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

Immediate mobilization after repair of Achilles tendon rupture may increase the incidence of re-rupture: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Achilles tendon rupture (ATR) is a significant injury that can require surgery and can have the risk of re-rupture even after successful treatment. Consequently, to minimize this risk, it is important to have a thorough understanding of the rehabilitation protocol and the impact of different rehabilitation approaches on preventing re-rupture.

MATERIALS AND METHODS

Two independent team members searched several databases (PubMed, EMBASE, Web of Science, Cochrane Library, and CINAHL) to identify randomized controlled trials (RCTs) on operative treatment of ATR. We included articles that covered open or minimally invasive surgery for ATR, with a detailed rehabilitation protocol and reports of re-rupture. The study protocol has been registered at PROSPERO and has been reported in the line with PRISMA Guidelines, Supplemental Digital Content 1, http://links.lww.com/JS9/C85 , Supplemental Digital Content 2, http://links.lww.com/JS9/C86 and assessed using AMSTAR Tool, Supplemental Digital Content 3, http://links.lww.com/JS9/C87 .

RESULTS

A total of 43 RCTs were eligible for the meta-analysis, encompassing a combined cohort of 2553 patients. Overall, the postoperative incidence of ATR patients developing re-rupture was 3.15% (95% CI: 2.26-4.17; I2 =44.48%). Early immobilization group patients who had ATR had a 4.07% (95% CI: 1.76-7.27; I2 =51.20%) postoperative incidence of re-rupture; Early immobilization + active range of motion (AROM) group had an incidence of 5.95% (95% CI: 2.91-9.99; I2 =0.00%); Early immobilization + weight-bearing group had an incidence of 3.49% (95% CI: 1.96-5.43; I2 =20.06%); Early weight-bearing + AROM group had an incidence of 3.61% (95% CI: 1.00-7.73; I2 =64.60%); Accelerated rehabilitation (immobilization) group had an incidence of 2.18% (95% CI: 1.11-3.59; I2 =21.56%); Accelerated rehabilitation (non-immobilization) group had a rate of 1.36% (95% CI: 0.12-3.90; I2 =0.00%). Additionally, patients in the immediate AROM group had a postoperative re-rupture incidence of 3.92% (95% CI: 1.76-6.89; I2 =33.24%); Non-immediate AROM group had an incidence of 2.45% (95% CI: 1.25-4.03; I2 =22.09%).

CONCLUSIONS

This meta-analysis suggests the use of accelerated rehabilitation intervention in early postoperative rehabilitation of the Achilles tendon. However, for early ankle joint mobilization, it is recommended to apply after one to two weeks of immobilization.

Functional Performance and Tendon Morphology After Operative or Nonoperative Treatment of Achilles Tendon Ruptures

Background

While controversy remains as to the relative benefit of operative (OM) versus non-operative management (NOM) of Achilles tendon (AT) ruptures (ATR), few studies have examined the effect on high impact maneuvers such as jumping and hopping.

Hypothesis/Purpose

The purpose of this study was to determine if functional performance including strength, jumping, and hopping outcomes differed between OM and NOM of acute ATR. The secondary objective was to assess the degree of association between AT morphology and performance outcomes.

Study Design

Retrospective cohort with a single prospective evaluation.

Methods

All patients were treated at an institutional secondary care center. Eligible participants (n=12 OM; 12 NOM) who were treated with OM or NOM of ATR within three weeks of injury were evaluated a minimum 20 months following ATR. AT length, thickness and gastrocnemius muscle thickness were assessed with B-mode ultrasound. Isokinetic plantar flexor strength, hop tests and countermovement and drop jumps were completed. Two-way ANOVAS were completed on all tests with unilateral values, independent t-tests were used for bilateral outcomes, and linear regressions were completed to assess the relationship between normalized AT length and performance.

Results

Affected limb AT was elongated and thickened (p\<0.01), gastrocnemius was atrophied (p\< 0.01) and angle-specific plantar flexor torque was reduced at 120°/s when measured at 20° plantar flexion (p = 0.028). Single leg drop vertical jump was higher in OM (p = 0.015) with no difference for hop and jump tests. AT length was related to plantar flexor torque but had no relationship with hopping performance.

Conclusions

Hop test performance was maintained despite plantarflexion weakness, gastrocnemius atrophy, and AT elongation. This may be the result of compensatory movement patterns. AT length holds limited explanatory power in plantar flexor strength, although this relationship should be evaluated further.

Level of Evidence

Level III.

The learning curve for minimally invasive Achilles repair using the "lumbar puncture needle and oval forceps" technique

INTRODUCTION

An acute Achilles tendon rupture represents a common tendon injury, and its operative methods have been developed over the years. This study aimed to quantify the learning curve for the minimally invasive acute Achilles tendon rupture repair.

METHODS

From May 2020 to June 2022, sixty-seven patient cases who received minimally invasive tendon repair were reviewed. Baseline data and operative details were collected. The cumulative summation (CUSUM) control chart was used for the learning curve analyses. Achilles tendon rupture score (ATRS), American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score, and visual analog scale (VAS) at 3/6/9/12 months were calculated to assess the clinical outcomes.

RESULTS

Thirty-six cases underwent at least a year of follow up and were enrolled in this study. The gender ratio and average age were 80.5% and 32.5 years. The linear equation fitted well (R2 = 0.95), and CUSUM for operative time peaked in the 12th case, which was divided into the learning phase (n = 12) and master phase (n = 24). No significant difference was detected between the two groups in clinical variables, except for the operative time (71.1 ± 13.2 min vs 45.8 ± 7.2 min, p = 0.004). Moreover, we detected one case with a suture reaction and treated it properly.

CONCLUSION

Minimally invasive Achilles repair provides an opportunity for early rehabilitation. Notably, the learning curve showed that the "lumbar puncture needle and oval forceps" technique was accessible to surgeons.

Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis

Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.

Females present larger deficit in heel-rise height at 3 months following an Achilles tendon rupture compared with males

PURPOSE

There is a lack of knowledge concerning differences between females and males in the early stages after an acute Achilles tendon rupture. This article aims to explore the different factors affecting early function after an Achilles tendon rupture with a validated test battery that includes functional tests, clinical measurements and patient-reported outcome at a 3-month follow-up analysis of a larger prospective study.

METHODS

This study was part of the DUSTAR-study (Diagnostic UltraSonography for the choice of Treatment of acute Achilles tendon Rupture) where the main aim was to evaluate if an acute ultrasonography could determine which patients, with an Achilles tendon rupture, should be treated surgically or nonsurgically. At the 3-month follow-up, the results between males and females were compared.

RESULTS

One hundred and twenty-seven patients were included at the 3-month follow-up; of these, 102 (80%) were males and 25 (20%) were females. Amongst the females, 11 (44%) were able to perform a single leg heel-rise compared to 48 (47%) of the males; however, the difference was not statistically significant. There was no difference between the sexes in the frequency of completing a single-leg heel-rise at 3 months after injury; however, there were statistically significant differences between the groups when comparing Limb Symmetry Index (LSI) of heel-rise height and heel-rise work. The females had a median heel-rise height LSI/median heel-rise work LSI of 45%/14% compared to males who reached a level of 57%/23% (p = 0.006/p = 0.010). At the 3-month follow-up, the median (range) Achilles tendon Total Rupture Score (ATRS) reported by females was 28.5 (8-51), which had a nonsignificant difference compared to males who reported a median (range) ATRS of 30 (1-86).

