Medscape Complete Ruptures of the Achilles Tendon

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Complete Ruptures of the Achilles Tendon Todd Sterling Atkinson, MD, Mark Easley, MD Posted: 05/11/2001; Medscape Orthopaedics. 2001;5(3) © 2001 Medscape Abstract Although Achilles tendon ruptures may occur in young athletes, they generally occur in 30- to 40-year-old sedentary males who overexert themselves, usually on weekends. The patient typically presents with pain, ecchymosis, and a history of an audible "pop" in the calf. Usually in these cases, a gap is palpable 2 cm to 6 cm above the insertion of the Achilles tendon; the patient is unable to perform repetitive heel rises; and Thompson, Copeland, and O'Brien tests scores are positive. Usually the diagnosis is made on clinical grounds, but MRI and ultrasound can be useful when the diagnosis is uncertain. During the late 1980s and 1990s, surgical treatment was favored in young active patients and in those with chronic tears. Although simple end-to-end repair achieves good results in acute tears, chronic tears usually require some type of augmentation. The trend in postoperative rehabilitation is moving toward progressive functional protocols. Background Although the Achilles tendon is the thickest, strongest, most powerful tendon in the human body, it can be vulnerable to injury. One of the best known descriptions of an Achilles tendon injury occurred in Homer's, The Iliad. After learning of the prophecy that her son would die in battle, Thetis immersed Achilles into the river, Styx, to render him invulnerable to injury. Unfortunately, in holding Achilles by the ankles, the magic water failed to touch his heels, which later left him victim to a poisonous arrow. [1] Achilles tendon ruptures are often in the media spotlight as because they have incapacitated many famed athletes, such as football

Transcript of Medscape Complete Ruptures of the Achilles Tendon

Page 1: Medscape Complete Ruptures of the Achilles Tendon

 Complete Ruptures of the Achilles TendonTodd Sterling Atkinson, MD, Mark Easley, MD

Posted: 05/11/2001; Medscape Orthopaedics. 2001;5(3) © 2001 Medscape

Abstract

Although Achilles tendon ruptures may occur in young athletes, they generally occur in 30- to 40-year-old sedentary males who overexert themselves, usually on weekends. The patient typically presents with pain, ecchymosis, and a history of an audible "pop" in the calf. Usually in these cases, a gap is palpable 2 cm to 6 cm above the insertion of the Achilles tendon; the patient is unable to perform repetitive heel rises; and Thompson, Copeland, and O'Brien tests scores are positive. Usually the diagnosis is made on clinical grounds, but MRI and ultrasound can be useful when the diagnosis is uncertain. During the late 1980s and 1990s, surgical treatment was favored in young active patients and in those with chronic tears. Although simple end-to-end repair achieves good results in acute tears, chronic tears usually require some type of augmentation. The trend in postoperative rehabilitation is moving toward progressive functional protocols.

Background

Although the Achilles tendon is the thickest, strongest, most powerful tendon in the human body, it can be vulnerable to injury. One of the best known descriptions of an Achilles tendon injury occurred in Homer's, The Iliad. After learning of the prophecy that her son would die in battle, Thetis immersed Achilles into the river, Styx, to render him invulnerable to injury. Unfortunately, in holding Achilles by the ankles, the magic water failed to touch his heels, which later left him victim to a poisonous arrow.[1]

Achilles tendon ruptures are often in the media spotlight as because they have incapacitated many famed athletes, such as football quarterbacks Dan Marino and Vinny Testaverde. About 75% of all Achilles tendon ruptures occur during sporting events.[2] However, the average victim of a complete Achilles tendon rupture does not engage in highly competitive professional athletics. Rather, the victim is usually the so-called "weekend warrior." This weekend warrior is typically a 30- to 40-year-old, sedentary, male, white-collar worker, who over-exerts himself while playing sports on the occasional weekend. This overexertion most commonly occurs while playing basketball (United States), badminton (Sweden), and soccer (Germany).[3]

With the increased popularity in recreational athletics, Western countries have watched the weekend warrior, and his associated injuries, flourish. Prior to 1929, fewer than 66 cases of Achilles tendon ruptures were reported in the literature.[2] In 1956, the Achilles tendon became the third most frequent tendon torn, following the finger and knee extensors.[4] Then, in 1989, it became the most frequently torn tendon and constituted 40% of all operated tendon ruptures.[2] According to a report from the University of Aberdeen Hospital in Scotland, Achilles tendon repairs are performed roughly every 7 to 10 days.[5]

In contrast, the incidence remains very low in underdeveloped countries, for example, those of Africa and East Asia.[6] Although inhabitants of these countries may be less physically vigorous on intermittent

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weekends, they are likely to be more active during the week than Western weekend warriors. The typical weekend warrior spends the work day in an air-conditioned office 5 or 6 days a week, those in less developed countries typically exercise their tendons and muscles during their daily routine.

