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OBJECTIVE:
To compare the effectiveness of the 3 methods (traditional open Achilles tendon anastomosis, minimally invasive percutaneous Achilles tendon anastomosis, and Achilles tendon anastomosis limited incision) for acute Achilles tendon rupture so as to provide a reference for the choice of clinical treatment plans.
METHODS:
Between December 2007 and March 2010, 69 cases of acute Achilles tendon rupture were treated by traditional open Achilles tendon anastomosis (traditional group, n=23), by minimally invasive percutaneous Achilles tendon anastomosis (minimally invasive group, n=23), and by Achilles tendon anastomosis limited incision (limited incision group, n=23). There was no significant difference in gender, age, mechanism of injury, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score between 3 groups (P > 0.05).
RESULTS:
Minimally invasive group and limited incision group were significantly better than traditional group in hospitalization days and blood loss (P < 0.01). Incision infection occurred in 2 cases of traditional group, and healing of incision by first intention was achieved in all patients of the other 2 groups, showing significant difference in the complication rate (P < 0.05). Re-rupture of Achilles tendon occurred in 1 case (4.3%) of minimally invasive group and limited incision group respectively; no re-rupture was found in traditional group (0), showing significant difference when compared with the other 2 groups (P < 0.05). All cases were followed up 12-18 months with an average of 14.9 months. The function of the joint was restored. The AOFAS score was more than 90 points in 3 groups at 12 months after operation, showing no significant difference among 3 groups (P > 0.05).
CONCLUSION:
The above 3 procedures can be used to treat acute Achilles tendon rupture. However, minimally invasive percutaneous Achilles tendon anastomosis and Achilles tendon anastomosis limited incision have the advantages of less invasion, good healing, short hospitalization days, and less postoperative complication, and have the disadvantage of increased risk for re-rupture of Achilles tendon after operations.
Structural and Biomechanical Characteristics After Early Mobilization in an Achilles Tendon Rupture Model: Operative Versus Nonoperative Treatment
Daniel Krapf, MD; Martin Kaipel, MD; Martin Majewski, MD Orthopedics September 2012 - Volume 35 · Issue 9: e1383-e1388
Quote:
Acute Achilles tendon ruptures are common sports injuries; however, treatment remains a clinical challenge. Studies show a superior effect of early mobilization and full weight bearing on tendon healing and clinical outcome; however, few data exist on structural and biomechanical characteristics in the early healing phase. This study investigated the histological and biomechanical characteristics of early mobilization and full weight bearing in an Achilles tendon rupture model. Eighty rats underwent dissection of a hindpaw Achilles tendon; 40 rats were treated conservatively and 40 underwent open repair of the transected Achilles tendon by suturing. Early mobilization and full weight bearing were allowed in both groups. At 1, 2, 4, and 8 weeks after tenotomy, tensile strength, stiffness, thickness, tissue characteristics (histological analysis), and length were determined. Dissected Achilles tendons healed in all animals during full weight-bearing early mobilization. One and 2 weeks after tenotomy, rats in the operative group showed increased tensile strength and stiffness compared with the nonoperative group. Repair-site diameters were increased at 1, 2, and 8 weeks after tenotomy. Tendon length was decreased in the operative group throughout observation, whereas the nonoperative group showed increased structural characteristics on the cellular level and a more homogeneous collagen distribution. Surgical treatment of dissected rat Achilles tendons showed superior biomechanical characteristics within the first 2 weeks. Conservative treatment resulted in superior histological findings but significant lengthening of the tendon in the early healing phase (weeks 1–8).
Results of a small, randomized controlled pilot study that involved mechanobiologic and clinical assessments showed that platelet-rich plasma improved healing in acute Achilles tendon tears that were either percutaneously sutured or nonoperatively treated.
Quote:
“Our findings showed that platelet-rich plasma had the potential to accelerate regeneration of the Achilles tendon in acute tears and really helped the return to function,” Alsousou said.
Purpose
The aim of this study was to assess inflammation and the presence and relative levels of cytokines, which may be involved in regulating early human Achilles tendon healing.
Methods
Nine patients with acute Achilles tendon rupture were included, operated on and post-operatively immobilized. Two weeks post-operatively, microdialysis of the peritendinous interstitial compartment was performed in the healing and intact contralateral Achilles tendons. Quantification of tumour necrosis factor (TNF)-α, interferon (IFN)-γ, interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12p70 and IL-17A was accomplished using a cytometric bead array. Prostaglandin (PG) E2 levels were measured by enzyme immunoassay.
Results
None of the patients displayed detectable PGE2 levels. Pro-inflammatory cytokines were below detection levels (IFNγ, IL-12, and IL-17) or did not differ between injured and control tendons (IL-1β and TNF). Notably, IL-6, IL-8 and IL-10 concentrations in the healing Achilles tendon were significantly elevated: 13-fold (p = 0.009), 28-fold (p = 0.02), and 3.7-fold (p = 0.03), respectively.
Conclusion
At 2 weeks post–human Achilles tendon rupture, healing is characterized by a resolving inflammatory phase and up-regulation of IL-6, IL-8 and IL-10. The absence of inflammation suggests that at this time point, these cytokines may be associated with anti-inflammatory and regenerative effects on the tendon healing process.
