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Achilles tendon rupture

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  #61  
Old 28th January 2012, 04:19 PM
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Default Re: Achilles tendon rupture

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Pre- and Post-Injury Running Analysis Along With Measurements of Strength and Tendon Length in a Patient With a Surgically Repaired Achilles Tendon Rupture.
Grävare Silbernagel K, Willy RW, Davis IS.
J Orthop Sports Phys Ther. 2012 Jan 25

Quote:
STUDY DESIGN:
Case report.

BACKGROUND:
The Achilles tendon is the most frequently ruptured tendon, with the incidence increasing in the last decades. The rupture generally occurs without any preceding warning signs and therefore pre-injury data are seldom available. This case represents a unique opportunity to compare pre-injury running mechanics with post-injury evaluation in a patient with an Achilles tendon rupture.

CASE DESCRIPTION:
A 23-year-old female sustained a right total Achilles tendon rupture while playing soccer. Running mechanics data were collected pre-injury, as she was a healthy participant in a study on running analysis. In addition, patient reported symptoms, physical activity level, strength, ankle range of motion, heel-rise ability, Achilles tendon length, and running kinetics were evaluated 1 year after surgical repair.

OUTCOMES:
During running greater ankle dorsiflexion and eversion and rearfoot abduction were noted on the involved side post injury when compared to pre-injury data. In addition, post-injury, the magnitude of all kinetics data were lower on the involved limb when compared to the uninvolved limb. The involved side displayed differences in strength, ankle range of motion, heel-rise, and tendon length when compared to the uninvolved side 1 year after injury.

DISCUSSION:
Despite a return to normal running routine and reports of only minor limitations with running, considerable changes were noted in running biomechanics 1 year after injury. Calf muscle weakness and Achilles tendon elongation were also found when comparing the involved and uninvolved side
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  #62  
Old 3rd February 2012, 04:05 PM
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Default Re: Achilles tendon rupture

Open repair of the acutely torn Achilles tendon under local anaesthetic.
Macquet AJ, Christensen RJ, Debenham M, Wyatt M, Panting AL.
ANZ J Surg. 2011 Sep;81(9):619-23.
Quote:
BACKGROUND:
Where surgery has been preferred, the torn Achilles tendon (AT) has most commonly been repaired under general or spinal anaesthetic (GA). Repair using local anaesthetic (LA) has been reported, but does not appear to be widely used.

METHODS:
We retrospectively reviewed 87 patients, following open repair using either GA or LA at Nelson Hospital, 2001–2005. Calf strength and ankle range of motion (ROM) were assessed. Subjective pain and function were assessed using the American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire. Complications, time off work and sport, time in theatre, and hospital were recorded.

RESULTS:
Fifty-nine tendons were repaired under GA (68%) and 28 under LA (32%). Outcomes were similar for each group. There was no significant difference in strength and ROM. Foot and Ankle Questionnaire scores were similar. Total theatre time averaged 57 min for GA and 37 min for LA (P = 0.01). LA repairs (82%) were performed as a day case compared with 10% of the GA repairs (P = 0.01). LA patients had a quicker return to work. GA complications included two deep vein thromboses and two pulmonary emboli. One patient from each group had a re-rupture.

CONCLUSION:
A repair of the acutely ruptured AT under LA is at least as effective as repair under GA with regard to function, long-term pain and patient satisfaction. LA repair results in significant cost savings due to less theatre time, fewer anaesthetic costs, and a shorter hospital stay.
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  #63  
Old 9th February 2012, 02:52 PM
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Default Re: Achilles tendon rupture

Surgical reconstruction of chronic achilles tendon ruptures using various methods.
Park YS, Sung KS.
Orthopedics. 2012 Feb 17;35(2)
Quote:
The purpose of this study was to evaluate the surgical outcomes of reconstruction of chronic Achilles tendon ruptures using various methods, including Achilles tendon allograft. Between October 2003 and March 2010, twelve patients with chronic Achilles tendon ruptures and a defect gap of >4 cm underwent surgical reconstruction with V-Y advancement, gastrocnemius fascial turn-down flap, flexor hallucis longus tendon transfer, or Achilles tendon allograft. The study group comprised 11 men and 1 woman. At last follow-up, all patients were assessed with regard to postoperative complications, self-reported level of satisfaction, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score, repetitive single-heel rises, single-leg hopping test, and ankle range of motion.The AOFAS scores increased from an average of 68.7 (range, 50-87) preoperatively to 98.0 (range, 88-100) postoperatively. All patients were able to perform 10 repetitive single-heel raises and single-leg hops at last follow-up. No patient experienced wound complications or deep infection. Seven patients were rated as excellent, 4 as good, and 1 as fair.Chronic Achilles tendon ruptures can be successfully treated by careful selection of the reconstruction method according to the length of defect gap and state of the remaining tissue. With an extensive defect, use of an Achilles tendon allograft can be a good option
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  #64  
Old 16th February 2012, 06:28 PM
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Default Re: Achilles tendon rupture

Weight Bearing in the Non Operative Treatment of Acute Achilles Tendon Ruptures: A Randomized Controlled Trial
Simon Young, Alpesh A. Patel, Matthew Tomlinson, Wesley P. Bevan, Peter McNair
Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.
Quote:
INTRODUCTION
Acute achilles tendon ruptures are increasing in incidence, however there remains a lack of consensus on the optimum treatment for acute ruptures. Randomized studies comparing operative versus non-operative treatment show operative treatment to have a significantly lower re-rupture rate, but these studies have generally used non-weight bearing casts in the non-operative group. Recent series utilizing more aggressive non-operative protocols with early weight-bearing have noted a far lower incidence of re-rupture, with rates approaching those of operative management. The purpose of this study was to compare outcomes of traditional casts versus Bohler-iron equipped weightbearing casts in the treatment of acute Achilles tendon ruptures.

METHODS
Eighty-three patients with acute Achilles tendon ruptures were recruited from three centers over a two-year period. Patients were randomized within one week of injury to receive either a weight-bearing cast with a Bohler iron or a traditional non weight-bearing cast. A set treatment protocol was used, with a total cast time of eight weeks. Patients underwent detailed muscle dynamometry testing at six months, with further follow up at one and two years. Primary outcomes assessed were patient satisfaction, time to return to work, and overall re-rupture rates. Secondary outcomes included return to sports, ankle pain and stiffness, footwear restrictions, and patient satisfaction.