CONCLUSION

The risk of reduced heel-rise height and worse heel-rise work 3 months after an acute Achilles tendon rupture increases by being a female. Through this knowledge, we highlighted the importance of an individualised treatment for acute Achilles tendon ruptures with better outcome for both males and females.

LEVEL OF EVIDENCE

Level II.

Feasibility of an early progressive resistance exercise program for acute Achilles tendon rupture

BACKGROUND

Long-term strength deficits are common after Achilles tendon ruptures. Early use of progressive resistance exercises may help reduce strength deficits, but the feasibility of this approach is unknown. The aim was to investigate the feasibility of early progressive resistance exercises regarding patient acceptability and compliance with the intervention.

METHODS

We recruited patients with an acute Achilles tendon rupture treated non-surgically. During 9 weeks of immobilisation with a walking boot, participants attended weekly supervised physiotherapy sessions of progressive resistance exercises and performed home exercises, consisting of isometric ankle plantarflexion, seated heel-rise, and elastic band exercises. Acceptability was evaluated using a 7-point Likert scale (1 = very unacceptable and 7 = very acceptable) with feasibility threshold at 80% of the participants rating ≥ 4. Adherence to the exercises was defined as 80% of the participants performing at least 50% of the home exercises. During the intervention, tendon healing and adverse events were monitored.

RESULTS

Sixteen participants (mean age 46 (range 28-61), male/female = 13/3) completed the intervention. Pre-injury Achilles tendon total rupture score was 98 (SD 8). All participants rated the acceptability of the exercises ≥ 5 (moderate acceptable to very acceptable) at 9- and 13-week follow-up and 9/16 rated 7 points (very acceptable). Participants performed 74% (range 4-117) of the total prescribed home exercises and 15/16 performed > 50%. One participant was not compliant with the home exercises due to feeling uncomfortable performing these independently. There were no re-ruptures, but one case of deep venous thrombosis.

CONCLUSIONS

The early progressive resistance exercise program for treatment of non-surgically treated Achilles tendon rupture was feasible. Future studies should investigate the efficacy of the progressive intervention.

TRIAL REGISTRATION

The study was registered at Clinical Trials (NCT04121377) on 29 September 2019.

CLINICALTRIALS

NCT04121377 .

Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year

OBJECTIVE

The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results.

HYPOTHESES

There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols.

METHODS

This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review.

RESULTS

Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07).

CONCLUSIONS

This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes.

LEVEL OF EVIDENCE

III; retrospective comparative, non-randomized.

Reverse Fragility Index Comparing Rates of Rerupture After Open Achilles Tendon Repair Versus Early Functional Rehabilitation: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Despite similar published rates of rerupture among patients treated with early functional rehabilitation and open repair for acute Achilles tendon rupture, uncertainty still exists regarding the optimal treatment modality. The reverse fragility index (RFI) is a statistical tool that provides an objective measure of the study's neutrality by determining the number of events that need to change for a nonsignificant result to be significant.

PURPOSE

The purpose was to utilize the RFI to appraise the strength of neutrality of randomized controlled trials (RCTs) comparing the rerupture rates of acute Achilles tendon ruptures treated with open repair versus early functional rehabilitation.

STUDY DESIGN

Systematic review; Level of evidence, 1.

METHODS

A systematic review was performed including all RCTs comparing the rerupture rates after operative repair and early functional rehabilitation for acute Achilles tendon ruptures. Studies were included that explicitly used early functional rehabilitation, defined as weightbearing and exercise-based interventions initiated within 2 weeks, as compared with open repair and reported a nonsignificant difference in rerupture rates. The RFI, with rerupture as the primary outcome, was calculated for each study (significance threshold, P < .05). The RFI quantifies a study's strength of neutrality and is defined as the minimum number of event reversals necessary to change a nonsignificant result to statistically significant.

RESULTS

Nine RCTs were included, with 713 patients and 46 reruptures. The median (interquartile range) rerupture rate was 7.69% (6.38%-9.64%) overall, 4.00% (2.33%-7.14%) in the operative group, and 10.00% (5.26%-12.20%) in the nonoperative group. The median RFI was 3, indicating that an outcome reversal of 3 patients was necessary to change the results from nonsignificant to statistically significant. The median number of patients lost to follow-up was 6 (3-7). Of 9 studies, 7 (77.8%) had a loss to follow-up greater than or equal to its RFI.

CONCLUSION

The statistical nonsignificance of studies reporting equivalent rerupture rates in the management of acute Achilles tendon ruptures with open repair versus nonoperative management with early functional rehabilitation can be reversed by changing the outcome status of only a few patients.

Socioeconomic Status and Race Are Rarely Reported in Randomized Controlled Trials for Achilles Tendon Pathology in the Top 10 Orthopaedic Journals: A Systematic Review

Background

Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals.

Methods

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high-impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details.

Results

Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA.

Conclusion

This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results.

Current Concepts in Achilles Tendon Ruptures

The Achilles tendon has a high incidence of ruptures often occurring in weekend warriors and the aging population. Based on anatomic studies of the Achilles tendon, ruptures are commonly found in the watershed area proximal to the insertion site. Traditionally, treatment options included conservative therapy with immobilization and a prolonged non-weight-bearing phase versus surgical treatment. Surgical treatment can vary between open, minimally invasive, or percutaneous approaches. In more recent years, early functional rehabilitation with or without surgery has shown to have successful results.

The Delayed Presentation of Achilles Tendon Ruptures Is Associated With Marked Alterations in the Gene Expression of COL1A1, MMPs, TIMPs, and IL-6

BACKGROUND

Both acute and chronic Achilles tendon ruptures are affected by alterations in the extracellular matrix during the healing process of the tendon. Yet, these alterations in gene expression patterns are not well characterized.

PURPOSE

To characterize temporal and spatial differences in gene expression patterns after an Achilles tendon rupture and to evaluate if cells from chronic Achilles tendon ruptures have the same ability to form new tendon tissue (tendon constructs) as healthy tendon cells.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 35 patients with surgically treated Achilles tendon ruptures were included in the study and divided into 3 groups: acute (<4 weeks), short-term chronic (1-6 months), and long-term chronic (>6 months). Biopsy specimens were collected during surgical repair and were used to analyze the gene expression within the different groups and to compare mRNA levels in the proximal and distal tendon ends. A complementary in vitro experiment was performed to evaluate if cells from chronic Achilles tendon ruptures can form tendon constructs.

RESULTS

The mRNA levels for COL1A1 and COL3A1 were significantly higher in the short-term chronic group compared with the acute group (P < .05). Both MMP-1 and MMP-13 had the highest mRNA levels in the acute group (P < .01) compared with the long-term chronic group, while MMP-2 had the highest mRNA level in the short-term chronic group. Significant differences between the proximal and distal tendon ends were only detected for the monocyte and macrophage marker CD163 (P < .05), which was more expressed proximally. Cells extracted from chronic Achilles tendon ruptures displayed a similar ability and effectiveness to form tendon constructs as healthy tendon cells.

CONCLUSION

A high collagenase gene activity after an Achilles tendon rupture indicated possible rapid matrix degradation in the acute phase. Chronic ruptures appeared to initiate the healing process even before treatment, indicated by the higher expression of collagen in the short-term chronic group. Cells from chronic Achilles tendon ruptures also displayed an ability to form new tendon tissue in vitro.