Mechanism of Injury

The weekend warrior ruptures the Achilles tendon in 1 of 3 ways. Most often, they occur when pushing off the weight-bearing foot while extending the knee joint, which occurs during sprinting or jumping. Because the right-handed warrior is apt to push off with the left leg, left Achilles tendon rupture is more prevalent in this population. Approximately 17% of ruptures occur when the warrior suddenly and unexpectedly dorsiflexes his ankle when stepping into a hole, falling forward, or slipping on a ladder. [7]

Approximately, 10% of ruptures result from jumping/falling from a height and violently dorsiflexing the plantarflexed foot.[7]

Although previous studies have reported male to female rupture ratios between 2:1 and 19:1, recent experiences at Union Memorial Hospital in Baltimore, Maryland, reflect a 30:1 ratio. [6] It is not known whether these widely varying ratios merely reflect a larger number of male vs female weekend warriors in the regions studied or whether the male tendon is somehow more susceptible.

Drug- and Disease-Related Risk Factors

Both corticosteroids and anabolic steroids as well as fluoroquinolones have been implicated in playing a role in Achilles tendon ruptures. The injection of corticosteroids into the tendons of rats has been shown to cause tendons necrosis.[1] Although injection into peritendinous areas is less detrimental, corticosteroids, nonetheless, inhibit healing. In addition, corticosteroids may mask painful symptoms, causing the individual to overexert a weakened tendon. Furthermore, both anabolic steroids[3] and fluoroquinolones[6] cause dysplasia of collagen fibrils, which, in turn, decrease tendon tensile strength. A recent study showed that animals administered fluoroquinolones at doses comparable to those given to humans had disruption of their extracellular cartilage matrix and a depletion of collagen. [1] Other reported causes of Achilles tendon ruptures include gout, hyperthyroid, renal insufficiency, and arteriosclerosis.[6]

Physical Examination

Along with gathering a detailed history, a careful physical exam is critical to diagnosing an Achilles tendon rupture. The classic findings are a palpable and painful defect 2 cm to 6 cm proximal to the tendo-calcaneal insertion. The reason for this distribution of injuries is not entirely clear, although some studies suggest that the blood flow in this vicinity is relatively poor.[3] Also, the leg bruises in the area of the tear and the patient has weak plantarflexion.

Despite the seemingly straightforward history and physical, about 25% of Achilles tendon ruptures are missed during the patient's first visit.[8] Although the patient initially feels the pain of a violent kick, or even a "gunshot," pain may not be present on palpation. In addition, the typical ecchymosis and edema may not be present early. If swelling is present, it can obliterate any palpable defect. The physician may incorrectly diagnose a "partial tear" if the patient can still plantarflex his ankle. This paradox is due to the functional flexor hallucis longus, flexor digitorum longus, posterior tibial, and peroneal tendons.

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These pitfalls can be avoided by using a few simple tests. First, the patient should be instructed to perform repetitive heel rises. Despite the other functioning plantarflexors, the patient with a torn Achilles tendon will be unsuccessful in this attempt. The well-known Thompson test can aid in the diagnosis. This is done by simply squeezing the midcalf of the affected leg, which is kneeling (90-degree angle) on a chair while the opposite leg remains standing. The absence of ankle plantarflexion is suggestive of a complete Achilles tendon rupture and is termed a "positive" Thompson test (Figure 1).

Figure 1.  Ruptured Achilles tendon, as indicated by absence of plantarflexion motion on Thompson testing.

Although relatively reliable, the Thompson test can be equivocal. In such cases, one or both of the following tests can be used. The Copeland test involves having the patient lie prone while flexing his knee to ninety degrees. A sphygmomanometer cuff is then placed around the bulk of the calf and inflated to 100 mm Hg with the ankle plantarflexed. When the ankle is dorsiflexed, the calf pressure in normal controls increases to about 140 mm Hg. In contrast, the pressure in those with a torn Achilles tendon will change by merely a flicker. It should be noted that the opposite leg may be used as a control for comparison purposes.[9]

Recently, O'Brien[8] described a test in which a 25-gauge needle is placed 10 cm proximal to the superior border of the calcaneus such that it penetrates the Achilles tendon. The ankle is then alternated with passive dorsiflexion and plantarflexion movements. If the needle end tilts such that it points in the direction opposite the movement, then the Achilles tendon is noted to be intact. However, if it remains relatively still, a rupture is the diagnosis.

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Ultrasonography and MRI

A careful history and physical examination as described above should result in an accurate diagnosis in more than 90% of patients. However, some patients and physicians may opt to forego the Copeland and O'Brien tests due to the pain involved and possible inaccurate results due to inexperience. If the diagnosis remains questionable, either ultrasound or MRI can be helpful.

