Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials

Minimal incision techniques for acute Achilles repair

This article reviews minimal incision techniques in the treatment of acutely ruptured Achilles tendon and the results that can be anticipated from these methods. However, lack of robust prospective randomized studies on the treatment of Achilles tendon rupture makes it impossible to draw conclusions on optimal treatment strategies. The bulk of the evidence available suggests that surgical repair reduces rerupture rates compared with non-operatively treated tendon ruptures. Surgery does have potential complications, but as outlined in the article, using a mini-open or percutaneous technique of repair might result in highly satisfactory outcomes with acceptably low complication rates.

Complications of the treatment of Achilles tendon ruptures

Since the first reports in the medical literature of treatment of the Achilles tendon, complications have been recognized from both non-operative and operative techniques. These include tendon rerupture, sural nerve morbidity, wound healing problems, changes in tendon morphology, venous thromboembolism, elongation of the tendon, complex regional pain syndrome, and compartment syndrome. This article delineates the incidence for each of these complications, with differing techniques, methods of avoiding these complications and treatment methods if they occur.

Non-surgical management of Achilles ruptures

Incidence of Achilles tendon injury has increased as people continue to be active in their later years. Although acute rupture of the Achilles tendon is most commonly diagnosed using history and physical examination, improvements in magnetic resonance and ultrasound imaging have led to their routine use in evaluating these injuries. Non-operative versus operative management of acute Achilles tendon ruptures has been the subject of much controversy in the current literature, especially in light of non-operative treatment with functional bracing. This article highlights the current controversy and outlines the rationale for nonsurgical treatment of acute Achilles tendon ruptures.

Open repair of acute Achilles tendon ruptures

Although the Achilles tendon is the strongest in the body, it also is the most often ruptured. Achilles tendon rupture most often occurs during sports activities in middle-aged men. Operative repair of a ruptured Achilles tendon can be accomplished with a variety of techniques, ranging from open repair, to minimally invasive technique, to endoscopic-assisted repair. This article focuses on open repair of acute Achilles tendon rupture. Surgical techniques, rehabilitation protocol, and the authors' preferred method are described.

Minimally invasive surgery of the achilles tendon

Minimally invasive surgical techniques for pathologies of the Achilles tendon (AT) hold the promise to decrease perioperative morbidity, allow faster recovery times, shorten hospital stays, and improve functional outcomes when compared with open procedures, which can lead to difficulty with wound healing because of the tenuous blood supply and increased chance of wound breakdown and infection. This article presents recent advances in the field of minimally invasive AT surgery for tendinopathy, acute ruptures, and chronic tears. All of the techniques described in this article are inexpensive and do not require highly specialized equipment and training. Future randomized controlled trials are required to address the issue of the comparison between open versus minimally invasive AT surgery.

Achilles tendon recurrent rupture following surgical repair: report on two cases

BACKGROUND

Rerupture is a main complication in Achilles tendon rupture surgery, with an incidence of 2-8%. Although wound break-down and rerupture are well known complications, spontaneous open rerupture has not been previously reported to the authors' knowledge.

METHODS

We report on two cases of open rerupture of Achilles tendon following augmented repair, through a transverse wound perpendicular to the primary incision line. Reruptures occurred 80 and 54 days after primary repair.

RESULTS AND CONCLUSIONS

After surgical repair long term follow-up results are good in both cases. This complication could be related to subtotal closure of the paratenon due to the bulk of the augmented repair and to an inadequate and a too extended period of postoperative ankle immobilization.

Treatment of acute Achilles tendon rupture: fibrin glue versus fibrin glue augmented with the plantaris longus tendon

In the surgical repair of Achilles tendon ruptures, suturing is standard, although fibrin glue also has been used for repair since the 1980s. Augmentation with the plantaris longus tendon is also a popular technique; however, no study has yet compared the outcome of augmented versus only glued repair of ruptured Achilles tendons. This study compares the long-term results of surgical repair of Achilles tendon rupture with fibrin glue versus fibrin glue augmented with the plantaris longus tendon. Forty patients who had undergone Achilles tendon repair with fibrin glue took part in a follow-up examination after an average of 11.5 years. The fibrin group consisted of 16 patients and the fibrin glue augmented with plantaris longus tendon group consisted of 15 patients. The modified Thermann score (adapted from Weber) and results of an isokinetic force measurement were the same in both groups, whereas complications in the 2 groups also did not differ. We conclude that augmentation with the plantaris longus tendon is not necessary when operatively treating acute ruptured Achilles tendons with fibrin glue.