CLINICAL RELEVANCE

The study shows a rapid increase in collagenase gene expression, which could lead to matrix degradation that continues for months after an Achilles tendon rupture.

A 5-year follow-up of Achilles tendon reconstruction using a full-thickness graft processed with the clearant method and retrograde fixation in the calcaneus: a case study of an amateur soccer player

We present a case of a 41-year-old male amateur soccer player with no comorbidities, who experienced a rerupture of the Achilles tendon 5 years after his initial end-to-end plasty. To address this, we opted for a full-thickness reconstruction using a graft under the Clearant Process of the Achilles tendon. As an innovative approach, we proposed an alternative fixation technique, employing a Bio Composite Arthrex 9 mm x 35 mm interference screw, placed at the apex of the calcaneus body. For a period of 5 years, the patient underwent regular imaging follow-ups with Magnetic Resonance Imaging (MRI) and clinical assessments using the Foot and Ankle Ability Measure Activity Subscale Score and Foot and Ankle Ability Measure Sports Subscale Score. This case highlights the importance of exploring novel fixation methods for Achilles tendon reconstruction, particularly in cases of rerupture. The use of the Bio Composite Arthrex screw, in conjunction with the Clearant Process graft, demonstrated promising results both in imaging and functional outcomes, but more case studies with positive results are needed to evaluate the effectiveness of this reconstruction.

Effect of the Copenhagen Achilles Rupture Treatment Algorithm (CARTA) on Calf Muscle Volume and Tendon Elongation After Acute Achilles Tendon Rupture: A Predefined Secondary Analysis of the First 60 Patients in a Randomized Controlled Trial

Background

Surgical treatment of acute Achilles tendon rupture (ATR) lowers the risk of rerupture and may reduce calf atrophy and elongation of the Achilles tendon. The Copenhagen Achilles Rupture Treatment Algorithm (CARTA) was developed to provide individualized treatment selection based on ultrasonographic evaluation of the rupture.

Purpose

In a randomized setup, the present study aimed to investigate whether treatment selection using the CARTA could reduce atrophy and tendon elongation compared with (1) patients treated surgically and (2) patients treated nonsurgically.

Study Design

Randomized controlled trial; Level of evidence, 2.

Methods

A total of 60 patients with an acute ATR were randomly assigned to receive treatment based on the CARTA (intervention), surgical treatment (control), or nonsurgical treatment (control) in a 1 to 1 to 1 ratio. After 1 year, magnetic resonance imaging of both calves was performed, and muscle volume and Achilles tendon length were measured. Results were presented as the ratio between the affected and the unaffected limbs (ie, limb symmetry index; %).

Results

A total of 156 patients were assessed for eligibility, 60 patients were randomized, and 54 patients provided data for the study-19 patients received treatment based on the CARTA (intervention group), 17 patients received nonsurgical treatment (control), and 18 patients received surgical treatment (control). No statistically significant differences were found between the intervention group and the 2 control groups regarding muscle volume and tendon length. No statistically significant differences were found between patients treated surgically and patients treated nonsurgically. Comparison between the affected and the unaffected limb showed statistically significant muscle atrophy (24%-30%) and tendon elongation (soleus, 59%-76%; gastrocnemius, 8%-14%) in the affected limb in all 3 groups.

Conclusion

Individualized treatment of acute ATR using an ultrasonographic selection algorithm did not reduce calf muscle atrophy or tendon elongation when compared with surgical and nonsurgical treatment. Surgical treatment did not reduce calf muscle atrophy or tendon elongation compared with nonsurgical treatment.

Midterm Outcomes of Operatively and Nonoperatively Managed Achilles Tendon Ruptures in Young Adults

Background

There continues to be controversy regarding treatment options for Achilles tendon ruptures (ATR). The aim of our study is to compare outcomes between operatively and nonoperatively managed Achilles ruptures in young adults (age 18-30 years), which has not been previously evaluated.

Methods

At a single institution, all patients aged 18-30 years at time of injury who underwent treatment for an acute ATR from 2014 to 2021 were evaluated. Medical records were reviewed to collect demographics, dates of injury and treatment, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), rate of deep venous thrombosis (DVT) after treatment, and rate of rerupture. Patients then completed Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) questionnaires. Mann-Whitney nonparametric testing was used to evaluate for any statistical differences in PROMIS scores.

Results

Sixty-six operative patients qualified and 28 (42%) participated. Thirty-seven nonoperative patients qualified and 14 (38%) participated. All patients had a CCI of 0. One patient in the operative cohort and 2 in the nonoperative reported active smoking. In the operative and nonoperative cohorts, respectively, the average age was 24.4 and 27.8 years; average BMI 26.5 (SD = 4.8) and 27.3 (SD = 4.3, P = .52); DVT rates 4 (6.1%) and 2 (5.4%); and rerupture rates 2 (3.0%) and 1 (2.7%), respectively. PROMIS scores did not differ in the operative and nonoperative groups: PROMIS PF mean of 60.4 (SD = 9.8) and 62.9 (SD = 9.1), respectively (P = .33); as well as PROMIS PI mean of 44.6 (SD = 5.9) and 43.9 (SD = 6.5), respectively (P = .59).

Conclusion

This study should be interpreted with the understanding that we had a considerable loss to follow-up rate. In the study cohort, we found that young adults with ATR may be considered for either operative or nonoperative management. Rates of DVT, rates of rerupture, and PROMIS scores were not dissimilar between the 2 cohorts.

Level of Evidence

Level III, retrospective cohort study.

Republication of "Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?"

Background

Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications.

Methods

A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted.

Results

There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected (P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature (P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature (P < .0001; CI 0.067-1.94).

Conclusion

In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature.

Level of Evidence

Level IV.

Analysis of the 50 Most Cited Articles on Achilles Tendon Injury

Background

Achilles tendon injuries represent one of the most common reasons for referral to orthopaedic surgeons.

Purpose

To outline the characteristics, examine trends in publication, and evaluate the correlation between citations and study quality of the 50 most cited articles on Achilles tendon injury.

Study Design

Cross-sectional study.

Methods

After searching the Web of Science for articles published in orthopaedic journals, we identified the 50 most cited articles on Achilles tendon injury and abstracted their characteristics. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Multiple bivariate analyses (Pearson or Spearman correlation coefficient) were used to evaluate the association among number of citations, citation rate (citations/year), 2020 journal impact factor (JIF), year of publication, level of evidence (LoE), study type (tendon rupture or chronic tendinopathy), sample size, and mCMS.

Results

The top 50 articles were cited 12,194 times. Each article had a mean ± SD 244 ± 88.8 citations (range, 157-657) and a citation rate of 12.6 ± 5.4 per year (range, 3-28). A total of 35 studies (70%) were published between 2000 and 2010. The citation rate of the 16 most recent studies was almost double that of the 16 oldest studies (17.5 vs 9.9; P < .001). Nineteen studies (49%) were classified as having poor quality (mCMS <50 points). The mean JIF of the 9 journals that published the studies was 5.1. The citation rate correlated with the number of citations (r = 0.56; P < .001), publication year (r = 0.60; P < .001), and LoE (r = -0.44; P = .005). The publication year correlated with the LoE (r = -0.40; P = .01). Study quality in terms of mCMS correlated with the JIF (r = 0.35; P = .03) and LoE (r = -0.48; P = .003) but not the citation rate (P = .15).

