is controversial.

PURPOSE

To determine the optimal management by using expected-value decision analysis.

STUDY DESIGN

Cross-sectional study.

METHODS

Outcome probabilities were determined from a systematic literature review, and patient-derived utility values were obtained from a visual analog scale questionnaire. A decision tree was constructed, and fold-back analysis was used to determine optimal treatment. Sensitivity analyses were used to determine the effect of varying outcome probabilities and utilities on decision-making.

RESULTS

Outcome probabilities (expressed as operative; nonoperative) were as follows: well (0.762; 0.846), rerupture (0.022; 0.121), major complication (0.030; 0.025), moderate complication (0.075; 0.003), and mild complication (0.111; 0.005). Outcome utility values were well operative (7.9), well nonoperative (7.0), rerupture (2.6), major complication (1.0), moderate complication (3.5), and mild complication (4.7). Fold-back analysis revealed operative treatment as the optimal management strategy (6.89 versus 6.30). Threshold values were determined for the probability of a moderate complication from operative treatment (0.21) and the utility of rerupture (6.8).

CONCLUSIONS

Operative management was the optimal strategy, given the outcome probabilities and patient utilities we studied. Nonoperative management was favored by increasing rates of operative complications; operative, by decreasing utility of rerupture. We advocate a model of doctor-patient shared decision-making in which both outcome probabilities and patient preferences are considered.

Rerupture and deep infection following treatment of total Achilles tendon rupture

BACKGROUND

The incidence of total Achilles tendon rupture has increased, but we are not aware of any reports on the incidence of reruptures or deep infections following treatment. The outcome after successful treatment is good, but that after complications has not been well documented.

METHODS

A group of 409 patients with a complete Achilles tendon rupture was treated at a university hospital orthopaedic unit between 1979 and 2000. Twenty-three reruptures (prevalence, 5.6%) and nine deep infections (prevalence, 2.2%) occurred in twenty-nine patients. We retrospectively reviewed the records of these patients to determine the overall incidence of ruptures, reruptures, and deep infections and to record the known risk factors for these major complications. We analyzed the final clinical outcome for twelve patients with a rerupture and seven patients with a deep infection at a mean of 4.1 years after the initial treatment.

RESULTS

The annual incidence of reruptures (per 100,000 inhabitants) increased from 0.25 in 1979-1990 to 1.0 in 1991-2000, and that of deep infections increased from 0 in the 1980s to 0.63 in the 1990s. The ratio of complications to primary ruptures did not change. The patients with deep infections were significantly older, received corticosteroid medication more often, had sustained the tendon injury during everyday activities more often, and had a longer delay before treatment than the patients with simple reruptures. At 4.1 years after the primary treatment, eight of twelve patients in the rerupture group had a satisfactory clinical outcome and the overall average isokinetic plantar flexion strength deficit in that group was only 10%. In contrast, two of the patients in the infection group had a fair clinical outcome and five had a poor outcome, and the average isokinetic plantar flexion strength deficit in that group was 35%.

CONCLUSIONS

The incidence of Achilles tendon reruptures and deep infections has increased. The outcome is satisfactory after a simple rerupture without infection, but the results after a deep infection are often devastating.

Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization

BACKGROUND

Deep-vein thrombosis is a well-recognized complication after trauma to the legs and subsequent immobilization, but there are no generally accepted approaches to preventing this complication.

METHODS

We performed a prospective, double-blind, placebo-controlled trial to evaluate the efficacy and safety of subcutaneous reviparin (1750 anti-Xa units given once daily) in 440 patients who required immobilization in a plaster cast or brace for at least five weeks after a leg fracture or rupture of the Achilles tendon. The study drug was given throughout the period of immobilization. Venography of the injured leg was performed within one week after removal of the plaster cast or brace, or earlier if there were symptoms suggesting deep-vein thrombosis.

RESULTS

Data on efficacy and end points were available for 371 patients. Deep-vein thrombosis was diagnosed in 17 of the 183 patients randomly assigned to receive reviparin (9 percent) and in 35 of the 188 patients randomly assigned to receive placebo (19 percent) (odds ratio, 0.45; 95 percent confidence interval, 0.24 to 0.82). Most of the thromboses were distal (14 in the reviparin group and 25 in the placebo group). There were two cases of pulmonary embolism, both in patients in the placebo group who also had proximal deep-vein thrombosis. There were no differences between the two groups with respect to bleeding or other adverse events.

CONCLUSIONS

Deep-vein thrombosis is common in persons with leg injury requiring prolonged immobilization. Reviparin given once daily appears to be effective and safe in reducing the risk of this complication.

Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis

A quantitative systematic review of randomized and quasirandomized trials was conducted to determine the effect of surgical versus conservative treatment of acute Achilles tendon ruptures on rates of rerupture. Secondary outcomes included deep infection rates, return to normal function, and minor complaints. A search of computerized databases was conducted to locate clinical studies published from 1969 to 2000. Additional studies were located through hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files. Of the 273 citations initially identified, 11 proved potentially eligible, and six met all eligibility criteria. Three investigators independently graded study quality and abstracted relevant data. Among the studies, surgical repair revealed a significant reduction in the risk of rerupture when compared with conservative treatment. Alternatively, the risk of infection with surgical repair was significantly increased. Pooled analysis of studies did not reveal any difference in the risk of minor complaints or return to normal function between surgical repair and conservatively treated groups. Surgical treatment significantly reduces the risk of Achilles tendon rerupture, but increases the risk of infection, when compared with conservative therapy. Wide confidence intervals around the estimates of risk reduction suggest a large trial is needed to establish risks and benefits.

Quantitative review of operative and nonoperative management of achilles tendon ruptures

BACKGROUND

There is no consensus on the best method for management of acute Achilles tendon ruptures. Individual preferences, drawn from experience and study, determine whether treatment is operative or nonoperative.

PURPOSE

Our goal was to review the literature to try to determine what management method was the most popular and effective. We wanted to ascertain the best results in terms of complication rates and patient outcomes.

STUDY DESIGN

Retrospective review of retrospectively and prospectively collected data.

METHODS

We analyzed 125 articles in peer-reviewed journals for year of publication, patient numbers, sex, management method, follow-up complications, and patient satisfaction. Each article was graded using a validated methods score. Methods, patient satisfaction, and complication rates were correlated with the year each article was published.

RESULTS

Skin-healing complications were lowest in conservatively managed patients (3 of 578, 0.5%) and highest in open repair and immobilized patients (543 of 3718, 14.6%). General complication rates were lowest in open repair and early-mobilization groups (16 of 238, 6.7%) and highest in percutaneous and early-mobilization groups (19 of 122, 15.6%). Rerupture rates were highest in immobilized conservative management groups (62 of 578, 10.7%) and lowest in groups with external fixation (0%).

CONCLUSIONS

In general, the number of publications reporting Achilles tendon ruptures is increasing, the quality of articles is increasing, and the trend for the number of reported complications is decreasing. The published articles had a low methods score (mean, 50.9; range, 25 to 77) and showed a trend toward earlier mobilization. Open repair and early mobilization give the best functional recovery and an acceptable complication rate.

Spontaneous bilateral rupture of the Achilles tendon in a patient with chronic obstructive pulmonary disease

A 69-year-old man with chronic obstructive pulmonary disease (COPD) presented with an exacerbation of cough and breathlessness, as well as a 5 day history of sudden-onset bilateral calf tenderness. He had been commenced on inhaled steroids 41/2 years earlier and then received maintenance oral prednisone. Upon examination, there was a haematoma inferior to the medial malleolus with no Achilles tenderness on the left side. On the right side, there was focal tenderness over the mid-portion of the Achilles tendon with pain accentuated upon dorsi flexion. A venous duplex study confirmed superficial venous thrombosis involving the left gastrocnemius vein extending proximally to the popliteal vein junction. The major axial deep veins of the left lower leg were patent. Findings on the right side were normal. A subsequent diagnostic ultrasound demonstrated unequivocal bilateral Achilles tendon ruptures. The patient subsequently underwent corrective surgery. There have been several reports of bilateral Achilles tendon rupture associated with long-term corticosteroid use. It is likely that this entity is underdiagnosed because of a lack of awareness of this association by physicians. Recognition and surgical intervention are likely to reduce morbidity and improve outcome.

Early ankle motion after triple bundle technique repair vs. casting for acute Achilles tendon rupture

The purpose of our study is to evaluate the triple bundle technique for acute Achilles tendon rupture repair followed by early (at 14 days) postoperative ankle range of motion compared to nonoperative treatment with delayed ankle range of motion. We retrospectively reviewed 73 patients with an acute Achilles tendon rupture treated with either a plantar flexed cast or surgical repair. We found operative treatment reduces immobilization time, allows safe early return to weight-bearing, and diminishes risk of rerupture compared to nonoperative treatment. However, at an average follow-up of greater than 3.5 years, there was no statistical difference in AOFAS hindfoot scores, strength, or patient satisfaction between the two groups. Significant complications were higher in the nonoperative group manifested by three reruptures (7.7%) vs. one deep wound dehiscence in the operative group (3%).

Modes of local drug delivery to the musculoskeletal system

A number of methods for the local delivery of drugs to musculoskeletal tissues in the horse are now available. Further research is required to document the disposition of drugs delivered by such methods and to correlate this information with efficacy. Perhaps the greatest potential area for the methods discussed is the treatment of synovial and bone infections. To be able to provide high and sustained therapeutic concentrations of antimicrobials to the site of infection should increase the chances of success in such cases. These methods of drug delivery need to be used in conjunction with other management procedures, however, including bacterial culture and sensitivity procedures, systemic antimicrobials, surgical drainage, removal of dead bone or surgical implants, establishment of fracture stability, use of autogenous bone grafts, systemic NSAIDs, and rest.