Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment

Surgical Management of Achilles Tendon Ruptures in the United States 2006-2020, an ABOS Part II Oral Examination Case List Database Study

Background

In correlation with a growing body of evidence regarding nonoperative management for Achilles tendon rupture (ATR), studies from Europe and Canada have displayed a decreasing incidence in surgical management, which has not been noted in the United States. The primary objective of this study is to evaluate the US trend in ATR repair volume.

Methods

The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination Case List Database was used. All cases using Current Procedural Terminology codes for primary ATR repair were requested from the years 2006-2020. Total submitted Achilles repair volume, the number of candidates submitting an Achilles repair case, and the overall submitted case volume per examination year was analyzed. Poisson and linear regressions were used to determine statistically significant trends.

Results

The total number of Achilles repair cases submitted for the ABOS Part II Oral Examination significantly increased from 2006 to 2011 and then decreased until 2020. Taking Achilles repair cases as a proportion of total orthopaedic cases submitted, the same trend was seen. The number of candidates submitting an Achilles repair case increased from 2006 to 2009 and then decreased until 2020. Foot and Ankle fellowship-trained candidates submitted an increasing number of ATR repair cases per candidate during the time period studied.

Conclusion

This is the first study to demonstrate a decline in the volume of ATR repair in the United States. The decline in ATR repair volume seen in the ABOS Part II Case Lists does not match previously published US surgeon practice patterns but is not necessarily generalizable to beyond this period. Although the overall ATR repair volume in the ABOS Part II Case Lists is decreasing, we found Foot and Ankle fellowship-trained surgeons are operating on an increasing number of ATRs during their board collection period.

Level of Evidence

Level III, retrospective cohort study.

Outcomes of Surgical Treatment for Sural Neuritis: A Retrospective Case Series

BACKGROUND

Somatic nerve pain is one of the most common complications following surgery of the foot and ankle but may also arise following traumatic injury or chronic nerve compression. The sural nerve is a commonly affected nerve in the foot and ankle; it is at risk given the proximity to frequently used surgical approaches, exposure to crush injuries, and traction from severe ankle inversion injuries. The purpose of this study is to investigate the outcomes of sural nerve neurectomy with proximal implantation for sural neuromas (SN) and chronic sural neuritis (CSN).

METHODS

Patients that underwent neurectomy with proximal implantation (20 muscle, 1 adipose tissue) by 2 foot and ankle specialists for isolated SN- and CSN-related pain at a single tertiary institution were included. Demographic data, baseline outcomes including 36-Item Short Form Health Survey (SF-36), Foot and Ankle Ability Measure (FAAM), and visual analog scale (VAS) were recorded. Final follow-up questionnaires using Patient Reported Outcomes Measurement Information System (PROMIS) lower extremity function, pain interference (PI), and neuropathic pain quality, FAAM, and VAS were administered using REDCap. Perioperative factors including neuropathic medications, diagnostic injections, the use of collagen wraps, and perioperative ketamine were collected from the medical record. Descriptive statistics were performed and potential changes in patient-reported outcome measure scores were evaluated using Wilcoxon signed-rank tests.

RESULTS

The 21 patients meeting inclusion criteria for this study had a median age of 47 years (interquartile range [IQR], 43-49) and had median follow-up duration of 33.7 months (IQR, 4.5-47.6). Median FAAM activities of daily living score improved from 40.6 (38.7-50.7) preoperatively to 66.1 (53.6-83.3) postoperatively, P = .032. FAAM sports scores improved from 14.1 (7.8-21.9) to 41.1 (25.0-60.9) postoperatively, P = .002. VAS scores improved from a median of 9.0 (8.0-9.0) to 3.0 (3.0-6.0), P < .001. At final follow-up, patients reported PROMIS lower extremity function score median of 43.8 (35.6-54.9), PROMIS neuropathic pain quality score of 54.1 (43.6-61.6), and PROMIS PI of 57.7 (41.1-63.8). Patients with both anxiety and depression reported less improvement in pain and physical. Other perioperative factors lacked sufficient numbers for statistical analysis.

CONCLUSION

Sural nerve neurectomy and proximal implantation (20 muscle, 1 adipose) provided significant improvement in pain and function for patients with sural neuromas and chronic sural neuritis at median follow-up of 33.7 months. Anxiety and depression were associated with significantly poorer outcomes following surgery. Patients with CRPS as well as recent nicotine use tended to report less improvement in pain and worse function after surgery, although this sample size was too limited for statistical analysis of these variables. Further research is needed to identify the ideal surgical candidates and perioperative factors to optimize patient outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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.

Learning curve of the Krackow suture technique for the repair of Achilles tendon rupture

INTRODUCTION

Knowledge on the learning curve for the repair of Achilles tendon rupture is limited. The aim of this study was to quantify the learning curve for the Krackow suture technique for the repair of Achilles tendon rupture and to identify the correlation between the cumulative volume of cases and clinical outcome measures.

MATERIALS AND METHODS

A total of 226 cases of Achilles tendon repair using the Krackow suture technique were reviewed. Each surgery was independently performed by four surgeons who started a foot and ankle specialty career after fellowship training. After logarithmic transformation of the operative time and cumulative volume of cases, a linear regression analysis was performed to determine the best-fit linear equations to predict the required time for the Krackow suture technique according to the cumulative volume of cases. The correlation between the cumulative volume of cases and clinical outcome measures was analyzed using Pearson correlation coefficients. Receiver operating characteristic curves were constructed to determine the minimum number of cases with an operative time shorter than the average in the first 30 cases.

RESULTS

In all four surgeons, significant log-linear correlations were observed between the operative time and cumulative volume of cases. The best-fit linear equations showed estimated learning rates of 90%, 87%, 92%, and 86% for each of the four surgeons, indicating that the necessary operative time decreased by 10%, 13%, 8%, and 14%, respectively, when the cumulative volume of cases had doubled. The minimum number of cases with an operative time shorter than the average was 9 (91% sensitivity and 59% specificity). The clinical outcome measures at 6 and 12 months postoperatively were available for one surgeon; however, no correlation was found with the cumulative volume of cases.

CONCLUSION

The learning rate for the Krackow suture technique for the repair of Achilles tendon rupture was approximately 89%, indicating that the required operative time can decrease by up to 11% when the cumulative volume of cases doubles. Therefore, it is important to rapidly accumulate surgical experience during the early phase of training.

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.

Absorbable versus nonabsorbable sutures for the Krackow suture repair of acute Achilles tendon rupture: a prospective randomized controlled trial

AIMS

Although absorbable sutures for the repair of acute Achilles tendon rupture (ATR) have been attracting attention, the rationale for their use remains insufficient. This study prospectively compared the outcomes of absorbable and nonabsorbable sutures for the repair of acute ATR.

METHODS

A total of 40 patients were randomly assigned to either braided absorbable polyglactin suture or braided nonabsorbable polyethylene terephthalate suture groups. ATR was then repaired using the Krackow suture method. At three and six months after surgery, the isokinetic muscle strength of ankle plantar flexion was measured using a computer-based Cybex dynamometer. At six and 12 months after surgery, patient-reported outcomes were measured using the Achilles tendon Total Rupture Score (ATRS), visual analogue scale for pain (VAS pain), and EuroQoL five-dimension health questionnaire (EQ-5D).

RESULTS

Overall, 37 patients completed 12 months of follow-up. No difference was observed between the two groups in terms of isokinetic plantar flexion strength, ATRS, VAS pain, or EQ-5D. No re-rupture was observed in either group.

CONCLUSION

The use of absorbable sutures for the repair of acute ATR was not inferior to that of nonabsorbable sutures. This finding suggests that absorbable sutures can be considered for the repair of acute ATRs. Cite this article: Bone Joint J 2022;104-B(8):938-945.

Effects and Mechanism of Particulate Matter on Tendon Healing Based on Integrated Analysis of DNA Methylation and RNA Sequencing Data in a Rat Model

Exposure to particulate matter (PM) has been linked with the severity of various diseases. To date, there is no study on the relationship between PM exposure and tendon healing. Open Achilles tenotomy of 20 rats was performed. The animals were divided into two groups according to exposure to PM: a PM group and a non-PM group. After 6 weeks of PM exposure, the harvest and investigations of lungs, blood samples, and Achilles tendons were performed. Compared to the non-PM group, the white blood cell count and tumor necrosis factor-alpha expression in the PM group were significantly higher. The Achilles tendons in PM group showed significantly increased inflammatory outcomes. A TEM analysis showed reduced collagen fibrils in the PM group. A biomechanical analysis demonstrated that the load to failure value was lower in the PM group. An upregulation of the gene encoding cyclic AMP response element-binding protein (CREB) was detected in the PM group by an integrated analysis of DNA methylation and RNA sequencing data, as confirmed via a Western blot analysis showing significantly elevated levels of phosphorylated CREB. In summary, PM exposure caused a deleterious effect on tendon healing. The molecular data indicate that the action mechanism of PM may be associated with upregulated CREB signaling.