What is the effect of the early weight-bearing mobilisation without using any support after endoscopy-assisted Achilles tendon repair? Doral MN. Knee Surg Sports Traumatol Arthrosc. 2012 Sep 26
Quote:
PURPOSE:
The aim of this study was to assess the effect of immediate weight-bearing mobilisation with intensive rehabilitation on muscle strength and lower extremity functional level after endoscopy-assisted Achilles tendon repairs.
METHODS:
After warming up for 5 min at a self-selected intensity on a stationary bike 32 male patients were tested for bilateral peak concentric isokinetic ankle dorsi- and plantar-flexor torque, passive range of motion for ankle joint, one-leg hop for distance, single-leg vertical jump height, Achilles Tendon Total Rupture Score, and perceived function using the Foot and Ankle Outcome Score (FAOS). A series of paired sample t tests were used to compare side-to-side differences (p < 0.05).
RESULTS:
There were no significant differences in hop and jump tests, dorsi- and plantar-flexor isokinetic muscle strength, and dorsi- and plantar-flexion range of motion between the affected and unaffected side of the patients. Pain score of FAOS was 95 ± 8, other symptoms score was 92 ± 11, function in daily living score was 95 ± 6, function in sport and recreation was 85 ± 16, and Quality of Life score was 85 ± 12. The mean of the Achilles Tendon Rupture Score was 86.
CONCLUSIONS:
There was no significant difference in both ankle muscle strength and lower extremity functional level between the endoscopy-assisted repairs and the unaffected sides. The early tolerated weight-bearing mobilisation without cast-brace and/or special shoe at the first day after the surgery may easily provide to return the daily living activities. It improves muscle strength, functional level, and range of motion. Further comprehensive and prospective studies on large patients should be warranted to analyse and compare the clinical and functional results in patients with endoscopy-assisted Achilles tendon repair.
Electromyographic analysis of the triceps surae muscle complex during achilles tendon rehabilitation program exercises.
Mullaney M, Tyler TF, McHugh M, Orishimo K, Kremenic I, Caggiano J, Ramsey A. Sports Health. 2011 Nov;3(6):543-6. t
Quote:
BACKGROUND:
Specific guidelines for therapeutic exercises following an Achilles tendon repair are lacking.
HYPOTHESIS:
A hierarchical progression of triceps surae exercises can be determined on the basis of electromyographic (EMG) activity.
STUDY DESIGN:
Randomized laboratory trial.
METHODS:
Bipolar surface electrodes were applied over the medial and lateral heads of the gastrocnemius as well as the soleus on 20 healthy lower extremities (10 participants, 27 ± 5 years old). Muscle activity was recorded during 8 therapeutic exercises commonly used following an Achilles repair. Maximal voluntary isometric contractions (MVICs) were also performed on an isokinetic device. The effect of exercise on EMG activity (% MVIC) was assessed using repeated measures analysis of variance with Bonferroni corrections for planned pairwise comparisons.
RESULTS:
Seated toe raises (11% MVIC) had the least amount of activity compared with all other exercises (P < 0.01), followed by single-leg balance on wobble board (25% MVIC), prone ankle pumps (38% MVIC), supine plantarflexion with red elastic resistance (45% MVIC), normal gait (47% MVIC), lateral step-ups (60% MVIC), single-leg heel raises (112% MVIC), and single-leg jumping (129% MVIC).
CONCLUSION:
There is an increasing progression of EMG activity for exercises that target the triceps surae muscle complex during common exercises prescribed in an Achilles tendon rehabilitation program. Seated toe raises offer relatively low EMG activity and can be utilized as an early rehabilitative exercise. In contrast, the single-leg heel raise and single-leg jumping should be utilized only during later-stage rehabilitation.
CLINICAL RELEVANCE:
EMG activity in the triceps surae is variable with common rehab exercises.
FLEXOR HALLUCIS LONGUS TENDON TRANSFER IN THE MANAGEMENT OF THE DELAYED PRESENTATION OF ACHILLES TENDON RUPTURE
J. Brown, P. Moonot, and H. Taylor J Bone Joint Surg Br 2012 94-B:(SUPP XLIII) 62.
Quote:
Introduction The delayed presentation of Achilles tendon rupture is common, and is a difficult problem to manage. A number of surgical techniques have been described to treat this problem. We describe the use of Flexor Hallucis Longus (FHL) transfer to augment the surgical reconstruction of the delayed presentation of achilles tendon rupture.
Materials and Methods Fourteen patients with chronic tendo-Achilles rupture, presenting between April 2008 and December 2010, underwent surgical reconstruction and FHL transfer. Surgery was performed employing standard operative techniques, with shortening of the Achilles tendon and FHL transfer into the calcaneum with a Biotenodesis screw (Arthrex). VISA-A scores were performed preoperatively and six months postoperatively. Complication data was collected by review of the electronic patient record and direct patient questioning.
Results One patient died of an unrelated cause shortly before outcome scoring, and another patient was excluded because casting in the preoperative period prevented accurate scoring, although he achieved a good post-treatment score. Analysis was therefore carried out on twelve patients. Eleven of the twelve patients had significant improvement in their VISA-A score, with a mean improvement in score of 30 (p < 0.05). There were no significant complications in any of the patients.