RESULTS
There were no significant differences in patient demographics or activity levels prior to treatment. At follow up, one patient (2%) in the Bohler iron group and two patients (5%) in the non weight bearing group sustained re-ruptures (p=0.62). There was a trend toward an earlier return to work in the weight bearing group, with 58% versus 43% returning to work within four weeks, but the difference was not significant. A total of 63% of patients in the weight bearing group reported freedom from pain at 12 months compared to 51 % in the non weight bearing group. There were no statistically significant differences in Leppilahti scores, patient satisfaction, or return to sports between groups.

DISCUSSION AND CONCLUSION
Weight-bearing casts in the non-operative treatment of Achilles tendon ruptures appear to offer outcomes that are at least equivalent to outcomes of non-weight bearing casts. The overall re-rupture rate in this study is low, supporting the continued use of initial non-operative management in the treatment of acute ruptures.
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  #65  
Old 16th February 2012, 06:37 PM
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Default Re: Achilles tendon rupture

Clinical vs. MRI Diagnosis for Acute Achilles Tendon Ruptures: Stochastic Simulation of Economic Implications
Suneel B. Bhat, David N. Garras, Steven M. Raikin,
Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.
Quote:
INTRODUCTION
Acute rupture of the Achilles tendon is a relatively common traumatic condition with an increasing incidence. Diagnosis of acute Achilles tendon rupture may be effectively accomplished clinically or with magnetic resonance imaging (MRI) - each of these diagnostic modalities is associated with differing costs, however controversy remains as to which approach is most efficient. This study characterizes the economic implications of clinical and MRI diagnosis of Achilles tendon rupture at the population level.

METHODS
After Institutional Review Board approval, consecutive cases of Achilles tendon repair at a single institution between August 2000 and March 2010 were identified. Only patients with acute rupture who had both clinical and MRI evaluation were included. Patient records were retrospectively reviewed for intra-operative confirmation of rupture, clinical exam findings at initial evaluation (abnormal Thompson test, decreased/absent resting tension compared to uninjured side, and palpable defect), and demographic data. A unique stochastic decision tree model was developed based on testing parameters derived from our data, and age and sex specific incidence estimates from the literature. MRI reimbursement rates for ankle MRIs were obtained from the CMS Physician Fee Schedule, and estimates for private insurance reimbursements were back projected from these values. A modified Monte Carlo simulation was conducted with each diagnostic approach using identical theoretical populations of 100,000 patients over the age of five modeled from the 2008 U.S. Census Estimates. The simulation was iterated 10 times to achieve stable estimates, and the results analyzed.

RESULTS
Sixty-six patients were identified as having complete Achilles rupture intra-operatively - each of these patients demonstrated an abnormal Thompson test, decreased or absent comparative resting tension on the injured side, and a palpable defect. Using intra-operative confirmation of Achilles rupture as the gold standard, clinical diagnosis demonstrated 100% sensitivity for rupture; MRI diagnosis rates were assumed to be similarly accurate in this study. Our simulation model demonstrated 31,628 (95%CI 26,909 to 36,346) Achilles ruptures in the U.S. annually, or an aggregate incidence of 10.4/100,000. MRI diagnosis of these cases was associated with excess costs of $10,678.80 (95%CI $9,207.24 to $12,150.36) per 100,000, which represents an annual incremental cost excess in the U.S. of $32,475,603.35 (95%CI $28,000,397.35 to $36,950,809.34) relative to clinical diagnosis.

DISCUSSION AND CONCLUSION
In the context of clinical diagnosis as an effective and efficient means of identifying Achilles tendon rupture, use of MRI for diagnosis is redundant and accrues a significant unnecessary cost. Use of clinical indicators without MRI for diagnosis of Achilles tendon rupture would result in over $32 million of economic savings annually in the U.S.
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  #66  
Old 16th February 2012, 06:48 PM
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Default Re: Achilles tendon rupture

Jumping Capability in High-demand Athletes Surgically Treated for Acute Achilles Tendon Rupture
Antonio Vadala, MD, Raffaele Iorio, Angelo De Carli,
Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.
Quote:
INTRODUCTION
Achilles tendon ruptures are common among high-demand athletes. Operative treatment represents the favorite choice of orthopaedics in the treatment of this pathology. In this study we report the functional results of a group of 36 high-demand athletes surgically treated with a mini-open technique modified by Kakiuchi, with the aim to assess the effectiveness of such a technique by testing the clinical outcome through functional tests.

METHODS
Between 2000 and 2010, 36 high-demand athletes (34 males, two females) with age less than 40 years old with complete spontaneous Achilles tendon rupture were surgically treated with combined mini-open and percutaneous technique as described by Kakiuchi M. Achilles tendon ruptures occurred in all cases during sports activities (24 patients playing soccer, seven playing tennis, one skiing, one jogging, one during sailing, and two during rings in gymnastics). All patients were evaluated at a mean follow up of 46 months with an accurate physical examination, the VISA-A questionnaire and the Hannover scale. The jumping capacity of the patients was evaluated using the Ergo-Jump Bosco System. Patients were assessed with the aim of testing maximum strength (Squat Jump test), elasticity (Counter Movement test) and endurance (Ten Repetition Counter Movement test) of the repaired musculotendinous unit, in a side-to-side (S/S) evaluation.

RESULTS
At a mean follow up of 46 months, we registered no re-ruptures but minor complications such as late skin adhesions and wound healing delay in five patients (14%). The ROM (S/S) was complete in 33 patients (91.6%), while there was a loss of 5° in dorsal flexion in three patients. Thickness of the repaired tendon (S/S) was twice the contralateral in 34 patients (94%), more than twice in one patient (3%), and similar to the contralateral in the other one (3%). The jumping capacity of patients assessed using the Ergo-Jump Bosco System showed (S/S) a 1.3% mean deficit of the affected limb with the Squatting Jump test, a 2.2% mean deficit of the affected limb with the Counter Movement Jump test, and a +6% mean improvement of the involved side with the Repetitive jump test. Twenty-eight athletes (77.7%) returned to sports after a mean time of 2.8 months: 25 patients (69.4%) resumed the same sports activities and 24 patients (66.6%) returned to their same pre-injury level.