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.

Is Early Controlled Motion and Weightbearing Recommended for Nonoperatively Treated Acute Achilles Tendon Rupture? A Systematic Review and Meta-analysis

Background

There is disagreement as to whether early controlled motion and weightbearing confer a beneficial effect for nonoperatively treated acute Achilles tendon rupture (ATR) compared with immobilization and late weightbearing.

Purpose

To conduct a meta-analysis of randomized controlled trials (RCTs) to determine whether early controlled motion and weightbearing results in different outcomes compared with immobilization and late weightbearing for nonoperatively treated patients with acute ATR.

Study Design

Systematic review; Level of evidence, 1.

Methods

We conducted a search in the PubMed, Web of Science, and EMBASE databases for relevant RCTs in humans from January 1981 to August 2020. The primary outcome was the Achilles Tendon Total Rupture Score (ATRS) at 1-year follow-up. The secondary outcomes were the rerupture rate, return to sports activity and work, and the heel-rise work (limb symmetry index [LSI]). Study quality was assessed using the Cochrane Collaboration risk of bias tool.

Results

Included were 7 RCTs involving 424 participants (n = 215 treated with early controlled motion and weightbearing [early group], n = 209 treated with immobilization and late weightbearing [late group]). The quality assessment indicated a low risk of bias in all included RCTs. There was no difference between the early and late groups regarding the ATRS (mean difference [MD], -0.220; 95% CI, -4.489 to 4.049; P = .920). Likewise, we found no difference between the 2 groups in terms of the rerupture rate (odds ratio [OR], 1.107; 95% CI, 0.552 to 2.219; P = .775), the number of patients who returned to sports (OR, 0.766; 95% CI, 0.438 to 1.341; P = .351) and returned to work (OR, 0.706; 95% CI, 0.397 to 1.253; P = .234), the time to return to work (MD, -2.802 days; 95% CI, -6.525 to 0.921 days; P = .140), or the heel-rise work LSI (MD, -0.135; 95% CI, -6.243 to 5.973; P = .965).

Conclusion

No significant differences were found between early controlled motion and weightbearing compared with immobilization and late weightbearing regarding the ATRS, the rerupture rate, return to sports activity and work, and the heel-rise work in nonoperatively treated patients with acute ATR.

The Achilles Tendon Rupture in Basketball: Systematic Review of the Present Literature

Background  The most common cause of the Achilles tendon ruptures in the U.S. population is sports, basketball is one among them. It is not one of the most frequent injuries of this sport, but it is one of the most serious and impactful in its practice.

Purpose  The objective of this work is to gather evidence and evaluate the relationship between Achilles' tendon ruptures and basketball.

Study Design  This study designed as a systematic review.

Material and Methods  A search of literature in the databases PubMed, Cochrane Library, and ClinicalTrials.gov was conducted during January and February 2020.

Results  After the search and selection, three relevant articles were obtained due to their epidemiological content, Raikin et al and Lemme et al. In 2013 and 2018, they, respectively, conducted studies in U.S. populations, establishing sport as the most frequent injury mechanism in Achilles' tendon ruptures. It was analyzed according to injury mechanism, gender, body mass index (BMI), and age. In both studies, the lesion resulted more frequently in men and the sport involved in most of the cases was basketball (32 and 42.6%, respectively). In 2019, Lemme et al published an epidemiological design analyzing the Achilles tendon ruptures in the National Basketball Association (NBA), identifying risk factors and results in professional players. After suffering the injury, 36.8% of the patients had to retire or were holders in less than 10 games to the rest of their sports career.

Conclusions  The relationship between basketball and Achilles' tendon rupture is clear in the general population. Despite this, new studies are required to complement the evidence obtained so far.

Mini-Invasive, Ultrasound Guided Repair of the Achilles Tendon Rupture-A Pilot Study

Percutaneous acute Achilles tendon rupture suturing has become a leading treatment option in recent years. A common complication after this mini-invasive procedure is sural nerve injury, which can reduce the patients’ satisfaction and final outcomes. High-resolution ultrasound is a reliable method for localizing the sural nerve, and it can be performed intra-operatively; however, the long-term results are yet unknown. The aim of the study was to retrospectively evaluate the long-term results of percutaneous Achilles tendon repair supported with real-time ultrasound imaging. We conducted 57 percutaneous sutures of acute Achilles tendon rupture between 2005 and 2015; 30 were sutured under sonographic guidance, while 27 were performed without sonographic assistance. The inclusion criteria were acute (less than 7 days) full tendon rupture, treatment with the percutaneous technique, age between 18 and 65 years, and a body mass index (BMI) below 35. The operative procedure was carried out by two surgeons, according to the surgical technique reported by Maffulli et al. In total, 35 patients were available for this retrospective assessment; 20 (16 men and 4 women) were treated with sonographic guidance, while 15 (12 men and 3 women) underwent the procedure without it. The mean follow-up was 8 years (range, 3–13 years). The sural nerve was localized 10 mm to 20 mm (mean, 15.8; SD, 3.02) laterally from the scar of the Achilles tendon tear. There was no significant difference between groups with respect to the FAOQ score (P < 0.05). High-resolution ultrasounds performed intra-operatively can minimize the risk of sural nerve injury during percutaneous Achilles tendon repair.

Duration of immobilisation after Achilles tendon rupture repair by open surgery: a retrospective cohort study

Background

The best treatment for acute Achilles tendon ruptures remains controversial. No cohort studies have compared different immobilisation durations after open surgery. This retrospective cohort study aimed to determine the optimal duration of immobilisation after this surgery.

Methods

A total of 266 patients with acute Achilles tendon rupture were divided into 4 groups (A, B, C, and D) according to immobilisation duration of 0, 2, 4, and 6 weeks, respectively. All patients underwent the same suture technique with a similar rehabilitation protocol and were examined clinically at 2, 4, 6, 8, 10, 12, 14, 16, 24, and 48 weeks, with a final follow-up at a mean of 22.3 months postoperatively. The primary outcome was the time of return to light sports activity (LSA). Secondary outcomes included range of motion (ROM) and single-legged heel rise height (SHRH). Data on operation time, complications, visual analogue pain scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and Achilles tendon Total Rupture score (ATRS) were also collected. Demographic baseline data were analysed using one-way analysis of variance; outcome parameters were analysed using Kruskal-Wallis H test, and complications were analysed using Fisher’s exact test. Statistical significance was considered at P ≤ 0.05.

Results

VAS scores decreased significantly, reaching 0 in all groups after 12 weeks. The AOFAS and ATRS scores were significantly different between the groups from weeks 2 to 12 (P<0.001) and weeks 2 to 16 (P<0.001), respectively. All the mean scores showed better results in group B than in the other groups. In terms of recovery time of ROM, SHRH, and LSA, groups A and B were significantly faster than groups C and D (P<0.001). There were 13 (13/266, 4.9%) complications: 5 superficial infections, 3 deep venous thrombosis, and 5 trauma-related re-ruptures. On the last follow-up, all complications had recovered. There were no significant differences in complications between the groups.

Conclusions

Immobilisation for 2 weeks after this open surgery is the best choice for early rehabilitation and weight-bearing while minimising pain and other complications.

Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture: A Comprehensive Meta-Analysis of RCTs

Background: The Achilles tendon is the strongest tendon in human and is frequently injured, mainly in the young to middle age active population. Increasing incidence of Achilles tendon rupture (ATR) is still reported in several studies. Surgical repair and conservative treatment are two major management strategies widely adopted in ATR patients, but the consensus of the optimal treatment strategy is still debated. We aimed at thoroughly reviewing the ATR topic with additional assessments and performed a most comprehensive meta-analysis of randomized controlled trials (RCTs). Method: We comprehensively searched PubMed, Embase, Cochrane, and ClinicalTrial.gov and retrieved all RCTs comparing surgical and conservative treatment on ATR for further analysis. Two independent reviewers performed data extraction and random effect model was adopted when I 2 > 50%, with data presentation of risk ratio, risk difference, or mean difference and 95% confidence interval. Results: A total of 13 RCTs were included in this meta-analysis. A significant difference was observed in re-rupture, complication rate, adhesion to the underlying tendon, sural nerve injury, and superficial infection. A substantial reduction in re-rupture rate could be observed for surgical treatment while the complication rate was higher compared with conservative treatment. Conclusion: Surgical treatment revealed significance in reducing the re-rupture rate but was associated with a higher complication rate, while conservative treatment showed similar outcomes with a lower complication rate. Collectively, we recommend conservative treatment if patients' status and expectations are suitable, but surgeon and physician discretion is also crucial in decision making.