Conclusion Our results show that FHL transfer in the management of chronic Achilles tendon rupture is a good, safe and reliable technique. There is excellent improvement in the mean VISA-A score, with no significant complications. Our results support the use of FHL tendon transfer for patients with chronic tendo-Achilles rupture.
PERCUTANEOUS REPAIR OF THE ACHILLES TENDON: A 3-YEAR PROSPECTIVE EVALUATION
A. Edge, J.D. Stevenson, R. Thangaraj, O. Mei-Dan, and M.R. Carmont J Bone Joint Surg Br 2012 94-B:(SUPP XLIII) 64.
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The percutanous repair of the Achilles tendon is a cost efficient method of restoring early limb function and may offer reduced risk of re-rupture and wound infection. This technique has been described in the elderly population and elite athletes; we present an evaluation of this technique in a District General Hospital setting. We have prospectively audited the outcome of 56 patients who have elected to have percutaneous repair for Achilles tendon rupture from 2009–2011. The majority were males (44) with mean age of 46 years (range 27–80). Twenty nine patients ruptured the right tendon and 27 the left. 82% (46) of injuries were sustained whilst exercising: e.g. football (22), badminton (7), running (5). All but 2 patients were managed on a Day Case basis and 4 requested general anaesthesia. Patients were immediately weight bearing in a brace following surgery and commenced physiotherapy at 2 weeks.
Functional outcome was measured using a modified Achilles Tendon Rupture Score (ATRS) at 3, 6, 9 and 12 months: 100 score equals maximal limitation. The mean ATRS scores a 3, 6, 9 and 12 months were 53 (7–82), 31 (0–74), 30 (0–67) and 15 (1–52) respectively. We have had 4 complications: 2 sural nerve injuries, 1 poor wound healing and 1 re-rupture at 8 weeks.
Overall complication rate was 7.1%, comparable to other studies. We have shown a good outcome following percutaneous Achilles tendon repair. The majority of patients show good restoration of function by 3 months and a minor limitation at 6 months. The majority of the improvement in function occurred between 3 and 6 months following surgery. Two patients reported ongoing tendinopathic pain following repair increasing mean scores.
We believe this technique can be introduced in District General Hospitals to give good outcome on a cost effective basis.
THE CLINICAL INCIDENCE OF VENOUS THROMOBOEMBOLISM (VTE) AFTER ACUTE ACHILLES TENDON RUPTURE MANAGED BY PLASTER CAST VERSUS FUNCTIONAL MOBILISATION
A Gulati, C Walker and M Bhatia J Bone Joint Surg Br 2012 vol. 94-B no. SUPP XXXVII 358
Quote:
Introduction Venous thromboembolism (VTE) is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. This incidence should in theory reduce if the patients are ambulatory early in the treatment phase. The aim of this study was, therefore, to identify a difference in the incidence of symptomatic VTE by treating acute Achilles tendon rupture patients with conventional non-weight bearing plaster versus functional weight bearing mobilisation.
Methodology The notes of 91 consecutive patients with acute Achilles tendon rupture were retrospectively reviewed and prospectively followed. The patients' demographics, treatment modality (non-weight bearing plaster versus weight bearing boot), and the type of plaster immobilisation was compared to assess whether they affect the incidence of clinical VTE. The predisposing risk factors were also analysed between the treatment groups.
Out of 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a conventional non-weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. On the other hand, 41 patients were treated with functional weight bearing mobilisation (Vacupad). Patients who did have a symptomatic thromboembolic event also had an ultrasound scan to confirm a deep vein thrombosis of the lower limb or a CT-scan to confirm pulmonary embolism.
Results Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients had a thromboembolic event (19.1%). On the other hand, out of the 41 patients who were treated with functional weight bearing mobilisation, only 2 patients had a symptomatic thromboembolic event (4.2%). This was statistically significant (p=0.012). This shows that patients who are treated in a non-weight bearing plaster have about five times increased risk of developing a sypmptomatic VTE compared to those treated by functional weight bearing mobilisation. There was however no difference in the predisposing factors in patients who developed VTE compared to those who did not.
Conclusion The incidence of symptomatic VTE after acute Achilles tendon rupture is high and under-recognised. Asymptomatic VTE after this injury is probably even higher. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non-weight bearing cast. There is a need for further research to define the possible benefit of thromboprophylaxis in patients treated by non-weight bearing plasters.
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.
Retrospective Analysis of Mini-Open Repair Versus Open Repair for Acute Achilles Tendon Ruptures
Erin E. Klein, et al Foot Ankle Spec October 11, 2012
Quote:
Purpose: Debate exists over optimal treatment for acute Achilles tendon ruptures. Recent literature suggests the mini-open technique may provide the reliability of the open repair with the decreased complication rate of non-operative treatment. This retrospective review compares acute tendon ruptures treated with one of two techniques: open repair (TO) or mini-open repair (MOA).