DISCUSSION AND CONCLUSION
The treatment of acute complete rupture of Achilles tendon in high-demand athletes always represents a challenge both for the surgeon and the patient. The choice of the right type of treatment for a successful long-term follow up positive clinical outcome is what the surgeon must always look for. In this study we tested the functional results of a group of high-demand patients, regularly involved in sports activities, with the aim of assessing the efficacy of such a technique, already considered as reliable in patients involved in regular sports activities. According to the results of the tests performed, we confirmed the positive clinical results recorded with the physical examination and the evaluation scales used. The combined mini-open and percutaneous technique as described by Kakiuchi M. seems to be effective and reliable in providing a satisfactory clinical and functional result in patients affected by acute complete rupture of the Achilles tendon
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  #67  
Old 6th March 2012, 12:52 PM
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Default Re: Achilles tendon rupture

Surgical versus nonsurgical treatment of acute achilles tendon rupture.
Donaldson PR.
Clin J Sport Med. 2012 Mar;22(2):169-70.
Quote:
OBJECTIVE:
To compare the incidence of reruptures and the functional outcomes of patients with acute Achilles tendon rupture treated with or without surgery in addition to identical rehabilitation protocols.

DESIGN:
Randomized controlled unblinded trial, with 1 year of follow-up. Sample size was calculated with 80% power to show a previously observed difference of 19% in rerupture rates between treatments at P ≤0.05.

SETTING:
The emergency department at the Sahlgrenska University Hospital, Gothenburg, Sweden, in the period 2004 to 2007.

PARTICIPANTS:
Persons between 16 and 65 years of age with a unilateral Achilles tendon rupture (based on medical history, tendon palpation, and the Thompson test) were included in the study if they were randomized and treated within 72 hours of the injury. Exclusion criteria were diabetes mellitus, previous Achilles tendon rupture, other lower leg injuries, immunosuppressive therapy, and neurovascular disease. The included patients were 79 men and 18 women, with a mean age of 41 years. The groups did not differ in age, sex, stature, side of injury, and whether their work was sedentary or heavy.

INTERVENTION:
Surgery was performed on 49 patients by orthopedic surgeons familiar with the modified Kessler suture technique. A longitudinal medial skin and paratenon incision was made, and the Achilles tendon was repaired using an end-to-end suture. The paratenon was repaired, and the skin was closed. After surgery, the patients were placed in a below-the-knee cast with the foot in 30 degree equinus position. The nonsurgical group (n = 48) were treated immediately with a similar cast. All patients kept the cast on for 2 weeks, when it was replaced by a brace for 6 weeks. The brace was adjusted by a physiotherapist to allow full flexion and to gradually increase dorsiflexion from -30 to +10 degrees. All patients followed a supervised standardized progressive exercise program from weeks 11 to 24 (or longer) and then started a group exercise program and a gradual return to sports.

MAIN OUTCOME MEASURES:
The primary outcome was occurrence of rerupture. Secondary outcomes were patient-reported Achilles tendon rupture scores and a physical activity scale and function evaluations using the MuscleLab (Ergotest Technology) measurement system, which included jump, strength, and muscular endurance tests. Patients were assessed at 6 and 12 months by 2 independent physiotherapists.

MAIN RESULTS:
There were 6 reruptures in the nonsurgical group compared with 2 in the surgical group (difference, 8.42%; 95% confidence interval, -2.46% to 19.3%). Achilles tendon rupture scores improved during rehabilitation for both groups (P < 0.001), but they did not differ between groups. Physical activity scale scores did not differ between groups but remained lower for both groups than before injury (P < 0.05). Complications of surgery included 1 Achilles tendon contracture, 2 infections, and 2 nerve disturbances on the side of the foot. The rate of deep vein thrombosis was 34% and did not differ between groups. After 6 months, 2 endurance tests, hopping, and a strength test were superior in the surgical group (P ≤ 0.05), but at 12 months, only heel-rise work remained superior (P < 0.012). The function of the injured leg was poorer than that of the uninjured leg after 6 and 12 months.

CONCLUSIONS:
Rerupture rates and patients' assessment of their function were similar after surgical or nonsurgical treatment for acute ruptures of the Achilles tendon. Some strength and endurance tests improved earlier in the surgery group.
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Old 28th March 2012, 08:31 PM
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Default Re: Achilles tendon rupture

Minimally Invasive Flexor Hallucis Longus Transfer in Management of Acute Achilles Tendon Rupture Associated With Tendinosis. A Case Report
Tun Hing Lui
Foot Ankle Spec April 2012 vol. 5 no. 2 111-114
Quote:
Chronic tendinopathy is characterized by pain in the tendon, generally at the start and completion of exercise. However, tendinosis may lead to decreased blood flow, increased stiffness of the tendon and reduced tensile strength, and predispose to rupture. Operative treatment is indicated to restore the function of the Achilles tendon and alleviate the prerupture heel cord pain. A case of acute Achilles tendon rupture with extensive tendinosis that was successfully treated with minimally invasive flexor hallucis longus transfer is reported.
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  #69  
Old 1st April 2012, 01:47 AM
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Default Re: Achilles tendon rupture

Initial Achilles tendon repair strength-synthesized biomechanical data from 196 cadaver repairs.
Sadoghi P, Rosso C, Valderrabano V, Leithner A, Vavken P.
Int Orthop. 2012 Mar 31
Quote:
PURPOSE:
The study aim was to describe what kind of operative technique performs best with respect to initial strength after the surgical repair of acute Achilles tendon ruptures.

METHODS:
We performed a systematic search of the keywords "Achilles tendon AND (suture strength OR biomechanics) AND (cadaver NOT animal)" in the online databases PubMed, EMBASE, CINAHL, and the Cochrane Library. We included studies that employed open, mini-open, or percutaneous Achilles tendon repair in human cadavers, and assessed some measure of tensile strength as a primary outcome.

RESULTS:
Our search produced 11 relevant papers reporting results for Kessler, Bunnell, and Krackow sutures in open repair, as well as the Achillon device, the Ma-Griffith repair technique, the triple bundle technique and the "giftbox" technique. The weighted tensile strengths ranged from 81 to 453 N (mean 222.7 N) with the Triple Bundle technique in combination with # 2 Ethibond performing best with a mean of 453 N.