Comparing Absorbable and Nonabsorbable Suture Materials for Repair of Achilles Tendon Rupture: A Magnetic Resonance Imaging-Based Study

We aimed to compare magnetic resonance imaging (MRI) findings and corresponding clinical outcomes of repaired Achilles tendons using absorbable and nonabsorbable sutures. Patients who underwent Achilles tendon repair were divided into 2 groups, with 11 in the absorbable group (group A) and 11 in the nonabsorbable group (group B). For all patients, MRI findings taken 6 months postoperatively were evaluated for morphological changes in the tendon. Concurrently, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score and incidence of postoperative complications were evaluated. Regarding MRI findings, the extent to which the cross-sectional area of the repaired tendon was thicker than that of the preoperative tendon was significantly greater in group B than in group A (p = 0.0012). Notably, more stitches remained within the tendon in group B than in group A (p = 0.0063). No other MRI findings showed a significant difference between the two groups. No significant difference was observed in the AOFAS score, and there was one re-rupture each in both groups. Because nonabsorbable suture material in the treatment of Achilles tendon rupture yielded a thicker postoperative MRI cross-sectional area, enhanced rehabilitation is recommended in order to prevent scar formation.

Suture Anchor Versus Allogenic Tendon Suture in Treatment of Haglund Syndrome

Background

Haglund’s deformity is an abnormal bony enlargement on the back of the heel. It can cause the impact of the posterior calcaneal bursa and Achilles tendon insertion, and finally result in pain. This syndrome is called Haglund syndrome. The purpose of this study was to explore the effect of the suture anchor and allogeneic tendon suture in the treatment of Haglund syndrome.

Material/Methods

We retrospectively studied 20 patients with Haglund syndrome treated from January 2015 to December 2016. The patients were randomly divided into Group 1 (the suture anchor group) and Group 2 (the allogeneic tendon group), with 10 patients in each group and an average follow-up of 32 months after surgery. The AOFAS, VAS, and Arner-Lindholm scales were used to summarize the patient follow-up results and complications.

Results

In the 2 groups of patients, the postoperative AOFAS, VAS scores, and the Arner-Lindholm scale showed good results. However, the postoperative AOFAS score and VAS of the suture anchor group were better than those of the allogeneic tendon group, with shorter operation times. No Achilles tendon rupture or wound infection occurred during the entire postoperative period in either group. These results show the superiority of suture anchors.

Conclusions

The higher AOFAS and VAS score and shorter operation time in the suture anchor group suggest it is the better alternative for treatment of Haglund syndrome.

Modified Bunnell suture repair versus bundle-to-bundle suture repair for acute Achilles tendon rupture: a prospective comparative study of patients aged <45 years

BACKGROUND

This study aimed to compare the operative outcome of percutaneous repair (modified Bunnell suture technique) versus open repair (bundle-to-bundle suture technique) of acute Achilles tendon rupture.

METHODS

Seventy-two consecutive patients who underwent surgical treatment of Achilles tendon rupture were evaluated in this prospective study. Thirty-six patients were treated using the bundle-to-bundle suture technique (group A), and 36 patients were treated using the modified Bunnell suture technique (group B). All patients underwent functional examination comprising measurement of the calf muscle circumference and performance of the single-leg heel-rise test. The length and diameter of the Achilles tendon were compared between the injured and uninjured sides on magnetic resonance imaging. The number of single-leg heel rises (height > 5 cm) performed within 15 s was compared between the injured and uninjured sides. The ankle range of motion was also recorded. The Achilles tendon total rupture score (ATRS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, and visual analog scale (VAS) pain score were used to evaluate the clinical outcome at 12 months postoperatively.

RESULTS

A total of 61 patients were followed up. The mean follow-up duration did not significantly differ between group A (23.73 ± 2.81 months) and group B (22.61 ± 3.96 months). However, there were significant differences between groups in the heel-rise test (group A, 1.74 ± 0.96; group B, 2.37 ± 1.42) and length of the Achilles tendon (group A, 11.98 ± 1.64 cm; group B, 11.11 ± 1.74 cm). The calf circumference of the injured side was significantly larger in group A than in group B (p = 0.043). The cross-sectional diameter of the Achilles tendon was significantly smaller in group A than group B. At final follow-up, there were no significant differences between the two groups in the ATRS, AOFAS score, or VAS score. One patient in group A had delayed wound healing, which resolved in 40 days.

CONCLUSIONS

Patients with acute Achilles tendon rupture treated with open repair (bundle-to-bundle suture technique) achieved a better clinical outcome regarding the heel-rise test and calf circumference compared with those treated with percutaneous repair (modified Bunnell suture technique).

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000035229 , 8/4/2020, Retrospectively registered.

Results of Surgical Management of Achilles Tendon Rupture Using the Modified Lindholm Procedure

Objectives

Achilles tendon rupture (ATR) in adults often results from sporting activities, especially in young adults. There is no consensus in the literature on the best treatment approach in the treatment of these ruptures. The objective of this study was to evaluate the clinical long-term results of the augmented ATR repair using the modified Lindholm procedure (MLP).

Methods

Patients who underwent MLP due to ATR in the orthopedics and traumatology clinic of our hospital between 2007 and 2014 were retrospectively evaluated. Medical history of the patients was noted, and preoperative physical examination was routinely performed using the Thompson compression test. Patients’ demographic data such as age and gender, tendon rupture side, postoperative follow-up duration, and gap range values were recorded and evaluated.

Results

The mean age of the patients was 29.43 ± 7.10 years. The mean postoperative follow-up duration was 50.1 ± 8.20 months. Of the patients, 16 were injured during football, 10 during basketball, 2 during volleyball, and the remaining 8 during other sporting activities. When Arner-Lindholm scores were evaluated during follow-up, excellent outcome was achieved in 30 patients and good outcome was achieved in 6 patients, whereas there was no patient with poor outcome. None of the patients developed tendon re-rupture. At the end of the fourth postoperative month, the range of ankle motion was 100% in all patients.

Conclusions

In patients with spontaneous AT tendon rupture, MLP seems to prevent the re-rupture in the long-term period and should be considered as a safe procedure to repair ATR.

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Pilot Economic Decision Analysis

Background

The operative treatment of Achilles tendon ruptures has been associated with lower rerupture rates and better function but also a risk of surgery-related complications compared with nonoperative treatment, which may provide improved outcomes with accelerated rehabilitation protocols. However, economic decision analyses integrating the updated costs of both treatment options are limited in the literature.

Purpose

To compare the cost-effectiveness of operative and nonoperative treatment of acute Achilles tendon tears.

Study Design

Economic and decision analysis; Level of evidence, 2.

Methods

An economic decision model was built to assess the cost-utility ratio (CUR) of open primary repair versus nonoperative treatment for acute Achilles tendon ruptures, based on direct costs from the practices of sports medicine and foot and ankle surgeons at a single tertiary academic center, with published outcome probabilities and patient utility data. Multiway sensitivity analyses were performed to reflect the range of data.

Results

Nonoperative treatment was more cost-effective in the average scenario (nonoperative CUR, US$520; operative CUR, US$1995), but crossover occurred during the sensitivity analysis (nonoperative CUR range, US$224-US$2079; operative CUR range, US$789-US$8380). Operative treatment cost an extra average marginal CUR of US$1475 compared with nonoperative treatment, assuming uneventful healing in both treatment arms. The sensitivity analysis demonstrated a decreased marginal CUR of operative treatment when the outcome utility was maximized, and rerupture rates were minimized compared with nonoperative treatment.

Conclusion

Nonoperative treatment was more cost-effective in average scenarios. Crossover indicated that open primary repair would be favorable for maximized outcome utility, such as that for young athletes or heavy laborers. The treatment decision for acute Achilles tendon ruptures should be individualized. These pilot results provide inferences for further longitudinal analyses incorporating future clinical evidence.

Treatment of Acute Achilles Tendon Rupture

There is no clear consensus on the optimal treatment of acute Achilles tendon rupture. Recently, studies have demonstrated the critical role of functional rehabilitation in the treatment of ruptured Achilles tendons. Hence, conservative treatment is preferred by a growing number of surgeons seeking to treat the condition without the risk of complications from surgery. However, operative treatment is still considered as a more reliable treatment option for acute Achilles tendon rupture. In this review article, we provide an overview of recent treatment strategies for acute rupture of the Achilles tendon.