Methods & Results: Records were reviewed and 34 patients were found to meet the inclusion criteria for open or mini-open repair of an acute Achilles tendon rupture with follow up of at least 12 months. TO (n=16) and MOA (n=18) had no statistically significant differences in age at time of injury [TO: 41 + 2.5 years (range 20 – 68); MOA: 46 + 2.5 years (range 33 – 73)] or time between injury and surgical repair [TO: 15 + 2 days (range 2 – 30); MOA: 15 + 2 days (range 2 – 30)]. Post-operative VISA-A scores were 82 + 10 (range 42 – 98) and 92 + 5 (range 66 – 100) for TO and MOA, respectively. Significant differences were found in the time between surgical intervention and beginning of rehabilitation [TO: Post op day 37 + 5 (range 21 – 46); MOA: Post op day 19 + 2 (range 7 – 32)] and the time between surgical intervention and full return to activity [TO: Post op month 7 + 1 (range 4 – 11); MOA: Post op month 5 + 0.6 (range 4 – 11)].
Conclusion: These results suggest that the mini-open repair provides acceptable surgical outcomes while optimizing patient function after Achilles tendon repair.
Primary achilles tendon repair with mini-dorsolateral incision technique and accelerated rehabilitation.
Hrnack SA, Crates JM, Barber FA. Foot Ankle Int. 2012 Oct;33(10):848-51
Quote:
BACKGROUND:
No consensus exists for the best primary repair of acute Achilles tendon ruptures. Problems with wound healing and nerve damage can occur. Prolonged immobilization leads to stiffness and calf atrophy. This study assesses the clinical outcome of acute Achilles tendon repairs using a mini-dorsolateral incision followed by a rapid rehabilitation program.
MATERIALS:
A consecutive series of acute Achilles tendon ruptures repaired using a mini-dorsolateral incision were reviewed with a minimum 12 months follow up. Fifteen patients with an average age of 44 (range, 32 to 60) years were followed an average of 45 (range, 14 to 72) months. Two modified, buried core high strength sutures were placed in each torn end of the Achilles tendon reinforced with a running circumferential whip-stitch. Ankle Hindfoot scores, single toe raises, calf circumference, and adverse events were recorded. An accelerated postoperative rehabilitation protocol was followed.
RESULTS:
Postoperative AOFAS Ankle Hindfoot scores averaged 98.3 [39 pain; 49.6 function; 9.3 alignment]. All patients could single heel raise. Eight of 15 demonstrated atrophy with an average calf circumference loss of 1.0 cm. The only postoperative complication was one case of superficial cellulitis successfully treated with oral antibiotics. There were no sural nerve injuries, wound break down, or re-ruptures at final followup.
CONCLUSION:
The repair of acute Achilles tendon ruptures through a minimal lateral incision provided excellent functional outcomes, avoided complications including sural nerve injury, and allowed a return to sports between 4 to 6 months.
Synthesis, characterization and histomorphometric analysis of cellular response to a new elastic DegraPol® polymer for rabbit Achilles tendon rupture repair.
Buschmann, J., Calcagni, M., Bürgisser, G. M., Bonavoglia, E., Neuenschwander, P., Milleret, V. and Giovanoli, P. J Tissue Eng Regen Med. 2012
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Tendon rupture repair is a surgical field where improvements are still required due to problems such as repeat ruptures, adhesion formation and joint stiffness. In the current study, a reversibly expandable and contractible electrospun tube based on a biocompatible and biodegradable polymer was implanted around a transected and conventionally sutured rabbit Achilles tendon. The material used was DegraPol® (DP), a polyester urethane. To make DP softer, more elastic and surgeon-friendly, the synthesis protocol was slightly modified. Material properties of conventional and new DP film electrospun meshes are presented. At 12 weeks post-surgery, tenocyte and tenoblast density, nuclei and width, collagen fibre structure and inflammation levels were analyzed histomorphometrically. Additionally, a comprehensive histological scoring system by Stoll et al. (2011) was used to compare healing outcomes. Results showed that there were no adverse reactions of the tendon tissue following the implant. No differences were found whether the DP tube was applied or not for both traditional and new DP materials. As a result, the new DP material was shown to be an excellent carrier for delivery of growth factors, stem cells and other agents responsible for tendon healing
Tendon pain after repair of an acute Achilles tendon rupture can result from suture granuloma formation, modification of the threshold of the pain receptors inside the tendon by scar tissue, expansion of the paratenon by tendon enlargement with secondary stimulation of mechanoreceptors, or underlying tendon degeneration. In the present technique report, an endoscopic technique of Achilles tenolysis for denervation and debulking is described that might be applicable in cases in which conservative treatment fails to alleviate the pain.
Minimally invasive repair of acute Achilles tendon ruptures with Achillon device.
Valente M, Crucil M, Alecci V, Frezza G. Musculoskelet Surg. 2012 Jun;96(1):35-9
Quote:
The subcutaneous rupture of the Achilles tendon is a frequently observed lesion. Its treatment, however, remains controversial. The treatment to be applied varies between the conservative method, open surgical procedure and percutaneous or minimally invasive techniques. While conservative treatment results in a high percentage of re-ruptures, the open surgical treatment also has its complications. Surgical wound dehiscence, delayed cutaneous healing due to infection, delayed weight-bearing capacity, and consequent hypertrophic scarring account for 4-19% of all complications. The need for a technique that minimizes these complications has led to the development of percutaneous techniques. From August 2005 to March 2009, 35 consecutive patients underwent reparative surgery of the Achilles tendon using a minimally invasive technique with the Achillon device. All patients were available for follow-up. Dynamometric evaluation was possible on 15 patients. Twenty-five patients reported being very satisfied and 10 as being satisfied. The average AOFAS score was 93.4 (range 88-100 points). No complications occurred as a result of surgery (re-rupture, infection, lesion of the sural nerve, wound complication). All patients returned to work within 2 months, to jogging within 3 months, and to their previous level of sporting activity within 6 months. The authors believe that the minimally invasive technique using the Achillon device is a reliable surgical treatment and provides satisfactory results with a low rate of complication.