Conclusion

The mean LoE and the citation rate of the most cited articles on Achilles tendon injury both significantly increased over time. Although the JIF was positively correlated with study quality, almost half of the studies had poor-quality methodology.

A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures

BACKGROUND

Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context.

METHODS

A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review.

RESULTS

Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study.

CONCLUSION

Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Rerupture and wound complications following Achilles tendon repair: A systematic review

Despite the relatively high frequency of Achilles ruptures, there is no general consensus on the optimal treatment method. A general trend toward more patients being treated nonoperatively has emerged recently with the advent of functional rehabilitation. However, much of the recent data on this subject has been highly variable. This systematic review focused on Achilles tendon rupture (ATR) treatment outcomes, with a focus on rerupture and complication rates. This systematic review specifically focused on articles regarding ATR treatment that also included rerupture and complication rates. Treatments were divided into three categories: open minimally invasive, open standard, and nonoperative. Bivariate analyses were performed to compare complication and rerupture rates among pairs of treatment options, as well as between early weight bearing versus immobilization. There was significantly higher complications for minimally invasive compared to nonoperative treatment (risk ratio [RR] = 4.4154; p < 0.05), lower complication rates for minimally invasive compared to open treatment (RR = 0.3231; p < 0.05), and higher complications for open standard compared to nonoperative treatment (RR = 5.6350; p < 0.001). There were significantly lower rerupture rates in minimally invasive compared to nonoperative treatment (RR = 0.4085; p < 0.001), a significantly lower rerupture rate in nonoperative treatment compared to open treatment (RR = 0.2282; p < 0.001), and no significant difference in rerupture rates when comparing minimally invasive to open standard treatment. We found that operative treatment is associated with fewer reruptures and more complications than a nonoperative approach. Minimally invasive surgery appears to be associated with a lower rate of complications than open operative treatment.

Percutaneous achilles tendon repair with absorbable suture: Outcomes and complications

OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

A prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted.

INCLUSION CRITERIA

≥18 years of age, non-insertional (2-8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected. Patients were assessed using visual analogue scale (VAS) at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score (ATRS) were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected.

CONCLUSIONS

In our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

Percutaneous achilles tendon repair with absorbable suture: Outcomes and complications

OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

A prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted.

INCLUSION CRITERIA

≥18 years of age, non-insertional (2-8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected. Patients were assessed using visual analogue scale at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected.

CONCLUSIONS

In our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Rupture: A Propensity Score-Matched Analysis of a Large National Dataset

Background

No consensus exists regarding the superiority of operative versus nonoperative management for Achilles tendon ruptures, as multiple randomized controlled trials conducted since the advent of early mobilization protocols have found outcomes for these 2 interventions to be more similar than were previously held.

Purpose

To use a large national database to (1) compare reoperation and complication rates between operative and nonoperative treatment of acute Achilles tendon ruptures and (2) evaluate trends in treatment and cost over time.

Study Design

Cohort study; Level of evidence, 3.

Methods

The MarketScan Commercial Claims and Encounters database was used to identify an unmatched cohort of 31,515 patients who sustained primary Achilles tendon ruptures between 2007 and 2015. Patients were stratified into operative and nonoperative treatment groups, and a propensity score-a matching algorithm-was used to establish a matched cohort of 17,996 patients (n = 8993 per treatment group). Reoperation rates, complications, and aggregate treatment costs were compared between groups with an alpha level of .05. A number needed to harm (NNH) was calculated from the absolute risk difference in complications between cohorts.

Results

The operative cohort experienced a significantly larger total number of complications within 30 days of injury (1026 vs 917; P = .0088). The absolute increase in cumulative risk was 1.2% with operative treatment, which resulted in an NNH of 83. Neither 1-year (1.1% [operative] vs 1.3% [nonoperative]; P = .1201) nor 2-year reoperation rates (1.9% [operative] vs 2% [nonoperative]; P = .2810) were significantly different. Operative care was more expensive than nonoperative care at 9 months and 2 years after injury; however, there was no difference in cost between treatments at 5 years. Before matching, the rate of surgical repair for Achilles tendon rupture remained stable, from 69.7% to 71.7% between 2007 and 2015, indicating little change in practice in the United States.

Conclusion

Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. Operative management was associated with an increased risk of complications and higher initial costs, which dissipated over time. Between 2007 and 2015 the proportion of Achilles tendon ruptures managed operatively remained similar despite increasing evidence that nonoperative management of Achilles tendon rupture may provide equivalent outcomes.

Surgical versus nonsurgical treatment of acute Achilles ruptures in the high demand patient: Using decision analysis to help clinical decisions

BACKGROUND

Recent literature suggests that functional treatment of acute non-insertional Achilles tendon ruptures yields outcomes (re-rupture and function) similar to those of surgery, but does not address the unique issues in treating high performance athletes or other high demand patients.

METHODS

Decision analysis was used to develop an estimate of outcome utility for both types of treatment using published Costs and Quality-Adjusted Life Years (QALYs) values. The expected value for either treatment was then calculated for high, intermediate, and normal demand patients, using the specific functional needs of the patients.

RESULTS

Nonoperative treatment is the preferred management for normal demand patients, while high and intermediate demand patients are more likely to experience better expected functional outcomes from surgery.

CONCLUSION

The combination of a decision analysis and expected value analysis provides evidence-based support for the existing intuitive recommendations that favor surgical treatment in elite athletes and other high demand patients.

LEVEL OF EVIDENCE

III.

Treatment outcome at 1 year did not differ between use of cast or walker in the first 3 weeks after an acute Achilles tendon rupture. A registry study of 1304 patients from the Danish Achilles tendon database

BACKGROUND

The best choice of orthosis in the treatment of acute Achilles tendon rupture is still under debate.

OBJECTIVE

To investigate if choice of orthosis in the first 3 weeks of treatment affected patient reported outcome (Achilles tendon Total Rupture Score (ATRS)), tendon elongation (Achilles Tendon Resting Angle (ATRA) and Heel Rise Height (HRH)) and re-rupture.

METHODS

Registry study in the Danish Achilles tendon Database. Patients treated with cast and patients treated with walker in the first 3 weeks of treatment were compared using a linear mixed-effects model adjusted for potential confounders.

RESULTS

1304 patients were included in the study. No clinically relevant difference was found: Adjusted mean difference (using walker the whole period as reference)(95% CI) ATRS after 1 year = 0.1(-3.0; 4.1), ATRS after 6 months = 2.0(-4.5; 5.8), ATRS after 2 years = 3.0(-0.7; 7.0), HRH difference = 0.6(-6.6; 8.2), ATRA difference = 0.03°(-1.5; 1.6), re-rupture(odds ratio) = 0.812(0.4; 1.61).

CONCLUSION

Patients treated with cast the first 3 weeks after acute Achilles tendon rupture did not have better treatment outcome than patients treated with walker.

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

BACKGROUND AND OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

Prospective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019).

INCLUSION CRITERIA

≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography. Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected.

RESULTS

VAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries).

CONCLUSIONS

Percutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

BACKGROUND AND OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

Prospective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019).

INCLUSION CRITERIA

≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography. Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected.

RESULTS

VAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries).

CONCLUSIONS

Percutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

Rerupture outcome of conservative versus open repair versus minimally invasive repair of acute Achilles tendon ruptures: A systematic review and meta-analysis

OBJECTIVE

To compare the rerupture rate after conservative treatment, open repair, and minimally invasive surgery management of acute Achilles tendon ruptures.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to August 2022.