Cost-effectiveness of Operative Versus Non-operative Management of Acute Achilles Tendon Ruptures

BACKGROUND

The management of acute Achilles tendon ruptures is controversial, and most injuries are treated with surgery in the USA. The cost utility of operative versus non-operative treatment of acute Achilles tendon injury is unclear.

QUESTIONS/PURPOSES

The purpose of this study was to compare the cost-effectiveness of operative versus functional non-operative treatment of acute Achilles tendon ruptures.

METHODS

A Markov cost-utility analysis was conducted from the societal perspective using a 2-year time horizon. Hospital costs were derived from New York State billing data, and physician and rehabilitation costs were derived from the Medicare physician fee schedule. Indirect costs of missed work were calculated using estimates from the US Bureau of Labor Statistics. Rates of re-rupture, major and minor complications, and the associated costs were obtained from the literature. Effectiveness was expressed in quality-adjusted life years (QALYs). For the base-case analysis, operative and non-operative patients were assumed to have the same utilities (quality of life) following surgery. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of model assumptions.

RESULTS

In the base-case model, non-operative management of acute Achilles tendon ruptures dominated operative management, resulting in both lower costs and greater QALY gains. The differences in costs and effectiveness were relatively small. The benefit of non-operative treatment was 1.69 QALYs, and the benefit of operative treatment was 1.67 QALYs. Similarly, the total cost of operative and non-operative management was $13,936 versus $13,413, respectively. In sensitivity analyses, surgical costs and days of missed work were important drivers of cost-effectiveness. If hospitalization costs dropped below $2621 (compared with $3145) or the hourly wage rose above $29 (compared with $24), then operative treatment became a cost-effective strategy at the willingness-to-pay threshold of $50,000/QALY. The model results were also highly sensitive to the relative utilities for operative versus non-operative treatment. If non-operative utilities decreased relative to operative utilities by just 2%, then operative management became the dominant treatment strategy.

CONCLUSION

For acute Achilles tendon ruptures, non-operative treatment provided greater benefits and lower costs than operative management in the base case; however, surgical costs and the economic impact associated with return to work are important determinants of the preferred cost-effective strategy.

Doxycycline-Embedded Nanofibrous Membranes Help Promote Healing of Tendon Rupture

Background

Despite recent advancements in surgical techniques, the repair of tendon rupture remains a challenge for surgeons. The purpose of this study was to develop novel doxycycline-loaded biodegradable nanofibrous membranes and evaluate their efficacy for the repair of Achilles tendon rupture in a rat model.

Materials and Methods

The drug-loaded nanofibers were prepared using the electrospinning process and drug release from the prepared membranes was investigated both in vitro and in vivo. Furthermore, the safety and efficacy of the drug-loaded nanofibrous membranes were evaluated in rats that underwent tendon surgeries. An animal behavior cage was employed to monitor the post-surgery activity of the animals.

Results

The experimental results demonstrated that poly(D,L-lactide-co-glycolide) (PLGA) nanofibers released effective concentrations of doxycycline for more than 40 days post-surgery, and the systemic plasma drug concentration was low. Rats receiving implantation of doxycycline-loaded nanofibers also showed greater activities and stronger tendons post-operation.

Conclusion

Nanofibers loaded with doxycycline may have great potential in the repair of Achilles tendon rupture.

Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review

BACKGROUND

Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines.

PURPOSE

To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture.

RESULTS

A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53).

CONCLUSION

Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.

Early weight-bearing in nonoperative treatment of acute Achilles tendon rupture did not influence mid-term outcome: a blinded, randomised controlled trial

PURPOSE

Acute Achilles tendon rupture leads to impaired outcome at short term, but little is known concerning medium-term results. The aim of the present study was to investigate the influence of early weight-bearing on clinical outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture.

METHOD

The study was performed as a medium-term follow-up on patients included in a randomised controlled trial. Both groups were treated with nonoperative management and controlled early motion. The intervention group was allowed full weight-bearing from day 1, and the control group was non-weight-bearing for 6 weeks. 60 patients were randomised 1:1. Of those, 56 were eligible for inclusion in the medium-term follow-up and 37 participated (18 control, 19 intervention). The outcomes were Achilles tendon Total Rupture Score (ATRS) and heel raise work performed at an average of 4.5 years after the initial injury. Statistical analysis was performed using paired t tests and linear regression.

RESULTS

No differences were found between control and intervention groups at 4.5 years. ATRS scores consistently improved in both the intervention and the control groups from 0.5 to 1 year and from 1 to 4.5 years, ending up at 80.5 on average after 4.5 years. Heel raise height kept improving from 0.5 to 4.5 years, reaching a limb symmetry index of 82.4%. The heel raise work improvement from 0.5 to 1 year did not continue. No significant change was found from 1 to 4.5 years, ending at a limb symmetry index of 60%.

CONCLUSION

Early weight-bearing did not influence outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. The calf muscle of the injured limb performs 40% less work, when compared to the healthy limb, though lifting height recovers better.

LEVEL OF EVIDENCE

II.

CLINICAL TRIALS IDENTIFIER

NCT02760784.

Long-Term Results With the Use of Modified Percutaneous Repair of the Ruptured Achilles Tendon Under Local Anaesthesia (15-Year Analysis With 270 Cases)

Controversy regarding the optimal treatment of fresh total Achilles tendon rupture remains. This article presents results with the use of modified percutaneous Achilles tendon repair under local anesthesia performed from January 1991 to December 2005 with a 2- to 10-year follow-up. There were 270 procedures in 247 male patients (92.51%) and 20 female patients (7.49%), mean ± SD age 38.7 ± 11.56 (range 20 to 83) years, in all consecutively treated patients within 7 days after acute total rupture; 3 patients sustained ruptures on both sides in different periods. Postoperative care consisted of wearing a cast or soft cast or functional immobilization for 6 weeks. The procedure was well tolerated in all patients. There were 3 (1.11%) complete and 5 (1.85%) partial repeat ruptures (8 [2.96%] altogether). Fourteen patients (5.18%) developed transient sural neuritis that spontaneously resolved in 2 to 10 months. One case (0.3%) of deep venous thrombosis was successfully treated. There were 25 (9.36%) major and minor complications altogether, with no cases of increased postoperative dorsiflexion, deep infection, or necrosis. Forty-four patients (16.48%) had a slightly decreased range of ankle motion, and 216 (80.89%) patients, including all high-caliber athletes, resumed all their previous activities. The mean American Orthopedic Foot and Ankle Society hindfoot-ankle score was 96.10 points. Long-term results of the analyzed modified method suggest a reasonable treatment option for acute total Achilles tendon ruptures, with a low number of complications and repeat rupture rate and return to preinjury activities comparable to those of open procedures.

Medical comorbidities increase the rate of surgical site infection in primary Achilles tendon repair

PURPOSE

To assess the effects of medical comorbidities on the incidence of surgical site infection following primary Achilles tendon repair. A secondary aim was to assess the effects of specific medical comorbidities on the cost and extent of healthcare utilization related to surgical site infection following primary Achilles tendon repair.

METHODS

24,269 patients undergoing primary Achilles tendon repair between 2005 and 2012 were examined. Current Procedural Terminology codes for primary Achilles tendon repair, and incision and drainage were used to search for and compile patient data from the United Healthcare Orthopedic and Medicare databases. Primary outcome measures regarding surgical site infection following primary Achilles tendon repair included the rate of occurrence, cost, and duration of treatment.

RESULTS

Patients with one or more preexisting medical comorbidities at the time of surgery had an increased rate of surgical site infection compared to those without. Diabetes and vascular complications were associated with the highest surgical site infection rates. The rate of surgical incision and drainage was higher in patients with cardiac arrhythmias and uncomplicated hypertension. The presence of a medical comorbidity significantly increased the cost and duration of surgical site infection treatment.

CONCLUSIONS

Medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment. A better understanding of the relationship between each medical comorbidity and surgical site infections following Achilles tendon repair may be ascertained with additional prospective studies, thus, allowing for a more accurate evaluation and stratification of surgical candidates to improve patient outcomes.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Minimally Invasive Treatments of Acute Achilles Tendon Ruptures

Achilles tendon rupture is a common injury to the lower extremity that requires appropriate treatment to minimize functional deficit. Available treatments of Achilles tendon ruptures include nonoperative, open surgical repair, percutaneous repair, and minimally invasive repair. Open surgical repair obtains favorable functional outcomes with significant potential for deep soft tissue complications, calling into question the value of open repair. Percutaneous repair is an alternative option with comparable functional results and minimal soft tissue complications; however, sural nerve injury is a complication. Minimally invasive Achilles repair offers optimal results with superior functional outcomes with minimal soft tissue complications and sural nerve injury.