LEVEL OF CLINICAL EVIDENCE

2.

Open minimally invasive Achilles tendon repair with early rehabilitation: functional results of 25 consecutive patients

BACKGROUND

Various treatment techniques have been described for the treatment of acute Achilles tendon rupture. However, there is no consensus among orthopaedic surgeons regarding the surgical technique and the postoperative rehabilitation program. Mid-term functional outcome results of the patients who had undergone open minimally invasive repair of fresh Achilles tendon ruptures followed by an early rehabilitation programme were evaluated.

METHODS

Twenty-five consecutive patients who underwent open minimally invasive repair of Achiles tendon ruptures during January 2004-October 2005 were independently reviewed at an average follow-up of 34 months (range 24-45 months). The mean age of the patients was 41 (35-47). A functional rehabilitation protocol based on early range of motion exercises was used after surgery. The American Orthopaedic Foot and Ankle Society score was used to evaluate the outcomes of the patients. Ankle range of motion; thigh, calf and ankle circumferences of the injured leg and the contralateral side, return to work and sports activities time were evaluated.

RESULTS

One patient had a partial rerupture and one had superficial wound infection. The mean American Orthopaedic Foot and Ankle Society score was 93 (80-100). Patients returned to work at 3 weeks (range 1-5 weeks) and to preinjury sportive activities at 3 months (range 2-4 months). Ankle ROM and circumference measurements did not reveal a significant difference between the two sides.

CONCLUSION

These results suggest that open minimally invasive Achilles tendon repair and an early rehabilitation programme provides satisfactory results with early return to previous functional status with low complication rates.

Achilles tendon ruptures, re rupture with revision surgery, tendinosis, and insertional disease

Achilles tendon pathology is one of the more common conditions encountered by the foot and ankle surgeon. While it most frequently affects the athletic population, it can also lead to significant morbidity in the older and sedentary patient. The etiology of Achilles tendon dysfunction is multifactorial and has been found to be associated with overuse injury, training error, malalignment of the lower extremity, inflammatory disorders, and intrinsic disease or degeneration. Achilles tendon disorders have been classified temporally as acute and chronic, with the later subdivided into insertional and non-insertional (intrinsic) involvement. Histopathology has contributed a great deal to the understanding of disease process. Classification systems have been developed in an attempt to determine methods of treatment and prognosis. This article reviews the clinical spectrum of disease and presents contemporary treatment options.

Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture

The use of fibrin glue for repairing Achilles tendon ruptures was introduced in the 1980s. Although fibrin glue has been in regular use since that time, suturing remains the standard for surgical repair. Studies have indicated that, in the short term, fibrin glue is as effective as suturing. To date, there have been no long-term studies comparing the outcomes of these 2 techniques. This study compares the long-term results of surgical repair of Achilles tendon rupture with sutures versus fibrin glue. Forty-two patients who had undergone Achilles tendon repair with either suture or fibrin glue took part in a follow-up examination after an average of 12.1 years. The fibrin group consisted of 31 patients and the suture group consisted of 11 patients. Patients treated with fibrin glue reached a higher modified Thermann score (adapted from Weber), achieved equal results in an isokinetic force measurement, and showed fewer complications. The authors concluded that the use of fibrin glue for the repair of ruptured Achilles tendon is a suitable alternative to traditional sutures.

LEVEL OF CLINICAL EVIDENCE

2.

Repair of achilles tendon rupture under endoscopic control

PURPOSE

To evaluate the functional outcomes and complications after endoscopically assisted percutaneous repair of Achilles tendon rupture.

METHODS

An arthroscopically assisted percutaneous repair was performed in 20 patients between the ages of 28 and 47 years. Two patients were suffering from a long-standing rupture. Follow-up was 2.5 years. Evaluation entailed Merkel's scale for pain, functional load (weight) bearing capacity, and the heel raise test. For statistical analysis, a random effects Poisson regression model was used.