CONCLUSIONS:
Due to the small sample sizes, different study designs, and heterogeneity of strength measurement techniques, definite recommendations on surgical technique cannot be made but presented information might help in the decision making process for foot and ankle surgeons.
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  #70  
Old 10th April 2012, 11:46 AM
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Default Re: Achilles tendon rupture

In-shoe plantar pressures within ankle-foot orthoses: implications for the management of achilles tendon ruptures.
Kearney RS, Lamb SE, Achten J, Parsons NR, Costa ML.Am J Sports Med. 2011 Dec;39(12):2679-85
Quote:
BACKGROUND:
Advances in the management of Achilles tendon rupture have led to the development of immediate weightbearing protocols. These vary regarding which ankle-foot orthoses (AFOs) are used and the number of inserted heel wedges used within them.

PURPOSE:
This study was conducted to evaluate plantar pressure measurements and temporal gait parameters within different AFOs, using different numbers of heel wedges.

STUDY DESIGN:
Controlled laboratory study.

METHODS:
Fifteen healthy participants were evaluated using 3 different AFOs, with 4 different levels of inserted heel wedges. Therefore, a total of 12 conditions were evaluated, in a sequence that was randomly allocated to each participant. Pressure and temporal gait parameters were measured using an in-shoe F-Scan pressure system, and range of movement was measured using an electrogoniometer.

RESULTS:
Ankle-foot orthoses that were restrictive in design, combined with a higher number of inserted heel wedges, reduced forefoot pressures, increased heel pressures, and decreased the amount of time spent in the terminal stance and preswing phase of the gait cycle (P = .029, .002, and .001).

CONCLUSION:
The choice of AFO design and the number of inserted heel wedges have a significant effect on plantar pressure measurements and temporal gait parameters. The implications of these changes need to be applied to the clinical management of acute Achilles tendon ruptures. This clinical management requires a balance between protected weightbearing and functional loading, requiring further research within a clinical context.

CLINICAL RELEVANCE:
The biomechanical data from this research imply that a carbon-fiber AFO, with 1 heel raise, protects against excessive dorsiflexion while facilitating the restoration of near-normal gait parameters. This could lead to an accelerated return to function, avoiding the effects of disuse atrophy. This is in contrast to the rigid rocker-bottom AFO design with a greater number of heel-wedge inserts. However, research within a clinical context would be required to ascertain if these biomechanical advantages translate into a functional benefit for patients. The results should also be considered in relation to the amount of force a healing Achilles tendon can withstand.
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Old 14th April 2012, 01:26 PM
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Default Re: Achilles tendon rupture

Deficits 10-Years after Achilles Tendon Repair.
Horstmann T, Lukas C, Merk J, Brauner T, Mündermann A.
Int J Sports Med. 2012 Apr 12.
Quote:
The purpose of this study was to determine the long-term impact of surgical repair and subsequent 6-week immobilization of an Achilles tendon rupture on muscle strength, muscle strength endurance and muscle activity. 63 patients participated in this study on average 10.8±3.4 years after surgically repaired Achilles tendon rupture and short-term immobilization. Clinical function was assessed and muscle strength, strength endurance and muscle activity were measured using a dynamometer and electromyography. Ankle ROM, heel height during heel-raise tests and calf circumference were smaller on the injured than on the contralateral side. Ankle torques during the concentric dorsiflexion tasks at 60°/sec and 180°/sec and ankle torques during the eccentric plantarflexion task and during the concentric plantarflexion task at 60°/sec for the injured leg were significantly lower than those for the contralateral leg. The total work during a plantarflexion exercise at 180°/sec was 14.9% lower in the injured compared to the contralateral leg (p<0.001). Muscle activity for the gastrocnemius muscle during dorsiflexion tasks was significantly higher in the injured than in the contralateral limb. Limited ankle joint ROM and increased muscle activity in the injured leg suggest compensatory mechanisms to account for differences in muscle morphology and physiology caused by the injury.
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Old 20th April 2012, 09:37 PM
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Default Re: Achilles tendon rupture

Treatment of an old Achilles tendon rupture with allografts. Report of case series
Matus-Jiménez J, Martínez-Arredondo H.
Acta Ortop Mex. 2011 Mar-Apr;25(2):114-8
Quote:
Rupture of Achilles tendon occurs at 2-6 cm from its attachment in the calcaneus; its frequency is estimated at 7-18 cases per 100,000 population in the United States and it occurs more frequently in males. The diagnosis is made clinically and with ultrasound or magnetic resonance imaging and treatment may be divided into acute or late. We present herein the use of allograft to treat patients with ruptures more than six weeks old; several techniques were used depending on the rupture site and the available allograft. Ten plasties were performed in ten patients with ruptures that occurred a mean of 8 months back; early rehabilitation was instituted and weight bearing was allowed at 4 weeks with a brace, which was removed at 12 weeks; patients could run at 12 weeks. Four wound dehiscence complications were reported, which resolved with second intention healing without the need for any other surgery, with good results and patient satisfaction.
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  #73  
Old 20th April 2012, 09:38 PM
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Default Re: Achilles tendon rupture

Long-term effects of chronic Achilles tendon rupture treatment, using reconstruction with peroneus brevis transfer, on sports activities.
Kosaka T, Yamamoto K.
West Indian Med J. 2011 Dec;60(6):628-35.
Quote:
OBJECTIVE:
This study reports long-term effects of chronic Achilles tendon rupture treatment, using reconstruction with peroneus brevis transfer (PBT), on sports activities based on an approximate 10-year follow-up study.

METHODS:
Twenty patients (6 women and 14 men; mean age, 43 +/- 12.85 years at the time of operation) underwent chronic Achilles tendon repair with an average follow-up of 164.05 +/- 5.07 months. Seven were involved in competitive sports, 10 participated in recreational activities and three were not involved in any sporting activities. All patients were Asians. Results were assessed using Cybex strength testing and the American Othopaedic Foot and Ankle Society (AOFAS) Score, the muscle manual test (MMT), sports activities and comprehensive satisfaction assessment.