Surgical Versus Non-Surgical Methods for Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Controlled Trials

We performed a meta-analysis to (1) compare surgical and non-surgical treatment methods for repair of acute rupture of the Achilles tendon, in terms of the re-rupture rate, incidence of complications other than re-rupture, functional outcomes, and proportion of patients returning to previous levels of sporting activities, and (2) explore the difference in the re-rupture rate if proven early functional rehabilitation protocols were followed. PubMed, EMBASE, Medline, and Cochrane Central Register of Controlled Trials databases were searched to identify randomized clinical trials. The quality of included studies was assessed by the Cochrane risk-of-bias tool. The random-effects model or subgroup analysis would be chosen to perform the meta-analysis if the data were heterogeneous; otherwise, the fixed-effect model would be selected. Ten randomized clinical trials with a total of 934 randomized patients were included. Patients in the non-surgical group underwent higher re-ruptures than patients in the surgical group (p = .0002), but the re-rupture rates were equivalent in the non-surgical group and the surgical group (p = .08) if an early range of motion exercises protocol was performed. Lower incidence of complications excluding re-rupture was found in non-surgical patients (p = .006). However, the surgical group had better results in functional outcomes when evaluated by 2 different jump tests (drop counter-movement jump [p = .002], Hopping [p = .004]) and 1 muscular endurance test (Heel-rise work [p = .01]). The 2 groups had no significant difference in the proportion of patients returning to previous levels of sporting activities (p = 0.87). The risk of re-rupture after surgical or non-surgical treatment was equivalent if a functional rehabilitation protocol with early range of motion was performed, but the risk of other complications happening after surgical treatment was higher than in non-surgical treatment.

Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis

OBJECTIVES

To compare re-rupture rate, complication rate, and functional outcome after operative versus nonoperative treatment of Achilles tendon ruptures; to compare re-rupture rate after early and late full weight bearing; to evaluate re-rupture rate after functional rehabilitation with early range of motion; and to compare effect estimates from randomised controlled trials and observational studies.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed/Medline, Embase, CENTRAL, and CINAHL databases were last searched on 25 April 2018 for studies comparing operative versus nonoperative treatment of Achilles tendon ruptures.

STUDY SELECTION CRITERIA

Randomised controlled trials and observational studies reporting on comparison of operative versus nonoperative treatment of acute Achilles tendon ruptures.

DATA EXTRACTION

Data extraction was performed independently in pairs, by four reviewers, with the use of a predefined data extraction file. Outcomes were pooled using random effects models and presented as risk difference, risk ratio, or mean difference, with 95% confidence interval.

RESULTS

29 studies were included-10 randomised controlled trials and 19 observational studies. The 10 trials included 944 (6%) patients, and the 19 observational studies included 14 918 (94%) patients. A significant reduction in re-ruptures was seen after operative treatment (2.3%) compared with nonoperative treatment (3.9%) (risk difference 1.6%; risk ratio 0.43, 95% confidence interval 0.31 to 0.60; P<0.001; I²=22%). Operative treatment resulted in a significantly higher complication rate than nonoperative treatment (4.9% v 1.6%; risk difference 3.3%; risk ratio 2.76, 1.84 to 4.13; P<0.001; I²=45%). The main difference in complication rate was attributable to the incidence of infection (2.8%) in the operative group. A similar reduction in re-rupture rate in favour of operative treatment was seen after both early and late full weight bearing. No significant difference in re-rupture rate was seen between operative and nonoperative treatment in studies that used accelerated functional rehabilitation with early range of motion (risk ratio 0.60, 0.26 to 1.37; P=0.23; I²=0%). No difference in effect estimates was seen between randomised controlled trials and observational studies.

CONCLUSIONS

This meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.

Outcomes of Limited Open Achilles Repair Using Modified Ring Forceps

Background

The optimal treatment of acute Achilles tendon ruptures remains controversial. When surgical repair is undertaken, the reported rate of infections and wound-healing complications ranges from 2% to 5%. Meta-analyses have demonstrated that minimally invasive approaches have equivalent rerupture rates, a significantly lower risk of superficial infections, and higher patient satisfaction rates compared with traditional open Achilles repair techniques.

Purpose

To review the clinical outcomes of acute, limited open Achilles tendon repair using modified ring forceps and to analyze functional results using foot and ankle-specific outcome measures.

Study Design

Case series; Level of evidence, 4.

Methods

The clinical records of 32 consecutive patients (mean age, 44 years) with 33 acute Achilles tendon ruptures were retrospectively reviewed. All patients underwent limited open repair with modified ring forceps through a 2- to 3-cm midline incision. Suture placement into the tendon stumps was guided using a pair of ring forceps bent 30°. Three No. 2 nonabsorbable sutures were placed in the proximal and distal segments, the tendon ends were reapproximated, and the sutures were tied to secure the tendon. Outcomes from a 10-cm visual analog scale (VAS), the Foot and Ankle Ability Measure (FAAM), and the Victorian Institute of Sport Assessment-Achilles (VISA-A) were assessed.

Results

At final follow-up (mean, 42.1 months [range, 6-90 months]), 31 of 32 patients (33 Achilles tendons) reported no pain in their Achilles, with a mean Achilles VAS score of 0.7 ± 4.2 of 100. The mean postoperative VISA-A score was 82.3 ± 19.5 of 100. The mean FAAM activities of daily living and sports subscores were 96.5% ± 5.2% and 85.1% ± 21.2%, respectively. Regarding current functional level, 19 of 33 tendons (57.6%) were rated as "normal," 10 (30.3%) as "nearly normal," and 4 (12.1%) as "abnormal"; none were rated as "severely abnormal." There was 1 case (3.0%) of a superficial infection; there were no cases of deep infections, sural neuritis, or reruptures. The cost of the modified ring forceps technique is 5.3 to 12.1 times less than commercially available devices.

Conclusion

Limited open Achilles repair with modified ring forceps provides an economical repair with excellent pain relief, favorable functional outcomes, and a very low complication rate at midterm follow-up.

Ultrasonographic Evaluation of the Early Healing Process After Achilles Tendon Repair

Background:

Little is known about early healing of repaired Achilles tendons on imaging, particularly up to 6 months postoperatively, when patients generally return to participation in sports.

Purpose:

To examine changes in repaired Achilles tendon healing with ultrasonography for up to 12 months after surgery.

Study Design:

Case series; Level of evidence, 4.

Methods:

Ultrasonographic images of 26 ruptured Achilles tendons were analyzed at 1, 2, 3, 4, 6, and 12 months after primary repair. The cross-sectional areas (CSAs) and intratendinous morphology of the repaired tendons were evaluated using the authors’ own grading system (tendon repair scores), which assessed the anechoic tendon defect area, intratendinous hyperechoic area, continuity of intratendinous fibrillar appearance, and paratendinous edema.

Results:

The mean ratios (%) of the CSA for the affected versus unaffected side of repaired Achilles tendons gradually increased postoperatively, reached a maximum (632%) at 6 months, and then decreased at 12 months. The mean tendon repair scores increased over time and reached a plateau at 6 months.

Conclusion:

Ultrasonography is useful to observe the intratendinous morphology of repaired Achilles tendons and to provide useful information for patients who wish to return to sports. Clinical parameters such as strength, functional performance, and quality of healed repaired tendons should also be assessed before allowing patients to return to sports.

A new less invasive surgical technique in the management of acute Achilles tendon rupture through limited-open procedure combined with a single-anchor and "circuit" suture technique

Background

Traditional incision repair and minimally invasive repair for acute Achilles tendon repair have limitations. This study aimed to present our series of 23 patients with acute Achilles tendon rupture that was repaired using two small incisions to assist the anchor repair of the tear and a new “circuit” suture technique.

Methods

This was a retrospective study of 23 patients with acute Achilles tendon rupture treated with the new technique at Changhai Hospital between January 2015 and December 2016 and followed up for 14–33 months. Clinical outcome was assessed using the AOFAS, Leppilahti, and Arner-Lindholm scores. Complications, range of motion (ROM), and time to return to work and light sport activity were assessed.

Results

The AOFAS score was 85–96 at 3 months and 92–100 at 12 months. The 3-month ROM was 27°–37°, and the 12-month ROM was 36°–48°. The Leppilahti score was 85–95 at 3 months and 90–100 at 12 months. The recovery time of the patients was 10–18 weeks. The postoperative recovery time to exercise was 16–24 weeks. There was only one case of deep venous thrombosis. According to the Arner-Lindholm assessment criteria, patient outcomes were rated as excellent in 20 (87.0%) cases, good in three (13.0%) cases, and poor in 0 cases. The excellent-to-good rate was 100%.