Ultrasound scanning will show an intact Achilles tendon as a hypoechogenic ribbon-like image contained within 2 hyperechoic bands (Figure 2).[10] When torn, the distal stump will be grossly thickened and contain an irregular echogenic pattern. This correlates with the operative findings of a degenerative stump surrounded by inflammatory cells. The site of the tear will also show a hyperechogenic area consistent with a partially organized hematoma (Figure 3).[10] Ultrasound is noninvasive, inexpensive, nonionizing, and fast. Unfortunately, it may not be sensitive in differentiating between partial and complete tears and its interpretation often requires a steep learning curve.

Figure 2.  Ultrasonographic appearance of a normal Achilles tendon -- a hypoechogenic ribbon with well-defined anterior border. Large arrow shows posterior subcutaneous fat; small arrow shows anterior border of the tendon; triangle placed at Kager's triangle. TE = tendon; TI = tibia; CA =

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calcaneus; K = Kager's triangle; H = hematoma; SF = subcutaneous fat. Reprinted with permission from Maffulli N, et al. J Sports Med. 1989:29:365-368.[10]

Figure 3.  Ultrasonographic appearance of a ruptured Achilles tendon. Smaller arrow shows rupture site; 2 larger arrows show swollen tendon distal to rupture site; hollow arrow shows hyperechogenic hematoma which obscures anterior wall of tendon. TE = tendon; TI = tibia; CA = calcaneus; K = Kager's triangle; H = hematoma; SF = subcutaneous fat. Reprinted with permission from Maffulli N, et al. J Sports Med. 1989:29:365-368.[10]

On MRI, an intact Achilles tendon will have low signal intensity on all pulse sequences; any increased signal intensity within the tendon is viewed as abnormal. The sagittal T1 images can differentiate fat from hemorrhage. It will show high signal intensity at a rupture site filled with edema and hemorrhage. In contrast, sagittal T2 images are best for delineating the size of the gap and the condition/orientation of the torn fibers (Figures 4A and 4B).[11] Although more time consuming and expensive, MRI is generally superior to ultrasound in differentiating hemorrhage from tendon at the rupture site as well as differentiating partial from complete tears.

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Figure 4.   (A) T1-weighted (TR 600, TE 20) sagittal image showing Achilles tendon tear between black arrowheads via obliteration of normally high signal pre-Achilles fat. soft tissue components not identifiable because this imaging sequence cannot differentiate between blood from tendon. (B) T2-weighted (TR 2000, TE 90) sagittal image shows 2-cm gap composed of high signal blood and fragments of low signal unopposed tendon (arrowheads). Arrow shows distal end of tendon has high signal intensity representing intratendinous hemorrhage. Reprinted with permission from Keene JS, et al. Am J Sp Med. 1989:17:333-337.[10]

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Figure 4.   (A) T1-weighted (TR 600, TE 20) sagittal image showing Achilles tendon tear between black arrowheads via obliteration of normally high signal pre-Achilles fat. soft tissue components not identifiable because this imaging sequence cannot differentiate between blood from tendon. (B) T2-weighted (TR 2000, TE 90) sagittal image shows 2-cm gap composed of high signal blood and fragments of low signal unopposed tendon (arrowheads). Arrow shows distal end of tendon has high signal intensity representing intratendinous hemorrhage. Reprinted with permission from Keene JS, et al. Am J Sp Med. 1989:17:333-337.[10]

In addition to aiding in the diagnosis, ultrasound and MRI can help the surgeon determine (1) whether to operate and (2) which operation is best. For example, if the test shows the intertendinous gap to be small with well-oriented fibers, the chances of the tendon healing with conservative treatment are likely to be greater. Some physicians use serial ultrasounds in patients who have received nonsurgical treatment to detect an increased gap that may lead to poor healing and is at increased risk for re-rupture.

Treatment of Acute Achilles Tendon Ruptures

Nonsurgical Treatment

The choice of treatment for acute ruptures of the Achilles tendon continues to be controversial. Nonsurgical treatment was favored prior to the turn of the century and regained favor during the 1970s. The conservative camp argues that equally good results can be obtained with cast immobilization without the complications associated with surgery. In 1972, Lea and Smith [12] reported on 66 patients who underwent 8 weeks of below-the-knee cast immobilization with the foot in gravity equinus. The patients gradually increased their weight bearing and used a 2.5-cm heel lift for 4 weeks after cast

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removal. Although 11% re-ruptured their tendon, 52 out of 55 patients stated they were satisfied with their result. One year later, The Lancet published an editorial stating, "... in view of the excellent results obtainable by conservative treatment it is doubtful whether surgical repair in closed rupture of the Achilles tendon can be justified."[13] In the late 1970s Lildholt[14] and Termansen[15] used similar protocols; Lildholt's series showed 11 of 14 patients to be satisfied, and Termansen's series showed 10 of 12 patients to be satisfied.