RESULTS:
Cybex strength testing resulted in an average gain of 87.05 +/- 14.83% in dorsiflexion strength (range 65-110%) and 98.05 +/- 9.02% in plantar flexion strength (range 85%-120%). The AOFAS score average was 86.9 +/- 7.27. There were no postoperative re-ruptures, no recurrences and no wound complications. Plantar flexion strength and the AOFAS score were negatively correlated with the age at the time of operation (r = -0.566, r = -0.669, respectively). Seventeen patients (85%) were level five of MMT in eversion strength. Following treatment, six patients (30%) returned to competitive sports, while 10 (50%) who, prior to the injury and surgery, were involved in recreational activities, returned to similar activities. The relatively younger group tended to continue sport activities as competitive athletes (p < 0.05). Significant differences were observed in age at the operation between non-satisfaction group and excellent group (p < 0.05). The under 40-year age group tended to show a poor value.

CONCLUSION:
Recreational athletes and non-athletes could return to their sports activities satisfactorily, while young competitive athletes found difficulties in certain actions, especially related to eversion.
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  #74  
Old 23rd April 2012, 12:05 PM
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Default Re: Achilles tendon rupture

Biomechanical comparison of four methods of repair of the Achilles tendon
A laboratory study with bovine tendons

C. Ortiz, et al
J Bone Joint Surg Br May 2012 vol. 94-B no. 5 663-667
Quote:
We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p < 0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot.

The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.
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Old 25th April 2012, 02:52 PM
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Default Re: Achilles tendon rupture

A survey on management of chronic achilles tendon ruptures.
Villarreal AD, Andersen CR, Panchbhavi VK.
Am J Orthop (Belle Mead NJ). 2012 Mar;41(3):126-31.
Quote:
No controlled trials regarding management of chronic Achilles tendon ruptures have been published. We conducted an online survey of orthopedic surgeons affiliated with US medical schools. One hundred twenty-seven surgeons responded, but not all responded to each survey question. Thirty-six percent had foot and ankle fellowship training. Nearly all respondents diagnosed tendon rupture by using palpation of the tendon gap (97%) and the Thompson calf-squeeze test (96%). The Matles test was used by 37% of respondents, with foot and ankle specialists nearly 5 times more likely to use it than nonspecialists (P<.001). For surgical repair of a ruptured tendon, most surgeons used the end-to-end Bunnell technique for gaps of a few centimeters, transitioning to the flexor hallucis longus procedure or V-Y tendinoplasty for larger gaps. Ninety-three percent of respondents used nonabsorbable sutures; absorbable suture use tended to increase with years of practice. Most surgeons (72%) preferred postoperative immobilization for up to 6 weeks and non-weight-bearing for up to 6 weeks (96%). In most instances, the responses of foot and ankle specialists did not differ significantly from those of other orthopedic surgeons, allowing generalization of the survey results to practice trends among all orthopedic surgeons. Practice trends tended to follow published expert opinions.
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Old 16th May 2012, 02:47 PM
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Default Re: Achilles tendon rupture

Peroneus Brevis Tendon Transfer for Reconstruction of Chronic Tears of the Achilles Tendon: A Long-Term Follow-up Study
Nicola Maffulli, MD, MS, PhD, FRCS(Orth); Filippo Spiezia, MD; Ernesto Pintore, MD; Umile Giuseppe Longo, MD, MSc; Vittorino Testa, MD; Giovanni Capasso, MD; Vincenzo Denaro, MD
The Journal of Bone & Joint Surgery. 2012; 94:901-905
Quote:
Background:
Chronic tears of the Achilles tendon can result in substantial loss of function. Those tears with a tendon gap of up to 6.5 cm can be treated surgically with use of an autologous peroneus brevis tendon graft.

Methods:
At an average follow-up period of 15.5 years after the surgery, we examined sixteen of twenty-two patients who had undergone peroneus brevis tendon graft reconstruction for a chronic Achilles tendon tear. Clinical and functional assessment was performed.

Results:
All sixteen patients were able to walk on tiptoe, and no patient used a heel lift or walked with a visible limp. The maximum calf circumference of the involved limb remained significantly decreased. The involved limb was significantly less strong than the contralateral one. One patient had developed a tendinopathy of the opposite Achilles tendon, one had developed a tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon five years after the original injury.

Conclusions:
The long-term results of treatment of chronic tears of the Achilles tendon by means of autologous peroneus brevis tendon grafting are encouraging. Patients retain good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.
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  #77  
Old 17th May 2012, 01:06 AM
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Default Re: Achilles tendon rupture

Deficits in Heel-Rise Height and Achilles Tendon Elongation Occur in Patients Recovering From an Achilles Tendon Rupture
Karin Grävare Silbernagel, Robert Steele, Kurt Manal
Am J Sports Med May 16, 2012

Quote:
Background: Whether an Achilles tendon rupture is treated surgically or not, complications such as muscle weakness, decrease in heel-rise height, and gait abnormalities persist after injury.

Purpose: The purpose of this study was to evaluate if side-to-side differences in maximal heel-rise height can be explained by differences in Achilles tendon length.

Study Design: Case series; Level of evidence, 4.

Method: Eight patients (mean [SD] age of 46 [13] years) with acute Achilles tendon rupture and 10 healthy subjects (mean [SD] age of 28 [8] years) were included in the study. Heel-rise height, Achilles tendon length, and patient-reported outcome were measured 3, 6, and 12 months after injury. Achilles tendon length was evaluated using motion analysis and ultrasound imaging.

Results: The Achilles tendon length test-retest reliability (intraclass correlation coefficient = 0.97) was excellent. For the healthy subjects, there were no side-to-side differences in tendon length and heel-rise height. Patients with Achilles tendon ruptures had significant differences between the injured and uninjured side for both tendon length (mean [SD] difference, 2.6-3.1 [1.2-1.4] cm, P = .017-.028) and heel-rise height (mean [SD] difference, –4.1 to –6.1 [1.7-1.8] cm, P = .012-.028). There were significant negative correlations (r = −0.943, P = .002, and r = −0.738, P = .037) between the side-to-side difference in heel-rise height and Achilles tendon length at the 6- and 12-month evaluations, respectively.