Conclusion

The limited-open procedure combined with a single-anchor and “circuit” suture technique could be used to repair torn Achilles sites, with a low occurrence of complications. This new and minimally invasive technique could be an alternative in the management of acute Achilles tendon rupture.

Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Acute Achilles tendon ruptures can be treated with surgical and nonsurgical treatment. However, the optimal intervention for acute Achilles tendon rupture remains controversial. The aim of the present study was to compare the clinical outcomes of surgical treatment versus conservative management for acute Achilles tendon rupture. Eight randomized controlled studies involving 762 patients were included in the meta-analysis. In general, re-rupture occurred in 14 of 381 surgically treated patients (3.7%) and 37 of 377 nonsurgically treated patients (9.8%). Pooled results showed that the total re-rupture rate was significantly lower in surgical group than that in the nonsurgical group (risk ratio 0.38, 95% confidence interval 0.21 to 0.68; p = .001). No significant differences were found between the 2 treatment groups in the incidence of deep venous thrombosis, the number who returned to sport, ankle range of motion (dorsiflexion, plantarflexion), Achilles tendon total rupture score, or physical activity scale. Surgical treatment can effectively reduce the re-rupture rate and might be a better choice for the treatment of acute Achilles tendon rupture. Multicenter, double-blind randomized controlled trials with stratification and long-term follow-up are needed to obtain a higher level of evidence and to guide clinical practice, especially in the comparison and selection of different treatments.

Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures

PURPOSE

An Achilles tendon rupture is a common injury that typically affects people in the middle of their working lives. The injury has a negative impact in terms of both morbidity for the individual and the risk of substantial sick leave. The aim of this study was to investigate the cost-effectiveness of surgical compared with non-surgical management in patients with an acute Achilles tendon rupture.

METHODS

One hundred patients (86 men, 14 women; mean age, 40 years) with an acute Achilles tendon rupture were randomised (1:1) to either surgical treatment or non-surgical treatment, both with an accelerated rehabilitation protocol (surgical n = 49, non-surgical n = 51). One of the surgical patients was excluded due to a partial re-rupture and five surgical patients were lost to the 1-year economic follow-up. One patient was excluded due to incorrect inclusion and one was lost to the 1-year follow-up in the non-surgical group. The cost was divided into direct and indirect costs. The direct cost is the actual cost of health care, whereas the indirect cost is the production loss related to the impact of the patient's injury in terms of lost ability to work. The health benefits were assessed using quality-adjusted life years (QALYs). Sampling uncertainty was assessed by means of non-parametric boot-strapping.

RESULTS

Pre-injury, the groups were comparable in terms of demographic data and health-related quality of life (HRQoL). The mean cost of surgical management was €7332 compared with €6008 for non-surgical management (p = 0.024). The mean number of QALYs during the 1-year time period was 0.89 and 0.86 in the surgical and non-surgical groups respectively. The (incremental) cost-effectiveness ratio was €45,855. Based on bootstrapping, the cost-effectiveness acceptability curve shows that the surgical treatment is 57% likely to be cost-effective at a threshold value of €50,000 per QALY.

CONCLUSIONS

Surgical treatment was more expensive compared with non-surgical management. The cost-effectiveness results give a weak support (57% likelihood) for the surgical treatment to be cost-effective at a willingness to pay per QALY threshold of €50,000. This is support for surgical treatment; however, additionally cost-effectiveness studies alongside RCTs are important to clarify which treatment option is preferred from a cost-effectiveness perspective.

LEVEL OF EVIDENCE

I.

Functional Outcome of Acute Achilles Tendon Rupture With and Without Operative Treatment Using Identical Functional Bracing Protocol

BACKGROUND

The purpose of this study was to compare the functional results of operative and nonoperative treatment of acute Achilles tendon rupture using an identical rehabilitation program of functional bracing.

METHODS

Over a 10-year period, 200 patients (99 operative, 101 nonoperative) aged between 18 and 65 years were treated at our institution's physiotherapy department after acute Achilles tendon rupture. There were 132 patients (62 operative, 70 nonoperative) available for a minimum 2-year follow-up (average 6.5 years; range, 2-13 years). Functional outcome was assessed using the Achilles tendon total rupture score (ATRS).

RESULTS

With the numbers available, no significant difference could be detected in ATRS between operative (mean 84.8, median 90) and nonoperative groups (mean 85.3, median 91; P = 0.55). No significant difference could be detected in ATRS between male and female patients however treated ( P = 0.30) or between patients younger and older than 40 years at time of injury ( P = 0.68). There was no correlation between ATRS score and age at injury in all patients (ρ = -0.0168, P = 0.85). In male patients, there was a weak trend with older patients at follow-up having better scores (ρ = 0.21, P = 0.069). However, among female patients, there was a significant negative correlation between ATRS scores and increasing age (ρ = -0.29, P = 0.03). Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS.

CONCLUSIONS

This study showed no significant difference detectable in ATRS between operative and nonoperative patients in the treatment of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

MR Imaging of the Achilles Tendon after Surgical Repair

Achilles tendon tear is common and increasingly frequent. Magnetic resonance imaging (MRI) is the modality of choice for radiological evaluation. It is accurate to assess the status and integrity of the tendon with well documented features. In this article, the MR findings of a normal Achilles tendon as well as common diseases like insertional and noninsertional tendinosis, chronic tendinosis with marked lengthening, tendon rupture are illustrated. After a torn Achilles tendon receives surgical repair, it undergoes different stages of healing process including inflammatory, reparative and remodeling phases. Acute scar tissue in the surgical bed may share similar MR features of tendon re-rupture especially in the early healing phase because both are T2W hyperintense. The size of the gap may even appear larger than expected on T2W images possibly due to tendon remodeling. Understanding of the healing process in post-operative period may prevent overestimation of tendon gap and misdiagnosis of re-tear. We describe the MR features of the post-operative changes with serial studies in different months after surgery. The MR findings with the highlights of the expected sequential changes in normal healing process are illustrated in different cases. A case with surgical repair on a partial tear of Achilles tendon is also included.

Early rehabilitation after open repair for patients with a rupture of the Achilles tendon

PURPOSE

As outdoor activities participation increase, Achilles tendon rupture incidence also tends to increase. There are a number of treatment and rehabilitation options for a ruptured Achilles tendon. However, the optimal rehabilitation protocols are still under debate. The purpose of this study is to determine whether early rehabilitation is more effective than conventional rehabilitation.

METHODS

Medical records of 56 patients who had been treated with open repair after a ruptured Achilles tendon were retrospectively reviewed. 24 patients were treated postoperatively with below knee cast immobilization for four weeks, and they started tolerable weight-bearing rehabilitation at four weeks' follow-up. The remaining 32 patients were managed postoperatively with short leg splint immobilization for two weeks and started the tolerable weight-bearing at two weeks' follow-up. We evaluated the patients several times to identify when the single heel raise was possible and measured the American Orthopedic Foot and Ankle Society (AOFAS) scores and Achilles tendon total rupture scores (ATRS) as a functional outcome.

RESULTS

The single heel raise test was positive in all patients at the last assessment. But there were no statistically significant differences between the groups (p=0.137). The patients in the Cast group took significantly more time to return to work than did the patients in the Splint group (p=0.032). And AOFAS scores and ATRS were slightly higher in the Splint group than in the Cast group. There were statistically significant differences (p=0.042, p=0.028) between the two groups.

CONCLUSION

The early rehabilitation did not lead to greater endurance, but it showed better results in the return to work and the Achilles functional score. Early rehabilitation after open repair for patients with a ruptured Achilles tendon is helpful for functional recovery. Type of study / Level of evidence: Therapeutic, Level III.

Acute Rupture Open Repair Techniques

Achilles tendon injuries can be serious injuries requiring either operative or nonoperative management. For appropriate surgical candidates, operative intervention may provide lower rerupture rates and adequate end-to-end tendon healing. Our preference is an open Achilles tendon repair, specifically a limited open technique using the PARS device (Arthrex, Naples, FL). Postoperatively, we use functional rehabilitation and early range of motion. Although the current literature remains controversial regarding operative versus nonoperative management, the authors have obtained satisfactory results in appropriately chosen surgical candidates.

Interlocking horizontal mattress suture versus Kakiuchi technique in repair of Achilles tendon rupture: a biomechanical study

BACKGROUND

In recent years, the type of surgical treatment for Achilles tendon rupture has been the subject of controversial debate. This biomechanical study evaluates for the first time in literature the ultimate failure load (UFL) of interlocking horizontal mattress (IHM) suture as compared with Kakiuchi suture in Achilles tendon rupture. The hypothesis is that IHM suture can be performed also for Achilles tendon rupture and ensures higher resistance compared with the traditional Kakiuchi suture.