METHODS

Randomised controlled trials involving different treatments for Achilles tendon rupture were included. The primary outcome was rerupture. Bayesian network meta-analysis with random effects was used to assess pooled relative risks (RRs) and 95% confidence intervals. We evaluated the heterogeneity and publication bias.

RESULTS

Thirteen trials with 1465 patients were included. In direct comparison, there was no difference between open repair and minimally invasive surgery for rerupture rate (RR, 0.72, 95% CI 0.10-4.4; I2 = 0%; Table 2). Compared to the conservative treatment, the RR was 0.27 (95% CI 0.10-0.62, I2 = 0%) for open repair and 0.14 (95% CI 0.01-0.88, I2 = 0%) for minimally invasive surgery. The network meta-analysis had obtained the similar results as the direct comparison.

CONCLUSION

Both open repair and minimally invasive surgery were associated with a significant reduction in rerupture rate compared with conservative management, but no difference in rerupture rate was found comparing open repair and minimally invasive surgery.

Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair

Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.

Calcaneal positioning in equinus immobilization of the ankle joint: A comparison of common orthoses used in the treatment of acute Achilles tendon ruptures

Orthoses are an important part of both conservative and operative treatment of acute Achilles tendon rupture as they can be used to position the foot in equinus and protect the torn tendon from strain in the healing phase. The aim of the study was to test four different orthoses ability to position the foot in equinus. The study was performed as a cross-sectional study. 15 healthy study participants underwent radiographic examination with 11 true lateral radiographs of the right ankle and foot, one with the ankle joint in neutral position; one of a circular equinus cast (CEC); three of an adjustable equinus boot (AEB) with the foot in 30°, 15°, and 0° of plantar flexion, respectively; three of a fixed angle orthosis with 1, 2, and 3 wedges with a plateau (WWP); and three of a fixed angle orthosis with 1, 2, and 3 wedges without plateau (WWOP). The primary outcome was the Achilles Relief Distance (ARD). Secondary outcomes were the tibiocalcaneal angle (TCA), the tibiotalar angle (TTA), and the tibio- 1st metatarsal angle (1MTP). All measurements were performed by a radiologist. The mean (SD) ARD was 11 mm (7) in CEC, 23 mm (6) with 3 WWP, 11 mm (5) with 3 WWOP, and 15 mm (5) using AEB in 30° of plantarflexion. The mean (SD) TCA was 86° (7,8) in CEC, 76° (7,3) with 3 WWP, 90° (6,9) with 3 WWOP, and 84° (6,6) using the AEB in 30° of plantarflexion. CEC, AEB, and WWOP showed statistically significantly larger plantarflexion than WWP. CEC, AEB and WWOP produced significantly greater plantarflexion compared to WWP.

Comparable Recovery and Compensatory Strategies in Heel-Rise Performance After a Surgically Repaired Acute Achilles Tendon Rupture: An In Vivo Kinematic Analysis Comparing Early Functional Mobilization and Standard Treatment

BACKGROUND

Deficits in calf muscle function and heel-rise performance are common after an Achilles tendon rupture (ATR) and are related to tendon elongation and calf muscle atrophy. Whether early functional mobilization (EFM) can improve calf muscle function compared with standard treatment (ST) with 2 weeks of immobilization and unloading in a plaster cast is unknown.

HYPOTHESIS

EFM would lead to superior recovery of heel-rise performance, as demonstrated by more symmetrical side-to-side ankle and knee joint kinematics, compared with ST.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

In total, 47 patients with an ATR were prospectively included and treated with open surgical repair and randomized 2:1 postoperatively to either EFM or ST. Overall, 29 patients were treated with a dynamic orthosis (EFM), and 18 underwent ST. At 8 weeks and 6 months after ATR repair, 3-dimensional motion analysis of heel-rise performance was conducted. At 6 months, tendon length and muscle volume were assessed with ultrasound imaging, calf muscle function with the heel-rise test, and patient-reported outcomes with the Achilles tendon Total Rupture Score.

RESULTS

At 8 weeks and 6 months, there were no significant group differences between the EFM and ST groups in heel-rise performance, but significant side-to-side differences in ankle and knee kinematics were detected. At 8 weeks and 6 months, both the EFM and ST groups showed a significantly decreased peak ankle plantarflexion angle and increased knee flexion angle on the injured limb compared with the uninjured limb during bilateral heel raises. Linear regression demonstrated that greater atrophy of the medial gastrocnemius muscle (P = .008) and higher body weight (P < .001) were predictors of a decreased maximum peak ankle plantarflexion angle on the injured limb at 6 months.

CONCLUSION

EFM after an ATR repair did not lead to superior recovery of calf muscle function, as assessed by heel-rise performance, compared with ST. Increased knee flexion seemed to be a compensatory strategy for decreased ankle plantarflexion. Medial gastrocnemius atrophy and increased body weight were additional factors associated with a decreased ankle plantarflexion angle.

REGISTRATION

NCT02318472 (ClinicalTrials.gov identifier).

[Reconstruction of Soft Tissue Defects of the Achilles Tendon Region: a Literature Review]

BACKGROUND

Soft tissue defects in the achilles tendon region occur after trauma, but also as a complication after open recon- struction of the tendon with subsequent infection.

OBJECTIVES

Recommendations for the treatment of soft tissue injuries involving the Achilles tendon are presented.

MATERIALS AND METHODS

A search of the German, French and English literature on reconstruction of soft tissue defects of the Achilles tendon region was performed, which were differentiated into singular and combined tendocutaneous defects. Combined defects were further subdivided into three reconstructive principles: a simple soft tissue reconstruction without tendon repair or a combined reconstruction of the soft tissue as well as the tendon using either a vascularized tendon transplant or an avascular tendon graft.

RESULTS

Local and distally-based pedicled flaps include a relatively high risk or perioperative morbidity, whereas free flaps are described with significantly lower complications rates. Therefore, the authors prefer free flaps for reconstruction. Potential donor sites are the Medial Sural Artery (MSAP-) flap for smaller defects or free fasciocutaneous or muscle flaps in patients with large defects. The standard for tendocutaneousreconstructions is the free anterolateral thigh flap including vascularized fascia. Non-vascularized tendon grafts are frequently applied from the flexor hallucis longus- or peroneus brevis tendon.

CONCLUSIONS

Reconstructions over the Achilles tendon require thin and stable reconstructions that additionally allow slippage of soft tissues. Moreover, the use of normal shoes should be possible. The postoperative strength and range of motion of the ankle joint show comparable functional results after vascularized and non-vascularized tendon reconstruction.

1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment

PURPOSE

The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics.

METHODS

The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control.

RESULTS

The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg.

CONCLUSION

The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain.

LEVEL OF EVIDENCE

II.

CLINICAL TRIALS IDENTIFIER

NCT02760784.

The Statistical Fragility of Operative vs Nonoperative Management for Achilles Tendon Rupture: A Systematic Review of Comparative Studies

BACKGROUND

The statistical significance of randomized controlled trials (RCTs) and comparative studies is often conveyed utilizing the P value. However, P values are an imperfect measure and may be vulnerable to a small number of outcome reversals to alter statistical significance. The interpretation of the statistical strength of these studies may be aided by the inclusion of a Fragility Index (FI) and Fragility Quotient (FQ). This study examines the statistical stability of studies comparing operative vs nonoperative management for Achilles tendon rupture.