Introduction The delayed presentation of Achilles tendon rupture is common, and is a difficult problem to manage. A number of surgical techniques have been described to treat this problem. We describe the use of Flexor Hallucis Longus (FHL) transfer to augment the surgical reconstruction of the delayed presentation of achilles tendon rupture.
Materials and Methods Fourteen patients with chronic tendo-Achilles rupture, presenting between April 2008 and December 2010, underwent surgical reconstruction and FHL transfer. Surgery was performed employing standard operative techniques, with shortening of the Achilles tendon and FHL transfer into the calcaneum with a Biotenodesis screw (Arthrex). VISA-A scores were performed preoperatively and six months postoperatively. Complication data was collected by review of the electronic patient record and direct patient questioning.
Results One patient died of an unrelated cause shortly before outcome scoring, and another patient was excluded because casting in the preoperative period prevented accurate scoring, although he achieved a good post-treatment score. Analysis was therefore carried out on twelve patients. Eleven of the twelve patients had significant improvement in their VISA-A score, with a mean improvement in score of 30 (p < 0.05). There were no significant complications in any of the patients.
Conclusion Our results show that FHL transfer in the management of chronic Achilles tendon rupture is a good, safe and reliable technique. There is excellent improvement in the mean VISA-A score, with no significant complications. Our results support the use of FHL tendon transfer for patients with chronic tendo-Achilles rupture.
Locating the Sural Nerve during Calcaneal (Achilles) Tendon Repair with Confidence: A Cadaveric Study with Clinical Applications.
Blackmon JA, Atsas S, Clarkson MJ, Fox JN, Daney BT, Dodson SC, Lambert HW. J Foot Ankle Surg. 2012 Oct 22.
Quote:
The sural nerve is at risk of iatrogenic injury even during minimally invasive operative procedures to repair the calcaneal (Achilles) tendon. Through 107 cadaveric leg dissections, the data derived from the present study was used to develop a regression equation that will enable surgeons to estimate the intersection point at which the sural nerve crosses the lateral border of the Achilles tendon, an important surgical landmark. In most cases, the sural nerve crossed the lateral border of the Achilles tendon 8 to 10 cm proximal to the superior border of the calcaneal tuberosity. By simply measuring the leg length of the patient (from the base of the heel to the flexor crease of the popliteal fossa), surgeons can approximate the location of this intersection point with an interval length of 0.68 to 1.80 cm, with 90% confidence, or 0.82 to 2.15 cm, with 95% confidence. For example, for a patient with a lower leg length of 47.0 cm, the mean measurement in the present study, a surgeon can be 90% confident that the sural nerve will cross the lateral border of the Achilles tendon 8.28 to 8.96 cm (interval width of 0.68 cm) proximal to the calcaneal tuberosity. Currently, ultrasound and clinical techniques have been implemented to approximate the location of the sural nerve. The results of the present study offer surgeons another method, that is less intensive, to locate reliably and subsequently avoid damage to the sural nerve during calcaneal (Achilles) tendon repair and other procedures of the posterolateral leg and ankle.
Only half of the patients with an Achilles tendon rupture can perform a single leg heel-rise 12 weeks after injury, with no difference between surgically and non-surgically treated patients.
Silbernagel, Karin G.; Olsson, Nicklas; Eriksson, Bengt I.; Brorsson, Annelie; Lundberg, Mari; Karlsson, Jon Combined Societies Mtg; American Physical Therapy Association; San Diego January 21-24. 2013
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Purpose/Hypothesis : The purpose of this study was to evaluate the short-term recovery of function after an acute Achilles tendon rupture, measured by a standing single leg heel-rise test, and to see how this correlate to patient-reported outcomes and fear of physical activity and movement (kinesiophobia). A secondary aim was to evaluate what patient characteristics correlated to return of heel-rise function.
Number of Subjects : 81 patients (69 males and 12 females)
Materials/Methods : This was a prospective study of patients treated surgically or non-surgically with early active rehabilitation after Achilles tendon rupture. The mean (SD) age of the patients was 40 (10) years. Patients’ ability to perform a single leg heel-rise, physical activity level (Physical Activity Scale-PAS), patient reported symptoms (using Achilles tendon Total Rupture Score – ATRS and Foot and Ankle Outcome Score – FAOS), general health (EQ-5D) and fear of movement (Tampa Scale for Kinesiophobia-TSK) were evaluated at a mean (SD) 12 (0.9) weeks after injury. At the time of inclusion (baseline) PAS and EQ-5D were measured. The ability to perform a single heel-rise was evaluated by having the participants stand on a box with ankle in neutral position. The patients were classified as being able to perform a single leg heel-rise if they were able to lift the heel at least 2 cm once while keeping the knee straight.