MATERIALS AND METHODS

Twenty fresh bovine Achilles tendons were obtained. Ten preparations were randomly assigned to each of two different groups: group A (10 specimens) sutured by IHM technique, and group B (10 specimens) sutured by Kakiuchi technique. Each construct was mounted and fixed on a tensile testing machine. Static preconditioning of 50 N was applied for 5 min as initial tensioning to stabilize the mechanical properties of the graft, then a load to failure test was performed at crosshead speed of 500 mm/min.

RESULTS

Ten specimens were tested for each group. The mean UFL was 228.6 ± 98.6 N in the IHM suture group and 96.57 ± 80.1 N in the Kakiuchi suture group. Statistical analysis showed a significant difference (p < 0.05) with better UFL in the IHM group. In both groups, the failure mode registered in each specimen was suture breakage (rupture of suture thread).

CONCLUSIONS

IHM suture achieved better UFL compared with Kakiuchi suture in an animal model of Achilles tendon repair. These results seem to support IHM as a valid option in Achilles tendon rupture.

Achilles tendon injuries

PURPOSE OF REVIEW

The purpose of this study is to review the current literature of Achilles tendon injuries, specifically chronic tendinopathy and acute ruptures in regard to etiology, diagnosis, treatment options, and outcomes.

RECENT FINDINGS

The incidence of Achilles tendon injuries is increasing, but the necessity for surgical intervention is decreasing due to improved conservative therapies, which may provide comparable outcomes without the implied surgical risk. If surgery is undertaken, no difference has been noted between open and minimally invasive techniques. The majority of patients are able to return to pre-injury level of activity, with the elite athlete as an unfortunate exception. Achilles injuries can be devastating injuries, but if addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality implemented. Further research is needed into the etiology, potential preventative measures, and longer-term outcomes of the different treatment options for wide range of Achilles pathology.

Quantitative US Elastography Can Be Used to Quantify Mechanical and Histologic Tendon Healing in a Rabbit Model of Achilles Tendon Transection

Purpose To determine the time-dependent change in strain ratios (SRs) at the healing site of an Achilles tendon rupture in a rabbit model of tendon transection and to assess the correlation between SRs and the mechanical and histologic properties of the healing tissue. Materials and Methods Experimental methods were approved by the institutional animal care and use committee. The Achilles tendons of 24 New Zealand white rabbits (48 limbs) were surgically transected. The SRs of Achilles tendons were calculated by using compression-based quantitative ultrasonographic elastography measurements obtained 2, 4, 8, and 12 weeks after transection. After in vivo elastography, the left Achilles tendon was harvested for mechanical testing of ultimate load, ultimate stress, elastic modulus, and linear stiffness, and the right tendons were harvested for tissue histologic analysis with the Bonar scale. Time-dependent changes in SRs, mechanical parameters, and Bonar scale scores were evaluated by using repeated-measures analysis of variance. The correlation between SRs and each measured variable was evaluated by using the Spearman rank correlation coefficient. Results Mean SRs and Bonar scale values decreased as a function of time after transection, whereas mechanical parameters increased (P < .001). SR correlated with ultimate stress (ρ = 0.68, P <.001,) elastic modulus (ρ = 0.74, P <.001), and the Bonar scale (ρ = 0.87, P <.001). Conclusion Quantitative elastography could be a useful method with which to evaluate mechanical and histologic properties of the healing tendon. ^© RSNA, 2017 Online supplemental material is available for this article.

Comparison of the early period effects of bone marrow-derived mesenchymal stem cells and platelet-rich plasma on the Achilles tendon ruptures in rats

INTRODUCTION

This study aims to histopathologically, biomechanically, and immunohistochemically compare the fourth-week efficiencies of local platelet-rich plasma (PRP) and bone marrow-derived mesenchymal stem cell (rBM-MSC) treatments of the Achilles tendon ruptures created surgically in rats.

MATERIALS AND METHODS

The study included 35 12-month-old male Sprague Dawley rats, with an average weight of 400-500 g. Five rats were used as donors for MSC and PRP, and 30 rats were separated into MSC, PRP, and control groups (n = 10). The Achilles tendons of the rats were cut transversely, the MSC from bone marrow was administered to the MSC group, the PRP group received PRP, and the control group received physiological saline to create the same surgical effect. In previous studies, it was shown that this physiological saline does not have any effect on tendon recovery. Thirty days after the treatment, the rats were sacrificed and their Achilles tendons were examined histopathologically, immunohistochemically, and biomechanically.

RESULTS

The use of rBM-MSC and PRP in the Achilles tendon ruptures when the tendon is in its weakest phase positively affected the recovery of the tendon in histopathologic, immunohistochemical, and biomechanical manners compared to the control group (p < 0.05). While the levels of pro-inflammatory cytokines TNF-α, IFNγ, and IL 1β were significantly low, the levels of anti-inflammatory cytokines and growth factors playing key roles in tendon recovery, such as IL2, VEGF, transforming growth factor-beta, and HGF, were significantly higher in the MSC group than those of the PRP and control groups (p < 0.05). In the MSC group, the [Formula: see text] (mm) value was significantly higher (p ˂ 0.05) than that in the PRP and control groups.

CONCLUSION

rBM-MSC and PRP promote the recovery of the tendon and increase its structural strength. The use of PRP and MSC provides hope for the treatment of the Achilles tendon ruptures that limit human beings' functionalities and quality of life, particularly for athletes. It is thought that the use of MSC can be more effective for tendon healing; hence, more extensive and advanced studies are needed on this topic.

Achilles Tendon Open Repair Augmented With Distal Turndown Tendon Flap and Posterior Crural Fasciotomy

The aim of the present study was to investigate the outcomes after open repair of Achilles tendon rupture augmented with a distal turndown gastrocnemius flap and deep posterior crural fasciotomy based on the modified Lindholm technique. Twenty-three patients with acute Achilles tendon injury underwent open end-to-end tendon repair augmented with a distal turndown gastrocnemius flap and deep posterior compartment fasciotomy. The concentric and eccentric muscle strength was measured using a functional squat system, and dynamic balance was assessed using the Y-balance test with anterior, posteromedial, and posterolateral reach distances. Jump performance was assessed using the vertical jump and 1-leg hop tests. All patients returned to their preinjury activity level, and their mean American Orthopaedic Foot and Ankle Society hindfoot scale score was 98.2 ± 2.3 after surgery. No significant difference was found between the involved and uninvolved extremities in terms of concentric and eccentric muscle strength (p = .82 and p = .53, respectively). In addition, no significant differences were seen between legs in the vertical jump (p = .16), one-leg hop (p = .15), and balance (p > .05) tests. Open end-to-end repair of the Achilles tendon rupture with augmentation and fasciotomy of the deep posterior compartment healed without any major complications. Functional performance of the involved leg after recovery was similar to that of the uninvolved leg. The modified Lindholm surgical technique described in our report appears to be a useful intervention for acute Achilles tendon rupture.

Using a Posterior Compartment Fasciotomy and Paratenon Closure in Acute Achilles Tendon Repair

Soft tissue management, dissection, and handling are of paramount importance during Achilles tendon repair. Although surgical repairs of Achilles tendons have predictably excellent outcomes, complications including wound infection and stiffness are not uncommon. The authors' surgical technique for Achilles tendon repair includes tagging the posterior paratenon for later layered repair and incising the posterior fascia, exposing the flexor hallucis longus muscle belly. This posterior compartment fasciotomy allows for both hematoma evacuation away from the tenuous posterior skin and mobilization of the posterior paratendon for complete closure over the repaired Achilles tendon. With this modified technique, the authors report a 1% infection rate and a 1% failure rate. [Orthopedics. 2016; 39(4):e790-e793.].

Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play

AIM

This systematic review and meta-analysis sought to identify return to play (RTP) rates following Achilles tendon rupture and evaluate what measures are used to determine RTP.

DESIGN

A systematic review and meta-analysis were performed. Studies were assessed for risk of bias and grouped based on repeatability of their measure of RTP determination.

DATA SOURCES

PubMed, CINAHL, Web of Science and Scopus databases were searched to identify potentially relevant articles.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies reporting RTP/sport/sport activity in acute, closed Achilles tendon rupture were included.

RESULTS

108 studies encompassing 6506 patients were included for review. 85 studies included a measure for determining RTP. The rate of RTP in all studies was 80% (95% CI 75% to 85%). Studies with measures describing determination of RTP reported lower rates than studies without metrics described, with rates being significantly different between groups (p<0.001).