In 1981, Nistor[16] published the first prospective randomized trial comparing surgical versus nonsurgical treatment of Achilles tendon ruptures. He found that the rate of re-rupture in the surgical group was 4% vs 8% in the nonsurgical group. However, because the nonsurgical patients had a shorter hospital stay, less absenteeism from work, , regained levels of strength similar to those seen in surgical patients, and a had a lower rate of complications, he favored conservative treatment.[16]

In the largest study of 775 patients, the overall complication rate of surgically treated Achilles tendon ruptures was 20%.[6] These complications include skin necrosis, wound infection, sural neuromas, adhesions of the scar to the skin, and the usual anesthesia risks. Problems with wound healing remain the most common and most difficult to manage given the degree of avascularization around the heel cord. Members of the conservative camp point out that the options for soft tissue coverage over the Achilles tendon are limited. Unfortunately, skin grafts will not adhere to an exposed tendon and local flaps may result in an unsightly donor site and an unacceptable scar. Therefore, these large defects often require a microvascular free flap from the forearm, groin, tensor fascia lata, or the latissimus dorsi.

Studies regarding conservative management of Achilles tendon ruptures have been based on protocols involving extended periods of rigid immobilization. Many authors used below-knee casts for 6 to 12 weeks with the casts first being set with the feet in gravity equinus. The cast was then changed at various intervals, placing the foot in greater dorsiflexion at each change. The last change brought the foot to a plantigrade position (Figures 5A and B). Patients eventually were allowed to bear weight with crutches while in the cast and were instructed to work toward full weight bearing at a gradual pace. [5,12,17-19] Many authors also used a heel lift for 6 weeks after cast removal.[5,12,16-18]

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Figure 5.  Casting for nonsurgical treatment of ruptured Achilles tendon. (A) Patient is seated and foot placed in gravity equinus. (B) Below-knee or above-knee cast is placed with foot in gravity equinus. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed St. Louis, Missouri: Mosby, Inc; 1999:826-861.[38]

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Figure 5.  Casting for nonsurgical treatment of ruptured Achilles tendon. (A) Patient is seated and foot placed in gravity equinus. (B) Below-knee or above-knee cast is placed with foot in gravity equinus. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed St. Louis, Missouri: Mosby, Inc; 1999:826-861.[38]

Recently, a more functional protocol has been used. Saleh and colleagues[20] compared a group of patients who were placed in a rigid cast for 8 weeks with a group that was placed in a rigid cast for 3 weeks followed by a Sheffield splint for 6 to 8 weeks. This splint is an ankle-foot orthosis that holds the ankle at 15 degrees of plantar flexion and allows controlled motion with physical therapy. The group with the splint gained dorsiflexion motion more rapidly, returned to normal activities quicker, and preferred the splint to the cast. In addition, there was no increased rate of re-rupture. Whether this protocol will influence more surgeons to opt for non-operative treatment remains to be seen.

Surgical Treatment

Despite the resurgence of the conservative camp in the 1970s, surgery has been the first choice of treatment for Achilles tendon ruptures in young fit individuals since the late 1980s. Advances in surgical

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techniques and new postoperative rehabilitation protocols have resulted in studies showing the advantages of direct tendon repair.[6,17,18,19,21]

With conservative treatment, extensive scarring often fills the gap between the torn tendons. This leads to a lengthened tendon, which, in turn, leads to decreased push-off strength. In separate studies, Helgeland[22] and Inglis[17] and colleagues showed that surgical treatment of Achilles tendon rupture resulted in increased strength. Cetti and colleagues[18] and Haggemark[23] independently showed that direct repair resulted in less calf atrophy when compared with non-surgical treatment. Mendelbaum and colleagues[19] showed that those undergoing direct repair lost only 2.6% of their strength when undergoing isokinetic testing and that 92% of athletes were able to return to their respective sports at a similar level at 6 months postoperatively. Cetti and colleagues [18] also showed a higher number of patients returning to their pre-injury athletic level. In addition, surgical repair appears to significantly increase the strength in those suffering re-ruptures. Those treated surgically for the second time increased their level of strength by 85% compared with a 51% strength gain in those treated conservatively.[3]

Perhaps the most well known benefit of surgical repair is the decreased re-rupture rate. Despite favoring nonsurgical treatment, Nistor[16] noted that those treated conservatively had an 8% re-rupture rate while those treated surgically had a 4% rate. Recent studies show an even greater difference. Cetti and colleagues[18] reported re-rupture rates of 1.4% 13.4% for surgical and conservative repair, respectively. In a meta-analysis by Kellam and coworkers,[21] re-rupture rates were found to be 1% and 18% for surgical and conservative repair, respectively. Even more impressive is a study by Inglis and colleagues[16] who reported that none of the 44 patients receiving direct repair re-ruptured, whereas 9 of 24 patients treated nonsurgically did re-rupture.