METHODS

A systematic search was performed of 10 orthopaedic journals between 2000 and 2021 for comparative studies focusing on management of Achilles tendon rupture reporting dichotomous outcome measures. FI for each outcome was determined by the number of event reversals necessary to alter significance (P < .05). FQ was calculated by dividing the FI by the respective sample size. Additional subgroup analyses were performed.

RESULTS

Of 8020 studies screened, 1062 met initial search criteria with 17 comparative studies ultimately included for analysis, 10 of which were RCTs. A total of 40 outcomes were examined. Overall, the median FI was 2.5 (interquartile range [IQR] 2-4), the mean FI was 2.90 (±1.58), the median FQ was 0.032 (IQR 0.012-0.069), and the mean FQ was 0.049 (±0.062). The FI was less than the number of patients lost to follow-up for 78% of outcomes.

CONCLUSION

Studies examining the efficacy of operative vs nonoperative management of Achilles tendon rupture may not be as statistically stable as previously thought. The average number of outcome reversals needed to alter the significance of a given study was 2.90. Future analyses may benefit from the inclusion of a fragility index and a fragility quotient in their statistical analyses.

Early Tensile Loading in Nonsurgically Treated Achilles Tendon Ruptures Leads to a Larger Tendon Callus and a Lower Elastic Modulus: A Randomized Controlled Trial

BACKGROUND

Early tensile loading improves material properties of healing Achilles tendon ruptures in animal models and in surgically treated human ruptures. However, the effect of such rehabilitation in patients who are nonsurgically treated remains unknown.

HYPOTHESIS

In nonsurgically treated Achilles tendon ruptures, early tensile loading would lead to higher elastic modulus 19 weeks after the injury compared with controls.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Between October 2015 and November 2018, a total of 40 nonsurgically treated patients with acute Achilles tendon rupture were randomized to an early tensile loading (loaded group) or control group. Tantalum bead markers were inserted percutaneously into the tendon stumps 2 weeks after the injury to allow high-precision measurements of callus deformation under mechanical testing. The loaded group used a training pedal twice daily to produce a gradual increase in tensile load during the following 5 weeks. Both groups were allowed full weightbearing in an ankle orthosis and unloaded range of motion exercises. Patients were followed clinically and via roentgen stereophotogrammetric analysis and computed tomography at 7, 19, and 52 weeks after the injury.

RESULTS

The mean ± standard deviation elastic modulus at 19 weeks was 95.6 ± 38.2 MPa in the loaded group and 108 ± 45.2 MPa in controls (P = .37). The elastic modulus increased in both groups, although it was lower in the loaded group at all time points. Tendon cross-sectional area increased from 7 weeks to 19 weeks, from 231 ± 99.5 to 388 ± 142 mm² in the loaded group and from 188 ± 65.4 to 335 ± 87.2 mm² in controls (P < .001 for the effect of time). Cross-sectional area for the loaded group versus controls at 52 weeks was 302 ± 62.4 mm² versus 252 ± 49.2 mm², respectively (P = .03). Gap elongation was 7.35 ± 13.9 mm in the loaded group versus 2.86 ± 5.52 mm in controls (P = .27).

CONCLUSION

Early tensile loading in nonsurgically treated Achilles tendon ruptures did not lead to higher elastic modulus in the healing tendon but altered the structural properties of the tendon via an increased tendon thickness.

REGISTRATION

NCT0280575 (ClinicalTrials.gov identifier).

Chronic Rupture of Achilles Tendon Caused by Haglund's Deformity: A Case Report

A chronic Achilles tendon rupture is a tendon rupture occurring more than 4-6 weeks after a traumatic injury. Haglund's deformity, caused by bony abnormalities in the ankle (mostly due to osteophyte or bone spur), can cause chronic inflammation and degeneration of the Achilles tendon, eventually leading to rupture. This presents a challenge for clinicians who provide tendon repair procedures. We present a 69-year-old woman who had difficulty moving her left leg and had a deformity on the left leg compared to her right leg after falling nine months before but with pain starting three months before the accident. There was a seven-centimeter gap in the calcaneus with a positive Thompson test. The Haglund's deformity on the left calcaneus was visible on the ankle X-ray. The patient had a chronic total rupture of the left Achilles tendon, which was treated with a flexor hallucis longus (FHL) tendon transfer and resection of the deformity. One week after surgery, the patient's ability to walk and the shape of the left leg improved. This case report describes a chronic left Achilles tendon condition that was successfully repaired through tendon repair surgery using FHL tendon transfer and removal of Haglund's deformity.

The Acute Achilles Tendon Rupture: An Evidence-Based Approach from the Diagnosis to the Treatment

Background and Objective: Acute Achilles tendon rupture (AATR) is a common injury with a significant impact on daily living. Although various systematic reviews and meta-analyses have been written on the topic, no actual consensus exists on the best treatment. We aimed to collect the highest quality of evidence on the subject and to produce a document to which to refer, from the diagnosis to the final treatment. Material and Methods: Inclusion criteria were systematic reviews discussing Achilles tendon rupture, concerning either diagnostic criteria, classification, or treatment; English language; clearly stated inclusion and exclusion criteria for patients’ selection. Results: Thirteen systematic reviews were included in the study. A strong consensus exists about the higher risk of re-rupture associated with non-operative treatment and a higher risk of complications associated with surgical repair. Conclusions: The combination of minimally invasive repair and accelerated functional rehabilitation seems to offer the best results in the treatment of Achilles tendon rupture.

No effects of early functional mobilization on gait patterns after acute Achilles tendon rupture repair

This study aimed to compare recovery of gait patterns in patients treated with early functional mobilization (EFM) or standard treatment (ST) after Achilles tendon rupture repair. Second, this study aimed to explore associations between gait patterns and tendon elongation and calf muscle atrophy, respectively. Forty-seven patients (12 females), mean age 38.7 (7.3) years, were included. Patients were postoperatively randomized to EFM (n = 29), including immediate weightbearing and ankle motion for 6 weeks, or ST (n = 18), with 2 weeks of unloading in a plaster cast followed by 4 weeks of weightbearing in an orthosis. Three-dimensional gait analyses were performed at 8 weeks and 6 months postoperatively to evaluate ankle and knee kinematics and kinetics. Ultrasound imaging was performed to assess tendon length and calf muscle atrophy. At 8 weeks, there were no significant group differences in ankle and knee kinematics and kinetics, while side-to-side differences between injured and uninjured side were present within both groups. At 6 months, the ST group exhibited higher generating ankle power and greater peak moments in ankle and knee compared to the EFM group. In both groups, peak ankle dorsiflexion angle was greater on the injured side compared to the uninjured side. No correlations were found between ankle joint gait deviations and degree of tendon elongation or muscle atrophy. Clinical significance: The accelerated rehabilitation regimen with EFM did not result in a more symmetrical gait pattern. The gait pattern deviations in the ankle joint were not related to the degree of muscle atrophy or tendon elongation.

Photobiomodulation Associated With Conservative Treatment for Achilles Tendon Rupture: A Double-Blind, Superiority, Randomized Controlled Trial

Objective

To investigate the effects of photobiomodulation on Achilles tendon rupture (ATR) treated conservatively.

Design

Prospective, patient- and assessor-blinded, parallel, randomized controlled trial.

Setting

Patients with acute ATR treated conservatively.

Participants

Thirty-four male individuals with acute unilateral ATR treated conservatively (N=34), equally divided in 2 groups: photobiomodulation group (PBMG) and sham group, with mean age of 45.5±9.47 and 48.7±8.38 years, respectively.