Results : The heel-rise test showed that 40 of 81 (49%) patients were unable to perform a single heel-rise 12 weeks after injury. There was no statistical difference (p=0.269) between surgical and non-surgical group according to heel-rise ability. We found that patients who were able to perform a single legged heel-rise were significantly younger (p=0.005), more often of male gender (p=0.013) and had a higher score in ATRS (p=0.002) and FAOS (p=0.001-0.017) and had a higher degree of physical activity (p=0.022) at 12 weeks. There were significant (p=0.001-0.032) negative correlations (r= -0.239− -0.376) between the TSK score and all the patient-reported outcomes and the physical activity level.
Conclusions : The heel-rise ability appears to be an important early achievement which influences patient reported outcome and physical activity. With current treatment protocols for patients with a complete Achilles tendon rupture, including both surgical and non-surgical interventions, it might not be realistic to expect all patients to achieve a single leg heel-rise 3 months after injury.
Clinical Relevance : Future treatment protocols focusing on regaining strength early seem of great importance. Fear of physical activity and movement need to be addressed early during the rehabilitation process. The heel rise-test can be recommended as part of the evaluation protocol.
Objective
In Achilles tendon injuries, it is suggested that a pathological continuum might be evident from the healthy Achilles tendon to Achilles tendinopathy to Achilles tendon rupture. As such, risk factors for both tendinopathy and rupture should be the same.
Hypothesis
Hereditary and medical risk factors for Achilles tendinopathy and Achilles tendon rupture are the same to a similar extent in a matched pair analysis.
Design
Matched pair study; level of evidence: 3.
Setting
Recreational sportsmen as well as athletes on national level.
Patients
566 questionnaires were analysed. 310 subjects were allocated to 3 groups (A, B, C) after matching the pairs for age, weight, height and gender: (A) healthy Achilles tendons (n = 89, age 39 ± 11 years, BMI 25.1 ± 3.9, females 36%), (B) chronic Achilles tendinopathy (n = 161, age 41 ± 11 years, BMI 24.4 ± 3.7, females 34%), (C) acute Achilles tendon rupture (n = 60, age 40 ± 9 years, BMI 25.2 ± 3.2, females 27%).
Results
We found a positive family history of Achilles tendinopathy as a risk factor for Achilles tendinopathy (OR: 4.8, 95% CI: 1.1–21.4; p = 0.023), but not for Achilles tendon rupture (OR: 4.0, 95% CI 0.7–21.1, p = 0.118). Smoking and cardiac diseases had a lower incidence in Achilles tendinopathy than in healthy subjects (both p = 0.001), while cardiovascular medication did not change the risk profile.
Conclusion
Identifying risk factors associated with Achilles tendon disorders has a high clinical relevance regarding the development and implementation of prevention strategies and programs. This cross-sectional study identified a positive family history as a significant solitary risk factor for Achilles tendinopathy, increasing the risk fivefold. However, in this matched pair analysis excluding age, weight, height and gender as risk factors no further factor necessarily increases the risk for either Achilles tendinopathy or Achilles tendon rupture.
BACKGROUND:
Achilles tendon rupture is a common injury, and its complications can impair function. Numerous operations have been described for reconstructing the ruptured tendon, but these methods can compromise microcirculation in the tendon and can seriously impair its healing. Suturing with a minimally invasive tenocutaneous technique soon after the rupture and systematic functional exercise can greatly reduce the possibility of complications.
METHODS:
Between June 1996 and February 2009, we treated 88 patients (54 males; age range, 21-66 years) with this method.
RESULTS:
After follow-up ranging from 1-7 years, the mean American Orthopedic Foot and Ankle Society ankle-hind foot score was 95 (range, 90-98), and the maximum length of postoperative scarring was 3 cm. One patient re-ruptured his Achilles tendon one year after surgery in an accident, but after 10 months, the repaired tendon was still intact. In another patient, the nervus suralis was damaged during surgery by piercing the tension suture at the near end, causing postoperative numbness and swelling. The tension suture was quickly removed, and the patient recovered well with conservative treatment. No large irregular scars, such as those sustained during immobilization, were present over the Achilles tendon.
CONCLUSION:
Minimally invasive percutaneous suturing can restore the original length and continuity of the Achilles tendon, is minimally invasive, and has fewer postoperative complications than other methods.
Novel surgical technique and early kinesiotherapy for acute achilles tendon rupture.
Jielile J, Sabirhazi G, Chen J, Aldyarhan K, Zheyiken J, Zhao Q, Bai J. Foot Ankle Int. 2012 Dec;33(12):1119-27
Quote:
BACKGROUND:
This prospective study was performed to investigate the contribution of early kinesiotherapy, the active exercise and movement of the ankle and knee joints, following a novel surgical technique for reconstruction of the acutely ruptured Achilles tendon and the underlying mechanisms involved.
MATERIALS AND METHODS:
One hundred and seven patients with an acute Achilles tendon rupture received postoperative early kinesiotherapy treatment following the novel ``Pa-bone'' surgical technique. Clinical outcomes were evaluated using the Achilles tendon rupture score, a score for measuring outcomes related to symptoms and physical activity, and bilateral ultrasonographic examination of the Achilles tendon.