RESULTS

All patients achieved good to excellent outcomes. The median score on Merkel's scale was 600. All patients were able to stand on the tiptoe of the operated leg and none had limitations placed on their daily activities. A 12% decrease in maximum torque and 16.5% decrease in work performance of the injured side were noted. There was no statistical significant difference in the heel raise test between the operated and non-operated leg. No wound problems, re-ruptures, or infections were reported. Two patients (10%) had sural neuralgia; in 1 case, it subsided without further treatment.

CONCLUSIONS

Endoscopy in percutaneous Achilles tendon repair is useful in determining the initial gap and providing adequate apposition of the tendon ends. It is a safe technique with good outcomes and minimal complications. Despite its promising results, potential problems include sural neuralgia and some decrease in strength.

Percutaneous and mini-open repair of acute Achilles tendon rupture

Treatment of acute Achilles tendon rupture is slowly evolving, but a lack of prospective, randomized trials leaves insufficient evidence for a definitive recommendation as to the best treatment. Percutaneous and mini-open techniques certainly have roles in treating the acutely ruptured Achilles tendon, and some trials suggest that these techniques can give results equivalent to or better than those of an open repair, with the added benefit of fewer complications. These findings have been backed up by a recent meta-analysis.

A preliminary study on the effects of acellular tissue graft augmentation in acute Achilles tendon ruptures

Acute Achilles tendon rupture injuries present surgical challenges because of the mechanical forces placed on this tendon. The purpose of this study was to evaluate the effectiveness of an acellular human dermal tissue matrix, GraftJacket Matrix (Wright Medical Technology, Inc., Arlington, TN), as an augmentation material in acute Achilles tendon repair. Eleven consecutive patients with acute tendon ruptures were evaluated and followed up (20-31 months). Primary repair was followed by augmentation with the graft sutured circumferentially around the tendon. Patients were placed in an early functional rehabilitation program with postoperative evaluation at 3, 6, and 12 months. Outcome scores were calculated based on the American Orthopaedic Foot and Ankle Society ankle-hindfoot scoring system. At 20-month postoperative follow-up, there have been no cases of rerupture or recurrent pain. The average return-to-activity time was 11.8 +/- 0.75 weeks. These retrospective clinical results suggest that with an acellular human dermal tissue matrix to augment acute Achilles tendon, primary repair offers a desirable return-to-activity time without any rerupture or complications. ACFAS Level of Clinical Evidence: 2c.

Pulmonary embolism associated with spontaneous bilateral Achilles tendon rupture

Bilateral Achillies tendon ruptures are a rare occurrence that usually occur in patients with chronic systemic disease. Many cases are also associated with corticosteroid or fluoroquinolone use. Nonoperative treatment is generally indicated in this patient population, as the patients are often considered poor surgical candidates. Nonoperative immobilization, however, conveys the risk of developing deep venous thrombosis and pulmonary embolism. Such risks are even greater in patients displaying bilateral Achilles tendon ruptures. In this report, we illustrate the case of a near-fatal pulmonary embolism as associated with bilateral spontaneous Achilles tendon ruptures. We also review the current literature and make recommendations for prophylaxis and treatment of these potentially devastating complications.

Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes

PURPOSE

To retrospectively review the clinical outcome and incidence of post-operative complications after open end-to-end repair of acute Achilles tendon ruptures.

METHODS

Seventy consecutive patients (74 open Achilles tendon repairs) operated on between 1989 and 2002 were identified for inclusion in this investigation. The medical records were reviewed and patients were contacted for a follow up interview in order to survey their post-operative function. Outcome scores were calculated based on the Boyden outcome and AOFAS ankle-hindfoot scoring systems. Post-operative complications were documented during the chart review and follow up interview, including an additional nine patients (nine repairs), who were not included in the clinical evaluation portion of the study.

RESULTS

Fifty-two patients (54 repairs) were successfully contacted and completed the follow up interview. Within this cohort there were 44 males and 8 females with a mean age of 41 years. Achilles tendon rupture in this population was attributable to participation in athletic activity in 87% of cases. At a mean post-operative follow up of 45 months, 96% of cases achieved an overall Boyden outcome score of good to excellent. The mean AOFAS ankle-hindfoot score was 96, with 74% of cases scoring greater than 90. Forty-two cases (78%) reported no pain and 40 cases (74%) reported no activity limitations. Fourteen post-operative complications were identified after 83 open Achilles tendon repairs, resulting in an institutional complication rate of 16.8%. The complications included four superficial wound infections, five deep wound infections requiring irrigation and debridement, one heel ulcer secondary to post-operative boot wear, three partial Achilles tendon re-ruptures, and one complete Achilles tendon re-rupture.