Intervention

All participants underwent through an immobilization period, followed by rehabilitation sessions (2 d/wk for 12 weeks) comprising strengthening, range of motion, and balance/weightbearing exercises. In PBMG, the tendon was irradiated with a photobiomodulation cluster (1 904 nm/50 mW infrared laser, 4 858 nm/50 mW infrared diodes, and 4 658 nm/40 mW red diodes; power density of 105 mW/cm² per cluster area) during the immobilization period (2 d/wk for 8 weeks) and the sham group received a simulation of the procedure with no irradiation. Outcomes were assessed at the removal of the immobilization 12 and 16 weeks after tendon rupture.

Main Outcome Measures

Primary outcome was the Achilles Tendon Rupture Score. Secondary outcomes included Numerical Pain Rating Scale at rest and during effort, plantar flexor strength, and ankle range of motion.

Results

Both groups demonstrated an increase in the Achilles Tendon Rupture Score and improvements in range of motion, plantar flexor strength, and pain. There were no significant differences in outcomes between the 2 groups (P>.05) except in pain during walking, which was significantly lower in the PBMG in week 12 (P<.01, effect size=0.56) and week 16 (P<.01, effect size=0.55).

Conclusion

Photobiomodulation associated with conservative treatment is not superior to conservative treatment alone for improving function in patients with acute ATR.

Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review

Persistent muscle weakness, tendon elongation, and incomplete return to preinjury level are frequent sequelae after acute Achilles tendon rupture, and evidence-based knowledge of how to best rehabilitate the injury is largely absent in the literature. The objective of this review is to illuminate and discuss to what extent an Achilles tendon rupture affects muscle, tendon, and function when assessed with the Achilles tendon total rupture score (ATRS), muscle strength, muscle cross-sectional area, tendon length, and the heel-rise test. The patient-reported outcome measures (PROM) data in the literature suggest that the recovery takes longer than 6 months (ATRS, 70 out of 100), that one-year postinjury, the ATRS only reaches 82, and that this does not appear to noticeably improve thereafter. Loss of muscle mass, strength, and function can in some cases be permanent. Over the first 6 months postinjury, the tendon undergoes elongation, which appears to be negatively correlated to heel-rise function. More recently, there has been some interest in how muscle length and excursion is related to the reduced function. The available literature indicates that further research is highly warranted and that efforts to restore normal tendon length may improve the likelihood of returning to preinjury level after an Achilles tendon rupture.

Efectos de los ejercicios pliométricos en pacientes postoperatorio de rotura del tendón calcáneo

De la ruptura del tendón Aquileo se tiene conocimiento desde la antigua Grecia, la cual ha ido en aumento en los últimos años, por ende, se busca implementar mejores herramientas para el tratamiento de la misma, siendo una de ellas los ejercicios pliométricos. Estudios tipo meta-análisis, ensayos controlados aleatorizados y experimentales observaron que la aplicación de ejercicios pliométricos en la mayoría de los participantes mejoraba la calidad del tendón, aumentando elasticidad y disminuyendo su rigidez  (p<0.01) en 14 estudios y en los 3 estudios restantes, no mejoraba la estructura del tendón, sin embargo, mejoraba la sintomatología y funcionalidad del mismo en estudios tardíos (p<0.01). La aplicación de ejercicios pliométricos es una herramienta adicional para tratar a los sujetos sometidos a una operación de ruptura de tendón Aquileo, el cual debe ser aplicado en estadios finales en rehabilitación, mejorando la rigidez del tejido, aumentando la funcionalidad y disminuyendo el dolor crónico.

Panda rope bridge technique versus open repair of acute Achilles tendon rupture: A comparative clinical study

PURPOSE

The treatment options of acute Achilles tendon rupture (AATR) remain controversial. This article aims to compare the efficacy of a new surgical procedure, the panda rope bridge technique (PRBT) with open surgery of AATR.

METHODS

Ninety-eight patients with AATR were recruited, 53 underwent the PBRT, and 45 underwent open surgery. The operation time, postoperative American Orthopaedic Foot and Ankle Score, Achilles Tendon Rupture Score, complications and time to return to work and restore exercise were documented.

RESULTS

The average operation time, intraoperative blood loss and complication rate were 35.1 min, 18.2 ml and 3.8%, respectively, in the PRBT group, which were significantly lower than those of the open surgery group (P<0.001). The post-operative American Orthopaedic Foot and Ankle Score of 99.6 and the Achilles Tendon Rupture Score of 97.5 in the PRBT group were significantly higher than that of the open surgery group (P<0.001). The time to return to work and return to exercise were shorter in the PRBT group (P<0.001).

CONCLUSION

Compared to open surgery, PRBT is a better approach to the management of AATR. PRBT offers accelerated recovery, lower occurrence of post-operative complications and improved recovery of ankle joint function.

The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors

PURPOSE

The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture.

METHODS

A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years.

RESULTS

Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050).

CONCLUSION

The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture.

LEVEL OF EVIDENCE

III.

Operative vs Nonoperative Treatment of Achilles Tendon Ruptures Using Early Functional Rehabilitation: Critical Analysis of Evidence

BACKGROUND

Nonoperative treatment with functional rehabilitation of Achilles tendon ruptures (ATRs) has become more common because of claim of "equivalent" risk of rerupture compared to operative treatment. We investigated how current evidence corroborates the often-claimed "equal" or "nondifferent" complication rates.

METHODS

A search of meta-analyses in PubMed, CENTRAL, and Scopus was performed. Meta-analyses including randomized controlled trials (RCTs) comparing open operative repair of ATR and nonoperative treatment with functional rehabilitation regarding reruptures and other complications were identified.

RESULTS

Four separate meta-analyses with 6 pooled treatment comparisons were identified. One of the 6 treatment effects (for risk ratio [RR]) showed a reduced risk of rerupture favoring operative treatment, whereas in the remaining analyses the null hypothesis assuming equal risk or an RR of 1 could not be rejected. The smallest RR (benefit in favor of surgery) that could be rejected based on the 95% CI was 0.28. The smallest risk difference that could be rejected in favor of surgery was 6.4%, indicating that nonoperative may have up to 6.4% higher rerupture rate. Treatment effects for complications other than rerupture had very large variability and imprecision.

CONCLUSION

The literature comparing surgery with nonoperative treatment using functional rehabilitation in ATR have been interpreted in favor of nonoperative treatment as the rerupture rates were falsely considered "equivalent." None of the published meta-analyses excluded a relative risk that is likely to affect the course of treatment in many cases. Increasing incidence of nonoperative treatment in ATRs is not clearly supported by current evidence.

Achilles: Failed Acute Repair

Acute Achilles tendon ruptures are commonly managed with surgical repair. This particular surgery is prone to rerupture, wound complications, deep vein thrombosis, and sural nerve injuries. In this chapter the authors discuss complications, how to avoid them, and ultimately how to manage complications with your patients.

Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis

OBJECTIVE

To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.

DESIGN

Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).

LITERATURE SEARCH

MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.

STUDY SELECTION CRITERIA

RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.

DATA SYNTHESIS

Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.

RESULTS

One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.

CONCLUSION

The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.

Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture

BACKGROUND

Whether surgical repair of an acute Achilles' tendon rupture by an open-repair or minimally invasive approach is associated with better outcomes than nonsurgical treatment is not clear.