RESULTS:
Range-of-motion recovery equal to the intact side averaged 7~weeks. Double-legged heel rises and sustained single-leg heel rise exercises were possible at an average of 1~week and 60± 2 days, respectively. All patients could perform single-leg heel rise of the injured foot for 60± 23 seconds at an average of 12 weeks. No rerupture was observed. In addition, ultrasonographic examination revealed that the cross-sectional areas of the ruptured tendon were significantly larger than those of the healthy side. Overall reconstruction of the Achilles tendon was obtained for most of the patients.
CONCLUSION:
Postoperative early kinesiotherapy treatment following Pa-bone surgical technique resulted in excellent clinical outcomes and contributed to the overall reconstruction of the Achilles tendon.
Immediate weight bearing after modified percutaneous achilles tendon repair.
Chandrakant V, Lozano-Calderon S, McWilliam J. Foot Ankle Int. 2012 Dec;33(12):1093-7.
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BACKGROUND:
Controversy exists regarding postoperative treatment of Achilles tendon repair. The purpose of this study was to evaluate the results of immediate weight bearing following modified percutaneous Achilles tendon repair using readily available materials.
METHODS:
Fifty-two patients who were treated at a single center from 2000 to 2009 underwent percutaneous Achilles tendon repair by a single surgeon and were allowed immediate weight bearing. They were followed for on average of 2 years postoperatively and evaluated with functional and subjective outcomes.
RESULTS:
The average American Orthopaedic Foot and Ankle Society ankle-hindfoot scale was 96 points (range, 81 to 100), with 95% confidence interval ranging from 89.1 to 102.9. Subjective evaluation demonstrated that 47 patients (90%) were able to return to a desired level of activity, with an overall complication rate of 11.5%.
CONCLUSION:
Immediate weight bearing after percutaneous Achilles tendon repair had a low overall complication rate with good clinical and functional outcomes.
What would happen if the patient never sought medical attention for an achilles tendon rupture?
I had a male patient many years ago with a ruptured achilles tendon with NO TREATMENT
who passed away at 92 yrs and never had any problems?
Steve Levitz
Percutaneous repair of Achilles tendon ruptures with Tenolig: Quantitative analysis of postural control and gait pattern
S. Mezzarobba, S. Bortolato, A. Giacomazzi, G. Fancellu, R. Marcovich, R. Valentini The Foot; Volume 22, Issue 4 , Pages 303-309, December 2012
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Background
Surgical approach in Achilles tendon's rupture involved during the last years has becoming safer and less invasive as possible. Lots of study investigate the outcomes of the mini-invasive technique with Tenolig proving its good results, but never in the long-term.
Objectives
Our study want to emphasize the effectiveness of this treatment exploring the postural and gait patterns in a 24-month follow up.
Method
Patients did self-training exercises without specific supervision, instead of a particular postoperative rehabilitation protocol. We compared 21 patients to a control group of 19 health subjects using a clinical examination, a podobarometric and an optokinetic analysis.
Results
Data shows no differences in time-distance parameters, despite a reduction of propulsion phase data, confirmed also by kinetic analysis. Podobarometric results show only a decrease in the anterior pressure of the injured limb (p=0.09). In standing an increase of anterior–posterior oscillation of the COP (center of pressure) (p=0.03).
Conclusions
The results underline the long-term outcome effectiveness of the technique but some functional alterations remain. This could be the reason of the weakness, which always affected the patients. Reduction of the triceps elongation and restoration of strength during the propulsion phase should be the key points in postoperative physiotherapy.
OBJECTIVE:
Platelet-rich plasma (PRP) can promote wound healing. To observe the effect of PRP injection on the early healing of rat's Achilles tendon rupture so as to provide the experimental basis for clinical practice.
METHODS:
Forty-six Sprague Dawley rats were included in this experiment, female or male and weighing 190-240 g. PRP and platelet-poor plasma (PPP) were prepared from the heart arterial blood of 10 rats; other 36 rats were made the models of Achilles tendon rupture, and were randomly divided into 3 groups (control group, PPP group, and PRP group), 12 rats for each group. In PPP and PRP groups, PPP and PRP of 100 microL were injected around the tendons once a week, respectively; in the control group, nothing was injected. The tendon tissue sample was harvested at 1, 2, 3, and 4 weeks after operation for morphology, histology, and immunohistochemistry observations. The content of collagen type I fibers also was measured. Specimens of each group were obtained for biomechanical test at 4 weeks.
RESULTS:
All the animals survived till the end of the experiment. Tendon edema gradually decreased and sliding improved with time. The tendon adhesion increased steadily from 1 week to 3 weeks postoperatively, and it was relieved at 4 weeks in 3 groups. There was no significant difference in the grading of tendon adhesion among 3 groups at 1 week and at 4 weeks (P > 0.05), respectively. The inflammatory cell infiltration, angiogenesis, and collagen fibers were more in PRP group than in PPP group and control group at 1 week; with time, inflammatory cell infiltration and angiogenesis gradually decreased. Positive staining of collagen type I fibers was observed at 1-4 weeks postoperatively in 3 groups. The positive density of collagen type I fibers in group PRP was significantly higher than that in control group and PPP group at 1, 2, and 3 weeks (P < 0.05), but no significant difference was found among 3 groups at 4 weeks (P > 0.05). The biomechanical tests showed that there was no significant difference in the maximal gliding excursion among 3 groups at 4 weeks postoperatively (P > 0.05); the elasticity modulus and the ultimate tensile strength of PRP group were significantly higher than those of control group and PPP group at 4 weeks (P < 0.05).