CONCLUSIONS

80 per cent of patients returned to play following Achilles tendon rupture; however, the RTP rates are dependent on the quality of the method used to measure RTP. To further understand RTP after Achilles tendon rupture, a standardised, reliable and valid method is required.

Functional rehabilitation of patients with acute Achilles tendon rupture: a meta-analysis of current evidence

PURPOSE

The optimal treatment for acute Achilles tendon rupture (ATR) is continuously debated. Recent studies have proposed that the choice of either operative or non-operative treatment may not be as important as rehabilitation, suggesting that functional rehabilitation should be preferred over traditional immobilization. The purpose of this meta-analysis of randomized controlled trials (RCTs) was to compare functional rehabilitation to immobilization in the treatment of ATR.

METHOD

This meta-analysis was conducted using the databases: PubMed, EMBASE, Rehabilitation and Sports Medicine Source, AMED, CINAHL, Cochrane Library and PEDro using the search terms: "Achilles tendon," "rupture," "mobilization" and "immobilization". Seven RCTs involving 427 participants were eligible for inclusion, with a total of 211 participants treated with functional rehabilitation and 216 treated with immobilization.

RESULTS

Re-rupture rate, other complications, strength, range of motion, duration of sick leave, return to sport and patient satisfaction were examined. There were no statistically significant differences between groups. A trend favoring functional rehabilitation was seen regarding the examined outcomes.

CONCLUSION

Functional rehabilitation after acute Achilles tendon rupture does not increase the rate of re-rupture or other complications. A trend toward earlier return to work and sport, and increased patient satisfaction was found when functional rehabilitation was used. The present literature is of low-to-average quality, and the basic constructs of the examined treatment and study protocols vary considerably. Larger, randomized controlled trials using validated outcome measures are needed to confirm the findings.

LEVEL OF EVIDENCE

II.

Percutaneous repair followed by accelerated rehabilitation for acute Achilles tendon ruptures

PURPOSE

To evaluate the outcome after percutaneous repair followed by accelerated rehabilitation for acute Achilles tendon ruptures.

METHODS

21 men and 9 women (mean age, 41 years) underwent percutaneous repair by a single senior surgeon for acute Achilles tendon ruptures, followed by early weight bearing and accelerated rehabilitation. Outcome measures included the Achilles tendon re-rupture rate, the Achilles tendon total rupture score (ATRS) at 3 and 6 months, the incidence of sural nerve injury, wound infection, wound dehiscence, patient satisfaction, and the time to return to pre-rupture activity.

RESULTS

The mean follow-up period was 12.5 months. The mean ATRS score improved from 57.65 at 3 months to 86.95 at 6 months (p<0.001). No patient had intra-operative complications, tendon re-rupture, sural nerve injury, wound dehiscence, or deep infection. Two patients developed a superficial wound infection, which was resolved with oral flucloxacillin. Two patients had a mass at the transverse incision, but neither had any symptoms or functional restriction. All patients were able to bear full weight comfortably without the walker boot at 8 weeks, and return to their work by 3 months. The mean time to return to pre-rupture activity, including sports, was 10.4 months. The mean satisfaction rate was 87% at 6 months.

CONCLUSION

Percutaneous repair of the Achilles tendon followed by early weight bearing and accelerated rehabilitation achieves good functional outcome.

Validation of a novel ultrasound measurement of achilles tendon length

PURPOSE

A clinically applicable and accurate method for measuring Achilles tendon length is needed to investigate the influence of elongation of the Achilles tendon after acute rupture. The purpose of this study was to develop and validate an ultrasonographic (US) length measurement of the Achilles tendon-aponeurosis complex.

METHODS

Both legs of 19 non-injured subjects were examined by magnetic resonance imaging (MRI) and US. The length from calcaneus to the medial head of m. Gastrocnemius was measured by three independent US examiners. Repeated US measurements were performed and compared to MRI measurements. Intra-rater and inter-rater reliability and the agreement between MRI and US were determined. Data were evaluated using the intraclass correlation coefficient (ICC), the standard error of the measurement (SEM) and the minimal detectable change (MDC).

RESULTS

Intra-rater reliability of US assessment showed no significant differences between test days: ICC 0.96, SEM 4 mm and MDC 10 mm. Inter-rater reliability showed a systematic difference between US observers of 2-5 mm (p = 0.001-0.036); ICC 0.97, SEM 3 mm and MDC 9 mm. MRI measurements were on average 4 mm longer than US (p = 0.001).

CONCLUSION

The novel ultrasound measurement showed good reliability and accuracy. For comparison between groups of non-injured subjects differences of more than 4 mm can be detected. For repeated assessment of individual subjects differences of more than 10 mm can be detected. The measurement needs to be further assessed in the setting of acute Achilles tendon rupture.

CLINICAL RELEVANCE

This new ultrasound measurement might allow for length measurement of ruptured Achilles tendons in the acute and chronic state after rupture.

LEVEL OF EVIDENCE

II.

Sex Differences in Outcome After an Acute Achilles Tendon Rupture

Background:

Tendon healing differs between the sexes. Comparisons in outcome between the sexes after an Achilles tendon rupture are often not possible because of the small cohort (<20%) of women.

Purpose:

To evaluate whether there are any differences in outcome between the sexes by combining the data from 2 large randomized controlled trials that used identical outcome measures.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included in the evaluation were patients from 2 consecutive randomized controlled trials comparing surgical and nonsurgical treatment performed at our research laboratory. Patients who had a rerupture were excluded from analysis. A total of 182 patients (152 males, 30 females), with mean ± SD age of 40 ± 11 years, were included; 94 (76 males, 18 females) were treated with surgery and 88 (76 males, 12 females) nonsurgically. Patient-reported outcome was evaluated using the Achilles tendon Total Rupture Score (ATRS), and the functional outcome was measured with a heel-rise test (measurement of muscular endurance and heel-rise height) at 6 and 12 months after injury.

Results:

Male patients had a greater improvement in heel-rise height at 12 months (P = .004). When each treatment group was analyzed separately, it was found that female patients had significantly (P < .03) more symptoms after surgical treatment (mean ± SD ATRS, 59 ± 24) compared with males at 6 (73 ± 19) and 12 months (74 ± 27 vs 86.5 ± 17). This sex difference was not found in the nonsurgical treatment group. For the entire group, there were no significant differences between treatments on ATRS at 6 and 12 months. The surgical group had significantly better results compared with the nonsurgical group in heel-rise endurance at 6 and 12 months and in heel-rise height recovery at 6 months (P < .03 for both).

Conclusion:

Sex differences were demonstrated, and female patients had a greater degree of deficit in heel-rise height as compared with males, irrespective of treatment. Females had more symptoms after surgery both at 6 and 12 months, but this difference was not found when treated nonsurgically.

Clinical Relevance:

Further research is needed to determine whether women will benefit more from nonsurgical compared with surgical treatment after an Achilles tendon rupture.

Long-term biomechanical outcomes after Achilles tendon ruptures

PURPOSE

The ideal treatment for Achilles tendon ruptures is still unknown. Biomechanical were correlated to radiological and clinical parameters to study outcomes.

METHODS

In this retrospective, assessor-blinded multi-centre cohort study, 52 patients with unilateral Achilles tendon rupture were assessed, each at least 3 years after injury. Patients underwent open surgery, percutaneous surgery or non-surgical treatment of Achilles tendon rupture. Both legs underwent plantar pressure distribution and isokinetic measures. Demographic parameters, maximum calf circumference (MCC) and clinical scores (American Orthopaedic Foot and Ankle Society, Achilles tendon rupture score, Hannover) were also evaluated. Complications were not assessed.

RESULTS

Peak plantar flexion torque (PPFT) was significantly weaker on the treated side compared to the untreated leg [80.4 ± 29.7 Nm (mean ± SD) vs. 92.1 ± 27.4 Nm, p < 0.0001]. PPFT and push-off force (POFF) were not different between treatment groups nor was there a leg difference in POFF alone. There was only a weak correlation of clinical scores and PPFT or POFF, respectively. MCC correlated significantly with both PPFT (R (2) = 0.21, p = 0.01) and POFF (R (2) = 0.29, p < 0.0001). POFF appeared to be a predictor of PPFT (R (2) = 0.31, p < 0.0001). Open surgery outperformed non-surgical treatment in terms of centre-of-pressure line (p = 0.007), torque per muscle volume (p = 0.04) and relative POFF per body weight (p = 0.02) and relative in side comparison (p = 0.03).

CONCLUSIONS

Clinical scores do not predict biomechanical outcomes. Clinically measured MCC is a good predictor of PPFT and POFF and can easily be used in clinical practice. Relative POFF in side comparison as well as per body weight favours surgical treatment.