Conclusion: The side-to-side difference found in maximal heel-rise height can be explained by a difference in Achilles tendon length in patients recovering from an Achilles tendon rupture. Minimizing tendon elongation appears to be an important treatment goal when aiming for full return of function.
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Old 18th May 2012, 08:07 AM
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Default Re: Achilles tendon rupture

Metabolic activity in early tendon repair can be enhanced by intermittent pneumatic compression.
Greve K, Domeij-Arverud E, Labruto F, Edman G, Bring D, Nilsson G, Ackermann PW.
Scand J Med Sci Sports. 2012 May 17.
Quote:
Since Achilles tendon healing is protracted, more knowledge of metabolites known to meet the demands for biosynthesis and proliferation is needed. We hypothesized that essential metabolites, glutamate, glucose, lactate, pyruvate and glycerol, are present and upregulated in healing Achilles tendons. We moreover hypothesized that adjuvant intermittent pneumatic compression (IPC), which increases blood flow, upregulates metabolite concentrations. Twenty patients with acute Achilles tendon rupture were recruited, operated, and included. The control group, 15 patients, received plaster cast immobilization, while five patients received adjuvant foot IPC beneath the plaster cast. At 2 weeks postoperatively, microdialysis of the healing and contralateral intact Achilles tendons was followed by quantification of metabolites. Healing compared to intact tendons of the controls exhibited significantly increased concentrations (mM) of glutamate (60 ± 14 vs 20 ± 11), lactate (1.15 ± 0.60 vs 0.64 ± 0.35), and pyruvate (81 ± 29 vs 35 ± 25, μM). Healing tendons of the IPC vs control group displayed higher levels of glutamate (84 ± 15 vs 62 ± 16) and glucose (3.44 ± 0.62 vs 2.62 ± 0.72); (P < 0.05) and trends toward higher concentrations of pyruvate, lactate, and glycerol (P < 0.10). The present study demonstrates that early Achilles tendon repair entails and upregulates local essential metabolites. This metabolic response can, during tendon healing with plaster cast immobilization, be promoted by adjuvant IPC.
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Old 24th May 2012, 11:36 AM
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Default Re: Achilles tendon rupture

Free gracilis tendon graft for reconstruction of chronic tears of the achilles tendon.
Maffulli N, Spiezia F, Testa V, Capasso G, Longo UG, Denaro V.
J Bone Joint Surg Am. 2012 May 16;94(10):906-10
Quote:
BACKGROUND:
Chronic tears of the Achilles tendon with a tendon gap exceeding 6 cm are a surgical challenge. The purpose of this study is to report the long-term results of reconstruction of such chronic Achilles tendon ruptures with use of a free autologous gracilis tendon graft.

METHODS:
Twenty-one patients underwent reconstruction of a chronic rupture of the Achilles tendon. Fifteen patients were available for clinical and functional assessment on the basis of anthropometric measurements, isometric strength testing, and the Achilles Tendon Total Rupture Score after a mean duration of follow-up of 10.9 years (range, eight to twelve years).

RESULTS:
All fifteen patients were able to walk on the tiptoes, and no patient used a heel lift or walked with a visible limp. At an average of 10.9 years of follow-up, the maximum calf circumference of the operatively treated leg remained substantially decreased and the operatively treated limb was significantly weaker than the contralateral, normal limb. Two patients had developed tendinopathy of the contralateral Achilles tendon, one had developed tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon eight years after the index tear.

CONCLUSIONS:
The long-term results of treatment of chronic tears of the Achilles tendon with free gracilis tendon grafting showed that patients retained good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.
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Old 24th May 2012, 11:37 AM
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Default Re: Achilles tendon rupture

Peroneus Brevis Tendon Transfer for Reconstruction of Chronic Tears of the Achilles Tendon: A Long-Term Follow-up Study.
Maffulli N, Spiezia F, Pintore E, Longo UG, Testa V, Capasso G, Denaro V.
J Bone Joint Surg Am. 2012 May 16;94(10):901-5.
Quote:
BACKGROUND:
Chronic tears of the Achilles tendon can result in substantial loss of function. Those tears with a tendon gap of up to 6.5 cm can be treated surgically with use of an autologous peroneus brevis tendon graft.

METHODS:
At an average follow-up period of 15.5 years after the surgery, we examined sixteen of twenty-two patients who had undergone peroneus brevis tendon graft reconstruction for a chronic Achilles tendon tear. Clinical and functional assessment was performed.

RESULTS:
All sixteen patients were able to walk on tiptoe, and no patient used a heel lift or walked with a visible limp. The maximum calf circumference of the involved limb remained significantly decreased. The involved limb was significantly less strong than the contralateral one. One patient had developed a tendinopathy of the opposite Achilles tendon, one had developed a tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon five years after the original injury.

CONCLUSIONS:
The long-term results of treatment of chronic tears of the Achilles tendon by means of autologous peroneus brevis tendon grafting are encouraging. Patients retain good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.
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Old 22nd June 2012, 01:42 PM
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Default Re: Achilles tendon rupture

Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture.
Olsson N, Karlsson J, Eriksson BI, Brorsson A, Lundberg M, Silbernagel KG.
Scand J Med Sci Sports. 2012 Jun 21.
Quote:
This study evaluated the short-term recovery of function after an acute Achilles tendon rupture, measured by a single-legged heel-rise test, with main emphasis on the relation to the patient-reported outcomes and fear of physical activity and movement (kinesiophobia). Eighty-one patients treated surgically or non-surgically with early active rehabilitation after Achilles tendon rupture were included in the study. Patient's ability to perform a single-legged heel-rise, physical activity level, patient-reported symptoms, general health, and kinesiophobia was evaluated 12 weeks after the injury. The heel-rise test showed that 40 out of 81 (49%) patients were unable to perform a single heel-rise 12 weeks after the injury. We found that patients who were able to perform a heel-rise were significantly younger, more often of male gender, reported a lesser degree of symptoms, and also had a higher degree of physical activity at 12 weeks. There was also a significant negative correlation between kinesiophobia and all the patient-reported outcomes and the physical activity level. The heel-rise ability appears to be an important early achievement and reflects the general level of healing, which influences patient-reported outcome and physical activity. Future treatment protocols focusing on regaining strength early after the injury therefore seem to be of great importance. Kinesiophobia needs to be addressed early during the rehabilitation process.
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Old 23rd June 2012, 03:00 PM
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Default Re: Achilles tendon rupture

THANK YOU
WHAT A GREAT IDEA
PLEASE DO THIS AGAIN WITH OTHER CLINICAL PATHOLOGIES
THIS IS A GREAT CLINICAL SYMPOSIUM
SINCERELY,
Steve Levitz
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  #83  
Old 27th June 2012, 11:45 AM
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Default Re: Achilles tendon rupture

Does accelerated functional rehabilitation after surgery improve outcomes in patients with acute achilles tendon ruptures?
Garrick JG.
Clin J Sport Med. 2012 Jul;22(4):379-80.
Quote:
OBJECTIVE:
: To compare the outcomes of patients with acute Achilles tendon ruptures treated operatively with subsequent accelerated functional rehabilitation or nonoperatively with the same rehabilitation regimen.