In contrast to Nistor's 1981 study,[16] more recent studies[18,24] show an increased complication rate in those treated conservatively. One prospective randomized study reported complication rates of 11.8% in patients treated surgically vs 18% for those treated nonsurgically;[18] 96.6% of the complications in the surgical group were considered minor. Leppilehti and coworkers[24] noted that complications related to surgery did not significantly influence the long term outcome as most of them were minor wound healing problems which eventually healed.

Increased operative treatment also leads to more experience in treating complications effectively. For example, it is now shown that physical therapy can overcome many of the problems associated with adhesions between the repair site and the skin.[6] Moreover, the vast majority of superficial wound infections can be treated effectively with limited weight bearing, oral antibiotics, and silver sulfadiazine (Silvadene).[6] Once the tissue granulates, the wound can simply be treated with wet to dry dressing changes; only in rare circumstances is a local or a free flap necessary.

Those favoring surgical treatment also point out the relatively uncomplicated nature of the procedure. There is no evidence showing that primary augmentation is more effective than simple end-to-end repair in acute tears. Therefore, more extensive procedures using tendon transfers, flaps, or mesh are best left for use with delayed tears, in which the repair will be under tension due to the chronically retracted ends.

Surgical Technique

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The patient is placed in the prone position with both prepped feet dangling from the end of the table. By placing the table in Trendelenburg, the feet receive less blood flow. An 8-cm to 10-cm longitudinal incision is made just medial to the Achilles tendon. A posterior lateral incision would place the sural nerve at risk and a mid-posterior incision can result in suture interference from the tendon repair site. After dissecting through the subcutaneous tissues, the paratenon is cut longitudinally with Mayo scissors. As the ruptured ends often have a "mop-end" appearance (Figures 6A-6C), some surgeons will wait one week before repair in order to allow the ends to better consolidate. After juxtaposing the ends, the tendon is sewn together with non-absorbable suture via a Krackow (Figure 7) or Bunnell stitch. Prior to tying the suture ends, the tendon's dynamic resting tension is optimized by comparing it with the control side. A circumferential stitch is used to further strengthen the repair site. After closing the paratenon, the plantaris fascia can be fanned out over the repair site to help prevent adhesions with the undersurface of the skin. The subcutaneous tissue is then approximated with absorbable suture and the skin sewn together in a nylon mattress fashion. A fasciotomy of the deep posterior compartment can facilitate closure in cases with excessive skin tension.[6] This allows for improved closure of the paratenon as well.

Figure 6.  Acute Achilles tendon ruptures. (A) Separation of fragments with lack of tendon fraying. (B) Rupture with marked tendon fraying. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]

Figure 6.  Acute Achilles tendon ruptures. (A) Separation of fragments with lack of tendon fraying. (B) Rupture with marked tendon fraying. Reprinted with permission from Coughlin, MJ. Disorders of

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tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]

Figure 7.  Krackow technique of double-lock suture used in the repair of ruptured Achilles tendon. Reprinted with permission from Coughlin, MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, Vol. 2, 7th ed. St. Louis, Missouri: Mosby, Inc; 1999: 826-861.[38]

Percutaneous repair. In 1977, Ma and Griffith[25] described a technique of repair that does not require the healing of a large incision. By placing 6 small stab incisions on the medial and lateral sides of the Achilles tendon, they showed that the tendon could be repaired. Only 2 of the 18 patients experienced minor noninfectious skin complications and none of the patients re-ruptured. Using a similar technique, Fitzgibbons noted good results in all 14 of his patients.[26] In Rowley and Scotland's series, those with percutaneous repair had increased plantarflexion strength and returned to their usual level of activity sooner than did those treated non-operatively with a cast.[27]

Unfortunately, most studies of percutaneous repair report inferior results when compared with open repair. Rowley and Scotland[27] noted a 10% rate of sural nerve entrapment and Klein and colleagues [28]

noted a 13% rate. Hockenbury and Johns[29] performed the procedure on cadavers and noted that 60% of the patients had an entrapped sural nerve. They also found that 80% had malaligned stumps. This may account for their further finding that these cadavers had only one half the strength at the repaired site as did those repaired in an open manner. This may explain why the re-rupture rate is higher after percutaneous repair than after open repair.

Currently, percutaneous repair is favored over open operative repair only in patients who have minimal requirements for playing sports, accept a higher risk of re-rupture, desire a re-approximated tendon, and place a high value on their cosmetic appearance. Given the current guidelines, the procedure likely will

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continue to be performed less frequently then open repair. Therefore, improvements in the technique will also most likely continue to lag.