METHODS

We performed a multicenter, randomized, controlled trial that compared nonoperative treatment, open repair, and minimally invasive surgery in adults with acute Achilles' tendon rupture who presented to four trial centers. The primary outcome was the change from baseline in the Achilles' tendon Total Rupture Score (scores range from 0 to 100, with higher scores indicating better health status) at 12 months. Secondary outcomes included the incidence of tendon rerupture.

RESULTS

A total of 554 patients underwent randomization, and 526 patients were included in the final analysis. The mean changes in the Achilles' tendon Total Rupture Score were -17.0 points in the nonoperative group, -16.0 points in the open-repair group, and -14.7 points in the minimally invasive surgery group (P = 0.57). Pairwise comparisons provided no evidence of differences between the groups. The changes from baseline in physical performance and patient-reported physical function were similar in the three groups. The number of tendon reruptures was higher in the nonoperative group (6.2%) than in the open-repair or minimally invasive surgery group (0.6% in each). There were 9 nerve injuries in the minimally invasive surgery group (in 5.2% of the patients) as compared with 5 in the open-repair group (in 2.8%) and 1 in the nonoperative group (in 0.6%).

CONCLUSIONS

In patients with Achilles' tendon rupture, surgery (open repair or minimally invasive surgery) was not associated with better outcomes than nonoperative treatment at 12 months. (Funded by the South-Eastern Norway Regional Health Authority and Akershus University Hospital; ClinicalTrials.gov number, NCT01785264.).

Achilles Injury and Access to Care in South Florida

Introduction. Despite the amount of orthopaedic research evaluating access to care based on insurance status, no study quantifies the effects of insurance status on the care of acute Achilles tendon ruptures. Methods. Using Current Procedural Terminology codes, we identified all patients who underwent surgical management of Achilles tendon rupture between December 31, 2013, and December 31, 2018, and followed-up at either a county hospital-based orthopaedic surgery clinic and/or private university-based clinic. Inclusion criteria included patients who (1) underwent surgical management of an Achilles tendon rupture during this time period and (2) were at least 18 years of age at the time of surgery. A univariate 2-tailed t test was used to compare various groups. Statistical significance was set at P < 0.05. Results. When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of injury to first clinic visit (14.5 days vs 5.2 days, P < .001), first clinic visit to surgery (34.6 days vs 4.8 days, P < .002), injury to surgery date (48.9 days vs 9.8 days, P < .001), initial presentation to when magnetic resonance imaging was obtained (48.1 days vs 1.9 days, P < .002). Conclusions. Disparities in access to care for Achilles tendon ruptures are intimately related to insurance status. Uninsured and Medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance.Levels of Evidence: Level III: Prognostic, retrospective.

Comparison Study of Mini-Incision Versus Original Open Technique of the Half-Mini-Bunnell Achilles Tendon Repair

Mini-incision surgical procedures in our institution have been developed by decreasing the total skin incision length from the original mini half-Bunnell tendon repair technique. We hypothesized that the mini-incision, or minimum invasive Achilles tendon repair technique, would promote the tendon healing process leading to better outcomes and a reduced complication rate compared to the conventional open repair. The study sought to determine the more optimal method by comparing 44 mini-incision sutures to the 99 sutures in the original open Achilles tendon repairs. The mean skin incision length of the mini-incision surgery was 2.9 (range 2.5-3.0) cm and the original repair was 4.2 (range 3.5-7.0) cm. The mean surgery time was 60.0 minutes in the mini-incision repair and 68.1 minutes in the original one (p = .0003). The mean achievement time of bilateral heel-rise, starting jogging, single-legged heel-rise movement and the time to return-to-play was not significantly different between the 2 groups. Achilles Tendon Rupture Score was not significantly different from 3 to 9 months after surgery. Re-injury rate was 1/44 (2.3%) in mini-incision and 4/99 (4.0%) in conventional open repair (p = .36). No patients in either group developed any postoperative infections nor deep vein thrombosis complications. Although the mini-incision half-mini-Bunnell suture was showed equivalent clinical results to the original open repair, the technique is recommended in terms of curtailment of the surgery time without increase of complication ratio.

Intra-operative ultrasound: does it improve the results of percutaneous repair of acute Achilles tendon rupture?

Purpose

Percutaneous repair is a good option for acute Achilles tendon rupture. Although it overcomes the complications of open technique, it carries the risk of sural nerve injury and inadequate repair. In this study, we explore if the use of intra-operative ultrasound with percutaneous technique has any advantageous effect on final results of repair.

Methods

This is a prospective randomized study done between May 2014 and December 2020. It included 91 patients with complete acute Achilles tendon rupture distributed in 2 groups with homogenous clinical and demographic data. Group A (n = 47) included those managed by percutaneous repair with assistant of an intra-operative ultrasound. Group B (n = 44) included those done without the assistant of ultrasound. Post-operative evaluation was done clinically by the American Orthopedic Foot and Ankle Society score, calf muscle circumference and single heel rise test and radiologically by Magnetic Resonance Image.

Results

Patients of both groups reported continuous improvement of the American Orthopedic Foot and Ankle Society score with time. However, patient of group A recorded better functional outcome score at 3 months postoperatively. We recorded longer operative time in group A than those in group B. Continuous improvement of maximum calf circumference was observed in both groups. Satisfactory healing was noticed to happen faster in patients of group A than those of group B. We recorded two cases of re-rupture and two cases of sural nerve injury in group B with no reported complication in group A.

Conclusion

The use of an intra-operative ultrasound with percutaneous repair of acute rupture of Achilles tendon can improve the quality of repair as evidenced by quicker satisfactory healing and earlier regain of activity. Also, it can help in proper localization of sural nerve in relation to lateral edge of Achilles tendon.

Trial registration

Clinical Trials.gov Identifier: NCT04935281.

The modified mini-open technique for repairing total ruptured Achilles tendon using fiber wire with calcaneal fixation. A prospective case series

Background

The purpose of this study was to evaluate clinical outcomes and complications of our modified Maffuli's mini-open technique for repairing acute Achilles tendon rupture using fiber wire and calcaneal fixation.

Material and methods

Between January 2017 and August 2020, 21 patients with acute rupture of the Achilles tendon who underwent the modified mini-open Maffulli's procedure have been enrolled in the study.

Result

All surgical incisions healed well without scar adhesions or infections. One year postoperatively, the ATRS score and AOFAS score were 91.2 ± 1.8; 97.2 ± 1.6 respectively; the range of ankle joint movement was normal. Patients could return to their work and their light sporting activities at the time of 16.9 ± 1.1 weeks and 19.7 ± 0.9 weeks postoperatively, respectively. 21 out of 21 patients were able to perform single heel raise. There were no sural nerve injuries, re-ruptures, tendon elongation, or deep vein thromboses.

Conclusion

We have shown that the modified Maffulli's technique using fiber wire with a calcaneal fixation for repairing acute Achilles tendon ruptures to be a safe and reliable method without requiring specialized or expensive materials. It allows a durable repairing, a limitation of healing problems, and a quick return to physical therapy and full activity. This technique can be widely employed in a low-income country.

•

The best treatment for acute Achilles tendon rupture is not defined.

•

The modified Maffulli's technique using fiber wire with a calcaneal fixation is a safe and reliable method.

•

It allows durable repairing, a limitation of wound healing problems, and a quick return to physical therapy.

•

This technique can be widely employed in a low-income country.