CONCLUSION

Our results demonstrate that open end-to-end repair of acute Achilles tendon ruptures provides long-term functional outcomes with consistent good to excellent results. However, this high clinical success rate was associated with a relatively high incidence of post-operative complications. With careful attention to the surgical wound and patient adherence to post-operative rehabilitation protocols, operative repair of acute Achilles tendon ruptures is a reliable treatment for active patients.

The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment

BACKGROUND

There is still controversy regarding the optimal surgical technique and post-operative treatment of acute Achilles tendon ruptures. We evaluated a treatment protocol for Achilles tendon ruptures consisting of a minimally invasive Achilles tendon repair combined with early full weight bearing.

METHODS

A consecutive group of 163 patients was prospectively followed during a 6 year period (1998-2004) in one university hospital and five teaching hospitals. Data were collected during the outpatient department visits at 1, 3, 5, and 7 weeks, 4 months and 12 months after the intervention. Outcome parameters were the incidence of re-rupture, other complications, the functional outcome and the period of sick leave concerning work and sport.

RESULTS

The patient group consisted of 128 men (79%) and 35 women (21%). The mean operating time was 41 min. In 9 patients (5.5%) a major complication occurred, necessitating 5 surgical re-interventions (2 for re-ruptures, 2 for infections and 1 for tendon necrosis). Fifteen patients (9.2%) suffered from dysfunction of the sural nerve. The median time of returning to work was 28 days (range 1-368) and the median time of returning to sport was 167 days (range 31-489). The majority of patients (150; 92%) were satisfied with the results.

CONCLUSION

Minimally invasive Achilles tendon repair in combination with a functional rehabilitation program is a safe and quick procedure with a low rate of re-rupture and a high level of patient satisfaction.

Bilateral spontaneous and simultaneous rupture of the Achilles tendons secondary to exercises for limb ischemia: A case report

Exercise is proven to be safe and effective treatment and is prescribed routinely for the conservative management of intermittent claudication. Before advising about the exercises, the assessment of these patients rarely includes risk factors for the Achilles tendon rupture. We present a case report of bilateral simultaneous and spontaneous rupture of the Achilles tendons secondary to the exercises prescribed for intermittent claudication in a patient with significant risk factors for Achilles rupture.

SURGICAL REPAIR FOLLOWED BY FUNCTIONAL REHABILITATION FOR ACUTE AND CHRONIC ACHILLES TENDON INJURIES: EXCELLENT FUNCTIONAL RESULTS, PATIENT SATISFACTION AND NO RERUPTURES

BACKGROUND

We evaluated 46 patients who underwent surgical repair of the Achilles tendon at our institution during a 4.5-year period, followed by early weight bearing, aiming to assess their return to activities, rerupture rate and satisfaction.

METHODS

A cohort of 46 patients who underwent Achilles tendon repair at our institution during a 4.5-year period, with a modified triple mini-Becker suture technique, for both acute as well as chronic Achilles tendon ruptures were studied. These patients were reviewed at a minimum of 2.5 years follow up (average 4.5 years ranging from 2.5 to 6.5 years), by chart review and questionnaire, to determine the functional outcome as well as patient satisfaction following an active postoperative protocol involving full weight-bearing ambulation in a controlled ankle motion walker and active stretching, followed by a graduated strengthening programme.

RESULTS

We found a very high level of satisfaction, with few minor complications and no reruptures in either the early or the delayed repair groups.

CONCLUSION

We believe that surgical repair using this technique associated with an early return to protected full weight-bearing ambulation and an active early rehabilitation programme provides not only excellent functional results, patient satisfaction and a zero rerupture rate, but also much less morbidity in the first 3 months and a quicker overall recovery compared with non-operative treatment.

Postoperative imaging of the ankle and foot

This article describes the relevant surgical detail and MR imaging appearance of common operations performed in the foot and ankle. To evaluate postsurgical patients critically, it is important to understand the primary clinical diagnosis, surgical treatment undergone, the interval since surgery, and patients' current clinical symptoms. Radiography is the most common imaging modality for evaluation of the postoperative ankle and foot. MR imaging may be useful for evaluating the soft tissues and osseous structures in the postsurgical foot and ankle.