Treatment of Chronic Achilles Tendon Ruptures

Because some Achilles tendon ruptures are missed on the initial physical exam, many patients will present late. Although there is no consensus regarding when an acute rupture becomes a chronic or neglected rupture, 4 weeks appears to be the most quoted time frame.[30] During this time lapse, disorganized scar tissue fills the gap between the retracted proximal stump and the distal stump. This nonlongitudinally oriented fibrous tissue lacks the contractile strength of normal tendon and contributes to a strength deficit.[31] In addition, it results in a lengthened tendinous unit, which, as mentioned, leads to a significant decrease in plantar flexion strength. If the patient (1) experiences a functional deficit as a result of his decreased push off strength and/or (2) does not have preexisting wound healing problems (eg, heavy smoker, chronic swelling, venous stasis, diabetic ulcers), then a delayed repair should be performed.[6] Since the proximal tendon tends to retract, the repair often requires some type of augmentation. These options include free fascial tendon grafts, synthetic bridges, fascial advancements, and local tendon transfers.

Bugg and Boyd[32] describe a technique in which they harvest a 7.5 cm by 15 cm fascia lata graft via an ipsilateral thigh incision. Three 1-cm-wide strips are cut from the end of the graft and then placed obliquely across the Achilles tendon defect. After suturing the strips to the proximal and distal tendon stumps, the remaining sheet of fascia lata is wrapped around the defect in a tube-like fashion. This is then sutured to the 2 tendon stumps with the serosal surface facing external (Figures 8A-8C). Despite the obvious disadvantage of requiring a second surgical site, Bugg and Boyd reported a satisfactory result in all 10 of their patients.

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Figure 8.  Achilles tendon repair using fascia lata. (A) Repair using fascia lata strips. (B) Three fascial strips bridge gap. (C) Fascia lata sheet used to cover and reinforce repair. Reprinted with permission from Bugg EI Jr, Boyd BM. Clin Ortho R & R. 1968;56:73-75.[32]

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Figure 8.  Achilles tendon repair using fascia lata. (A) Repair using fascia lata strips. (B) Three fascial strips bridge gap. (C) Fascia lata sheet used to cover and reinforce repair. Reprinted with permission from Bugg EI Jr, Boyd BM. Clin Ortho R & R. 1968;56:73-75.[32]

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Figure 8.  Achilles tendon repair using fascia lata. (A) Repair using fascia lata strips. (B) Three fascial strips bridge gap. (C) Fascia lata sheet used to cover and reinforce repair. Reprinted with permission from Bugg EI Jr, Boyd BM. Clin Ortho R & R. 1968;56:73-75.[32]

Carbon fiber, Marlex mesh, and Dacron have also been used to bridge the gap between torn tendons. These procedures avoid the need for a second incision as well as the sacrifice of another tendon. However, Amis and Campbell[33] showed that they initiate a significant foreign body response in the early stage of collagen scaffolding. They noted large edematous areas within the neotendon within 6 months. Although Ozaki[34] reported good results with Marlex mesh in 6 patients (average 6-year follow-up), many surgeons are reticent to place a foreign body into a area that is notorious for tenuous wound healing.

Bosworth[35] describes a technique in which a 20-cm strip of aponeurosis is dissected from the central portion of the gastrocnemius-soleus fascia. Leaving the distal end of the proximal segment attached, the flap is turned downward to bridge the Achilles tendon defect. The fascia is woven transversely through the proximal and distal tendon stumps. The augmentation is then reinforced by weaving the fascia through the stumps in an anterior and posterior direction at 90 degrees to the initial transfer. Bosworth [35]

reported good results with this technique in 6 adults at 1 to 14 months postrupture.

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Abraham and Pankovich[36] showed that a V-Y myotendinous lengthening procedure corrected the strength deficit in 3 of 4 patients. This technique involves a long incision that begins proximal to the myotendinous junction in the midline and curves postero-medially to the Achilles tendon and ends distal to the tendon insertion. An inverted V of gastrocnemius fascia is cut free from the muscle with the arms of the V being about 2 times the length of the Achilles tendon gap. The flap is then advanced and the proximal fascia repaired side to side. The Achilles tendon is then repaired end to end after adequate resection of the scar (Figures 9A and 9B ). Kann and Myerson[31] prefer to combine an FHL transfer with this procedure in gaps longer than 5-cm. Their experience showed that without an FHL transfer, the V-Y lengthening did not allow for early range of motion and compromised their aggressive rehabilitation protocol.