DESIGN:
: Randomized controlled trial, with a minimum 2-year follow-up. Sample size was calculated with 80% power to show a minimum difference of 11% in rerupture rate at P ≤ 0.05. Patients who were lost to follow-up (12%) were excluded from the analysis.

SETTING:
: Two university hospitals in Canada.

PARTICIPANTS:
: Patients presenting within 14 days of an acute Achilles tendon rupture (a positive Thompson squeeze test and a palpable gap), who were 18-70 years, and who were able to comply with the rehabilitation protocol were eligible. Exclusion criteria were open or additional ipsilateral injury, fluoroquinolone-associated rupture, avulsion from the calcaneus, diabetes, diseases requiring medications that impair tendon healing, and surgical contraindications. The 144 patients randomized had a mean age of 40 years, 82% were men, and 85% of the injuries were sport related.

INTERVENTION:
: Surgical treatment included a vertical posteromedial incision to the level of the paratenon. The tendon tear was closed with nonabsorbable sutures in a Krackow-type stitch pattern, using the contralateral extremity as a guide to tendon length. The paratenon and skin were closed. Postoperatively, or as soon as possible after the injury in the nonoperative group, a posterior back slab splint was applied with the foot in 20 degrees of plantar flexion. The patients were advised to use crutches and not to bear weight. After 2 weeks, the back slab was removed. An Aircast (Summit, New Jersey) walking boot was worn for about 6 weeks. The accelerated functional rehabilitation program included progressive resistance, fitness, and range-of-motion exercises. Weight bearing was permitted as tolerated. After 12 weeks, sport-specific retraining could be commenced.

MAIN OUTCOME MEASURES:
: The primary outcome was the 2-year rate of rerupture, diagnosed as previously, plus loss of plantar flexion strength. Secondary outcomes included isokinetic strength (assessed with a dynamometer), peak planter flexion and dorsiflexion torques at several velocities, range of motion, calf circumference, and the Leppilahti score, which includes patient ratings and objective measurements.

MAIN RESULTS:
: Reruptures occurred during the first 3 months after the initial injury, 2 in the operative group (3.2%) and 3 in the nonoperative group (4.6%). After 2 years, both groups were able to achieve a mean of 80% of the plantar flexion strength and 100% of the dorsiflexion strength of the unaffected limb. A difference in favor of the operative group, in the ratio of affected to unaffected limb in planter flexion strength at 240 degrees per second that was shown after 1 year, was slightly greater after 2 years (mean difference between groups, 14.15%; 95% confidence interval [CI], 1.12%-27.9%). The unaffected limb maintained a greater range of motion than the affected limb at each follow-up. The side-to-side difference in plantar flexion range of motion was greater in the operative than the nonoperative group (difference, 2.21%; 95% CI, 3.9%-0.5%), but the groups did not differ in dorsiflexion. After 1 and 2 years, the groups did not differ in calf circumference or Leppilahti score. Including the 5 reruptures, there were 13 complications in the operative group and 6 in the nonoperative group (difference, 9%; 95% CI, 1.2%-20.7%). There was 1 deep vein thrombosis in each group, and 1 case of serious pain and 1 failure to heal in the nonoperative group. The remaining 10 (mostly soft tissue) complications in the operative group included 1 deep infection and 1 pulmonary embolus.

CONCLUSIONS:
: Patients with acute Achilles tendon ruptures treated with accelerated functional rehabilitation recovered as well whether the initial treatment was surgical or not. Rates of rerupture were also similar and the rate of complications was lower for nonoperative treatment.
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Old 28th June 2012, 11:50 AM
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Default Re: Achilles tendon rupture

Ultrasound-Guided Minimally Invasive Surgery for Achilles Tendon Rupture: Preliminary Results
Chen-Chie Wang, MD, PhD; Pei-Yu Chen, MD; Ting-Ming Wang, MD PhD
Foot & Ankle International July 2012 (Vol. 33 #7) July 1, 2012
Quote:
Many surgeons prefer surgical repair for Achilles tendon ruptures in an
attempt to reduce the risk of rerupture. To minimize wound
complications, the use of minimally invasive surgery has become more
popular recently. In line with this, the use of ultrasound to guide
Achilles tendon repair is reported in this study.

Methods: From March
2005 to January 2008, 23 patients with Achilles tendon rupture were
repaired by the same surgeon. The ages of the patients ranged from 19
to 67 years old, with an average of 43 years old. The repair of the
Achilles tendon was achieved through a stab wound under the guidance
of ultrasonography. A control group consisted of 25 patients who
received traditional open Achilles tendon repair.

Results: The average
operation time was 52 minutes, and the average wound size was 1.1 cm.
The short leg cast was removed 4 weeks after the surgery, and serial
casting was used for another 3 to 4 weeks. The postoperative AOFAS
ankle-hindfoot scores were 98.7 in the experimental group, 96.5 in the
control group with no significant difference. The rates of local
infection, stiffness of the ankle, pain of the scar and sural nerve
injury were better in the experimental group than in the control group
with significant difference.

Conclusions: Ultrasound-guided surgery
was a good choice due to its availability and real-time soft tissue
visualization. It can further minimize the size of the surgical wound.
Our method has the potential to achieve reliable results.
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  #85  
Old 5th July 2012, 11:25 AM
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Default Re: Achilles tendon rupture

Acute Achilles Tendon Rupture: A Questionnaire Follow-up of 487 Patients.
Bergkvist D, Aström I, Josefsson PO, Dahlberg LE.
J Bone Joint Surg Am. 2012 Jul 3;94(13):1229-33.
Quote:
BACKGROUND:
The optimum treatment of acute total Achilles tendon rupture remains controversial. In the present study, the outcomes of surgical and nonsurgical treatment in a large number of patients were compared on the basis of patient age and sex.