CONCLUSION:
PRP injection can improve the healing of Achilles tendon in early repair of rat's Achilles tendon rupture.
The Achilles tendon total rupture score: a study of responsiveness, internal consistency and convergent validity on patients with acute Achilles tendon ruptures
Rebecca S Kearney, Juul Achten, Sarah E Lamb, Nicholas Parsons, Matthew L Costa Health and Quality of Life Outcomes 2012, 10:24 (29 February 2012)
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Background
The Achilles tendon Total Rupture Score was developed by a research group in 2007 in response to the need for a patient reported outcome measure for this patient population. Beyond this original development paper, no further validation studies have been published.
Consequently the purpose of this study was to evaluate internal consistency, convergent validity and responsiveness of this newly developed patient reported outcome measure within patients who have sustained an isolated acute Achilles tendon rupture.
Methods
Sixty-four eligible patients with an acute rupture of their Achilles tendon completed the Achilles tendon Total Rupture Score alongside two further patient reported outcome measures (Disability Rating Index and EQ 5D). These were completed at baseline, six weeks, three months, six months and nine months post injury. The Achilles tendon Total Rupture Score was evaluated for internal consistency, using Cronbach's alpha, convergent validity, through correlation analysis and responsiveness, by analysing floor and ceiling effects and calculating its relative efficiency in comparison to the Disability Rating Index and EQ 5D scores.
Results
The Achilles tendon Total Rupture Score demonstrated high internal consistency (Cronbachs alpha > 0.8) and correlated significantly (p < 0.001) with the Disability Rating Index at five time points (pre-injury, six weeks, three, six and nine months) with correlation coefficients between -0.5 and -0.9. However, the confidence intervals were wide. Furthermore, the ability of the new score to detect clinically important changes over time (responsiveness) was shown to be greater than the Disability Rating Index and EQ 5D.
Conclusions
A universally accepted outcome measure is imperative to allow comparisons to be made across practice. This is the first study to evaluate aspects of validity of this newly developed outcome measure, outside of the developing centre. The ATRS demonstrated high internal consistency and responsiveness, with limited convergent validity. This research provides further support for the use of this outcome measure, however further research is required to advocate its universal use in patients with acute Achilles tendon ruptures. Such areas include inter-rater reliability and research to determine the minimally clinically important difference between scores.
Press Release: Functional rehab avoids surgery for Achilles rupture
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Conservative nonsurgical treatment of acute Achilles tendon rupture is as good as surgery, provided the nonsurgical protocol includes functional rehabilitation, Canadian research shows.
"This resulted in re-rupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications," report Alexandra Soroceanu (Dalhousie University Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia) and colleagues in the Journal of Bone and Joint Surgery.
However, if early range-of-motion rehabilitation is not used, surgery reduces the risk for re-rupture by 8.8%, leaving the researchers to suggest that surgical repair should be preferred at centers that do not employ functional rehabilitation protocols.
Surgery was associated with an absolute 15.8% increased risk for complications other than re-rupture. One complication would be expected for every seven patients treated with surgery, say the researchers.
The team performed a meta-analysis of 10 studies that included 418 patients treated surgically and 408 patients who underwent nonsurgical treatment.
The absolute difference in the re-rupture rate in the pooled analysis was 5.5% favoring surgical repair, a difference that translated into a significant 60% lower relative risk for re-rupture among those treated with surgery.
If a functional rehabilitation protocol with early range-of-motion was used, however, the absolute difference in the re-rupture rate was just 1.7%, a nonsignificant difference between the two treatment approaches.
By contrast, if the treatment protocol included a prolonged period of immobilization after the Achilles rupture, the absolute reduction in the re-rupture risk obtained with surgery was 8.8%, a statistically significant difference.
Without functional rehabilitation, just 12 patients would require treatment with surgery to prevent one tendon re-rupture. Patients treated with surgery returned to work 19 days sooner than those who underwent conservative nonsurgical therapy.
Treatment of the ruptured Achilles tendon without surgery requires the use of a cast, a cast-boot, or a splint with the foot placed in plantar flexion. Surgery, on the other hand, may include open, minimally invasive, or percutaneous repair of the tendon.
Given that not all complications are major, some surgeons and patients "may consider the increased rate of other complications following surgical treatment to be an acceptable trade-off for the reduced re-rupture rate," write Soroceanu and colleagues.
Press Release: Functional rehab avoids surgery for Achilles rupture
Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Trials
Alexandra Soroceanu, MD, CM, MPH, Feroze Sidhwa, MD, MPH, Shahram Aarabi, MD, MPH, Annette Kaufman, MPH, PhD, Mark Glazebrook, MD, PhD J Bone Joint Surg Am, 2012 Dec 05;94(23):2136-2143.
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Background:
Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate.
Methods:
A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion.
Results:
Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226).
Conclusions:
The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients.
Re: Achilles tendon rupture
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