Figure 9.  V-Y myotendinous lengthening procedure for Achilles tendon repair. (A) After exposure, incision is made into the fascia of the gastrocnemius. the arms of the inverted V should be twice the length of the defect. (B) The inverted V is then advanced and end-to-end repair is performed, with the Y being closed with a 2-0 nonabsorbable suture. Reprinted with permission from Kann JN, Myerson MS: Surgical management of chronic ruptures of the Achilles tendon. In: Myerson MS, Mandelbaum BR, eds: Foot and Ankle Clinics. Philadelphia, Pennsylvania: WB Saunders Company; 1997;2:535-545.[31]

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Figure 9.  V-Y myotendinous lengthening procedure for Achilles tendon repair. (A) After exposure, incision is made into the fascia of the gastrocnemius. the arms of the inverted V should be twice the length of the defect. (B) The inverted V is then advanced and end-to-end repair is performed, with the Y being closed with a 2-0 nonabsorbable suture. Reprinted with permission from Kann JN, Myerson MS: Surgical management of chronic ruptures of the Achilles tendon. In: Myerson MS, Mandelbaum BR, eds: Foot and Ankle Clinics. Philadelphia, Pennsylvania: WB Saunders Company; 1997;2:535-545.[31]

The plantaris, peroneal, flexor digitorum longus (FDL) and flexor hallucis longus (FHL) tendons have all been used to augment an Achilles tendon repair. Lynn [37] fanned out the plantaris tendon to cover the Achilles tendon defect with a 2.5-cm wide membrane. Although this adds little strength to the repair, some surgeons continue to use this technique in acute repairs to decrease adhesions between the repair site and the skin. Others will weave the plantaris tendon through the Achilles tendon rupture site to add strength to the repair. Unfortunately, the plantaris tendon is absent in up to one third of patients and, when present, it is often incorporated into the scar tissue of long-standing ruptures.[38]

Teuffer[39] noted 28 excellent and 2 good results when transferring the peroneus brevis through a hole in the calcaneus although they did not differentiate between acute and delayed repairs. Turco and Spinella[40] later also used this approach and, like Teuffer, did not report any functional deficit. However,

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as this technique involves sacrificing an important lateral ankle stabilizer, it remains less appealing than the FHL and flexor digitorum longus (FDL) tendon transfers.

Mann[41] transected the FDL just proximal to the division of the individual tendons to supplement his repair. The distal stump of the FDL was sutured to the FHL at the site of the release. The tendon was then pulled through a drill hole in the calcaneus before using it to bridge the Achilles tendon stumps. No lesser toe dysfunction was reported.

Kann and Myerson[31] state that the FHL is the most optimal tendon to transfer and they use this technique for 2- to 5-cm gaps. In addition to being the second strongest plantar flexor (after the gastrocnemius-soleus complex) and twice as strong as the FDL, its excursion is compatible with its function as a transfer tendon. The advantages of using the FHL over the peroneus brevis also include its proximity to the Achilles tendon and its ability to maintain better ankle balance because it substitutes for another plantar flexor. An incision is made at the talo-navicular joint proximally and the midportion of the first metatarsal distally. The FHL is identified after dissection deep to the abductor hallucis and flexor hallucis brevis. After retracting the medial plantar branch of the medial plantar nerve, the FHL is cut and its distal end tenodesed to the FDL. The fibrous connections between the FHL and FDL at the Knot of Henry are released to further free the FHL. An incision is made medial to the Achilles tendon from the myotendinous junction to 2 cm distal to the Achilles tendon insertion. After opening the deep posterior compartment, the FHL is pulled into the proximal incision. A hole is then made in the calcaneus with a 4.5 mm drill (Figures 10A and 10B). Next, a 1-cm incision is made on the lateral side of the calcaneus at the drill hole site and the FHL tendon is pulled through the hole from medial to lateral. The FHL tendon is then woven through both the Achilles tendon stumps from distal to proximal. Finally, the FHL tendon and muscle are sutured to the Achilles tendon.

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Figure 10.  Flexor hallucis longus (FHL) tendon to transfer for Achilles tendon repair. (A) The FHL is mobilized into proximal wound, then a 4.5-mm hole is drilled 1 cm distal to the insertion of the Achilles tendon and 1.5 cm anterior to the posterior calcaneal cortex (medial to lateral). (B) The FHL is pulled from medial to lateral through drill hole. A subcutaneous tunnel is made over the dorsal cortex of the calcaneus then the length of FHL is woven from distal to proximal through the Achilles tendon. The FHL tendon and muscle are then sutured to the Achilles tendon. Reprinted with permission from Kann JN, Myerson MS. Surgical management of chronic ruptures of the Achilles tendon. In: Myerson MS, Mandelbaum BR, eds: Foot and Ankle Clinics. Philadelphia, Pennsylvania: WB Saunders Company; 1997;2:535-545.[31]