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

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

CONCLUSIONS:
The good Achilles Tendon Total Rupture Score in the nonsurgically managed group, together with the relatively low rate of re-ruptures and other complications in these patients, makes this treatment a preferable option for most patients. However, the tendency for a lower re-rupture rate and better performance on the heel-raise test in surgically treated patients suggest surgery may be beneficial in selected patients.
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Old 12th July 2012, 09:47 AM
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Default Re: Achilles tendon rupture

Z-shortening of healed, elongated Achilles tendon rupture.
Maffulli N, Spiezia F, Longo UG, Denaro V.
Int Orthop. 2012 Jul 11
Quote:
PURPOSE:
A rupture of the Achilles tendon may heal in continuity, resulting in a lengthened Achilles tendon. The elongated structure must be shortened to restore effective push off. We report the results of a longitudinal study using Z-shortening of ruptured Achilles tendons that healed in continuity but were elongated.

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

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

CONCLUSIONS:
Managing a healed Achilles tendon rupture using Z-shortening is safe and effective, providing good recovery and early weight bearing and active ankle mobilisation. Such patients should be warned that they are at risk for postoperative complications and that their ankle-plantar flexion strength is likely to be permanently reduced.
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Old 16th July 2012, 08:20 PM
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Default Re: Achilles tendon rupture

Operative Versus Nonoperative Management of Acute Achilles Tendon Ruptures
A Quantitative Systematic Review of Randomized Controlled Trials

Ryan Wilkins nd Leslie J. Bisson,
Am J Sports Med July 16, 2012
Quote:
Background: Despite several randomized controlled trials comparing operative to nonoperative management of Achilles tendon ruptures, the optimal management of this condition remains the subject of significant debate. Rerupture is a known complication, but most level I studies have not shown a significant difference in the incidence of reruptures when comparing operative to nonoperative management.

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

Study Design: Meta-analysis.

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

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

Conclusion: Open surgical repair of acute Achilles tendon ruptures significantly reduces the risk of reruptures when compared with nonoperative management. Several other complications, which are clearly avoided with nonoperative treatment, occur with a significantly higher incidence when surgical repair is performed. The available literature makes it difficult to compare the return of strength in the involved lower extremity after operative or nonoperative management. Future studies may focus on testing strength in a more functional and reproducible manner than isokinetic testing.
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Old 21st July 2012, 01:08 PM
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Default Re: Achilles tendon rupture

Hindfoot plantarflexion: a radiographic aid to the diagnosis of achilles tendon rupture.
Pearce S, Gupte C, Singh S, Prince M, Elsabagh S.
J Foot Ankle Surg. 2012 Mar-Apr;51(2):176-8
Quote:
Although tendo Achilles (TA) rupture is a clinical diagnosis, radiographs are sometimes taken to exclude bony injury. In equivocal clinical examination findings, an ultrasound examination is often performed. We investigated whether any radiographic signs of TA rupture existed that could help diagnose TA rupture in equivocal cases. We examined the case notes of 25 consecutive patients who had undergone repair for complete TA rupture. Their lateral radiographs were reviewed and the following angles were measured: calcaneal pitch, lateral talocalcaneal, and tibiocalcaneal. These were compared with a control group of patients who had undergone radiographic examination for ankle injuries resulting in a diagnosis of ankle sprain. The results were compared using an unpaired Student's t test. The mean tibiocalcaneal angle of the patients with complete TA rupture was 87.0 compared with 69.4 for the control group (p < .05). No significant difference was found with the other angles measured. The tibiocalcaneal angle can be a useful adjunct to the clinical examination in the diagnosis of TA rupture. It might also have a role in the evaluation of serial cast application after TA repair.
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Old 25th July 2012, 12:03 PM
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Default Re: Achilles tendon rupture

MRI is Unnecessary for Diagnosing Acute Achilles Tendon Ruptures: Clinical Diagnostic Criteria
David N. Garras et al
Clinical Orthopaedics and Related Research; Volume 470, Number 8 (2012), 2268-2273,
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Background
Achilles tendon ruptures are common in middle-aged athletes. Diagnosis is based on clinical examination or imaging. Although MRI is commonly used to document ruptures, there is no literature supporting its routine use and we wondered whether it was necessary.

Questions/purposes
We (1) determined the sensitivity of physical examination in diagnosing acute Achilles ruptures, (2) compared the sensitivity of physical examination with that of MRI, and (3) assessed care delays and impact attributable to MRI.

Methods
We retrospectively compared 66 patients with surgically confirmed acute Achilles ruptures and preoperative MRI with a control group of 66 patients without preoperative MRI. Clinical diagnostic criteria were an abnormal Thompson test, decreased resting tension, and palpable defect. Time to diagnosis and surgical procedures were compared with those of the control group.

Results
All patients had all three clinical findings preoperatively and complete ruptures intraoperatively (sensitivity of 100%). MR images were read as complete tears in 60, partial in four, and inconclusive in two patients. It took a mean of 5.1 days to obtain MRI after the injury, 8.8 days for initial evaluation, and 12.4 days for surgical intervention. In the control group, initial evaluation occurred at 2.5 days and surgical intervention at 5.6 days after injury. Nineteen patients in the MRI group had additional procedures whereas none of the control group patients had additional procedures.

Conclusions
Physical examination findings were more sensitive than MRI. MRI is time consuming, expensive, and can lead to treatment delays. Clinicians should rely on the history and physical examination for accurate diagnosis and reserve MRI for ambiguous presentations and subacute or chronic injuries for preoperative planning.
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Old 25th July 2012, 12:05 PM
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Default Re: Achilles tendon rupture

Treatment of the neglected Achilles tendon rupture.
Bevilacqua NJ.
Clin Podiatr Med Surg. 2012 Apr;29(2):291-9
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Achilles tendon ruptures are best managed acutely. Neglected Achilles tendon ruptures are debilitating injuries and the increased complexity of the situation must be appreciated. Surgical management is recommended, and only in the poorest surgical candidate is conservative treatment entertained. Numerous treatment algorithms and surgical techniques have been described. A V-Y advancement flap and flexor halluces longus tendon transfer have been found to be reliable and achieve good clinical outcomes for defects ranging from 2 cm to 8 cm. This article focuses on the treatment options for the neglected Achilles tendon rupture.
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