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Figure 10.  Flexor hallucis longus (FHL) tendon to transfer for Achilles tendon repair. (A) The FHL is mobilized into proximal wound, then a 4.5-mm hole is drilled 1 cm distal to the insertion of the Achilles tendon and 1.5 cm anterior to the posterior calcaneal cortex (medial to lateral). (B) The FHL is pulled from medial to lateral through drill hole. A subcutaneous tunnel is made over the dorsal cortex of the calcaneus then the length of FHL is woven from distal to proximal through the Achilles tendon. The FHL tendon and muscle are then sutured to the Achilles tendon. Reprinted with permission from Kann JN, Myerson MS. Surgical management of chronic ruptures of the Achilles tendon. In: Myerson MS, Mandelbaum BR, eds: Foot and Ankle Clinics. Philadelphia, Pennsylvania: WB Saunders Company; 1997;2:535-545.[31]

Wapner and Hecht[42] used a similar technique when describing the FHL transfer. After a mean of 17 months, none of their 7 patients had postoperative infections, loss of skin, or repeat ruptures. Although all 7 patients had some loss in the range of motion in the great toe and ankle, it was not of functional importance and all were satisfied with their results.

Postoperative Rehabilitation

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Traditionally, postoperative rehabilitation involved wearing a splint with the ankle in equinus during the immediate postoperative period. A cast is then placed within a few days and continued for 6 weeks. The patient is seen in the clinic at 2-week intervals during which the cast is changed and placed in an increasingly more dorsiflexed position. After 4 to 6 weeks in the cast, it is advanced to a plantigrade position. With the cast in place, the patient is instructed to begin isometric gastrocnemius-soleus complex exercises once weight bearing is tolerated. Following cast removal, the ankle is mobilized with supervision of a physical therapist. Two weeks later, the patient is encouraged to swim and bicycle, and can usually return to sports within 3 to 6 months.

Although popular, the above protocol can have detrimental effects. The long period of immobilization increases the likelihood of muscle atrophy, joint stiffness, cartilage atrophy, degenerative arthritis, adhesions, and deep venous thrombosis. In contrast, early mobilization limits atrophy, promotes fiber polymerization to collagen, and increases the organization of collagen at the repair site, which ultimately increases muscle and tendon strength.[6]

A recent trend toward a more functional rehabilitation program is gaining popularity. These protocols use an anterior plaster slab or an orthosis/walking boot (Figure 11) for 6 weeks allowing full range of motion with the exception of dorsiflexion beyond neutral. The patient performs progressive exercises and is allowed to bear weight, as tolerated with crutches. Myerson's [6] program involves use of the bicycle at 3 weeks, the pool at 4 weeks, and push off strengthening exercises with a stair climbing device at 8 weeks. At 2 months, the patient can perform heel rises, jog, and increase push-off strengthening activities. In comparing the traditional with a more functional rehabilitation protocol, Cetti and colleagues[18] found that those in the latter group had a 1% plantarflexion deficit compared with 9% in the traditional rehabilitation group. In addition, 80% of those in the functional rehabilitation group resumed sports activities at the same level and 7% at a diminished level. In contrast, only 50% of those treated with a rigid cast resumed at the same level of sports activity and 13% a diminished level. Mandelbaum and colleagues[19] have also shown that functional protocols are effective in the compliant well-motivated athlete. Whether superior results can be obtained in the general population is not yet known.

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Figure 11.  Mobile Achilles tendon cast which allows immediate protected postoperative ankle movements. Reprinted with permission from Cetti R. Operative versus nonoperative options. In: Myerson MS, Mandelbaum BR, eds: Foot and Ankle Clinics. Philadelphia, Pennsylvania: WB Saunders Company; 1997;2:511.[43]

Summary

Accompanying the increased popularity of weekend recreational sporting contests is an increased incidence of Achilles tendon ruptures. These usually occur in otherwise sedentary males who are in their 30s or 40s. Although the history and physical remain the most accurate way to diagnose the injury, MRI and ultrasonography can prove helpful in select circumstances. The current preferred treatment in young and otherwise healthy patients and in virtually all chronic ruptures is surgical repair. Conservative treatment remains an acceptable alternative in older patients who have fewer physical demands. Improved rehabilitation protocols have enhanced recovery for patients who receive either nonsurgical or surgical treatment. However, more studies comparing patients treated nonsurgically with follow-up functional rehabilitation vs those treated surgically with follow-up functional rehabilitation are needed. MRI and ultrasonography may prove useful in studies comparing surgical and nonsurgical treatment in patients whose tendons have similar conditions, orientations, and gap sizes.

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 Authors and Disclosures

Todd Sterling Atkinson, MD, is a Resident in the Department of Orthopaedic Surgery at Duke University Medical Center; Mark Easley, MD, is Assistant Professor in the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.

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