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A new surgical method to treat chronic ruptures and reruptures of the Achilles tendon

Knee Surgery, Sports Traumatology, Arthroscopy volume 16, pages 614–620 (2008)Cite this article

Abstract

In patients with a chronic rupture or rerupture of the Achilles tendon, the recommended treatment is surgical. Various surgical techniques have been reported in the literature; however, the outcome is rarely evaluated with a sufficiently long follow-up, using appropriate end-points. The purpose of this study was to evaluate the subjective and objective outcome following a new surgical treatment for chronic rupture or rerupture of the Achilles tendon using augmentation with a free gastrocnemius aponeurosis flap. A total of 28 consecutive patients (22 male and 6 female) with a mean (SD) age of 46 (10.4) years were evaluated at a median (range) of 29 (12–117) months after surgery. The surgical technique involved making a single incision and then using a free gastrocnemius aponeurosis flap to cover the tendon gap after an end-to-end suture. The patients were evaluated using the Achilles tendon rupture score (ATRS) and a detailed questionnaire relating to symptoms, physical activity and satisfaction with treatment. The functional evaluation consisted of a validated test battery measuring different aspects of muscle/tendon function of the gastrocnemius/soleus and Achilles tendon complex. The median (range) ATRS was 83 (24–100). There were no reruptures. In terms of surgical complications, there was one deep infection, three wound closure complications and deep venous thrombosis in two patients. All but one patient returned to work within 6 months of surgery. Sixteen (57%) patients were satisfied with the treatment. There was a significant decrease in the level of physical activity after the injury compared with before the injury (p = 0.004). Of the 25 patients who participated in recreational sports prior to injury, 13 (52%) returned to the same activity level after treatment. In terms of jump performance, no significant differences were found between the healthy and injured sides. There was, however, a significant decrease in strength, in terms of both concentric and eccentric–concentric toe raises and the toe-raise test for endurance compared with the healthy side. The use of a free gastrocnemius aponeurosis flap to treat chronic ruptures and reruptures of the Achilles tendon rendered a good overall subjective and objective outcome in the majority of patients. The use of a single incision in combination with a free flap augmentation produced favourable results.

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References

  1. Abraham E, Pankovich AM (1975) Neglected rupture of the Achilles tendon. Treatment by V–Y tendinous flap. J Bone Joint Surg Am 57:253–255

    PubMed  CAS  Google Scholar 

  2. Arner O, Lindholm A (1959) Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand Suppl 116:1–51

    PubMed  CAS  Google Scholar 

  3. Barnes MJ, Hardy AE (1986) Delayed reconstruction of the calcaneal tendon. J Bone Joint Surg Br 68:121–124

    PubMed  CAS  Google Scholar 

  4. Bosworth DM (1956) Repair of defects in the tendo achillis. J Bone Joint Surg Am 38-A:111–114

    PubMed  CAS  Google Scholar 

  5. Carden DG, Noble J, Chalmers J, Lunn P, Ellis J (1987) Rupture of the calcaneal tendon. The early and late management. J Bone Joint Surg Br 69:416–420

    PubMed  CAS  Google Scholar 

  6. Cetti R, Junge J, Vyberg M (2003) Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients. Acta Orthop Scand 74:78–84

    PubMed  Article  Google Scholar 

  7. Christensen I (1953) Rupture of the Achilles tendon; analysis of 57 cases. Acta Chir Scand 106:50–60

    PubMed  CAS  Google Scholar 

  8. Gabel S, Manoli A 2nd (1994) Neglected rupture of the Achilles tendon. Foot Ankle Int 15:512–517

    PubMed  CAS  Google Scholar 

  9. Gerdes MH, Brown TD, Bell AL, Baker JA, Levson M, Layer S (1992) A flap augmentation technique for Achilles tendon repair. Postoperative strength and functional outcome. Clin Orthop Relat Res:241–246

    Google Scholar 

  10. Haas F, Seibert FJ, Koch H, Hubmer M, Moshammer HE, Pierer G, Scharnagl E (2003) Reconstruction of combined defects of the Achilles tendon and the overlying soft tissue with a fascia lata graft and a free fasciocutaneous lateral arm flap. Ann Plast Surg 51:376–382

    PubMed  Article  Google Scholar 

  11. Inglis AE, Scott WN, Sculco TP, Patterson AH (1976) Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment. J Bone Joint Surg Am 58:990–993

    PubMed  CAS  Google Scholar 

  12. Kangas J, Pajala A, Ohtonen P, Leppilahti J (2007) Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med 35:59–64

    PubMed  Article  Google Scholar 

  13. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M (2005) Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 87:2202–2210

    PubMed  Article  Google Scholar 

  14. Kissel CG, Blacklidge DK, Crowley DL (1994) Repair of neglected Achilles tendon ruptures––procedure and functional results. J Foot Ankle Surg 33:46–52

    PubMed  CAS  Google Scholar 

  15. Komi PV, Fukashiro S, Jarvinen M (1992) Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med 11:521–531

    PubMed  CAS  Google Scholar 

  16. Lapidus LJ, Rosfors S, Ponzer S, Levander C, Elvin A, Larfars G, de Bri E (2007) Prolonged thromboprophylaxis with dalteparin after surgical treatment of achilles tendon rupture: a randomized, placebo-controlled study. J Orthop Trauma 21:52–57

    PubMed  Article  Google Scholar 

  17. Lerch K, Caro W, Perlick L, Baer W, Schubert T, Grifka J (2003) [Unrecognized and untreated rupture of the Achilles tendon-operative treatment in cases of unstable scar tissue]. Orthopade 32:816–823

    PubMed  Article  CAS  Google Scholar 

  18. Leslie HD, Edwards WH (2005) Neglected ruptures of the Achilles tendon. Foot Ankle Clin 10:357–370

    PubMed  Article  Google Scholar 

  19. Maffulli N, Leadbetter WB (2005) Free gracilis tendon graft in neglected tears of the achilles tendon. Clin J Sport Med 15:56–61

    PubMed  Article  Google Scholar 

  20. Möller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J (2001) Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 83:843–848

    PubMed  Article  Google Scholar 

  21. Nilsson-Helander K, Thomee R, Gravare-Silbernagel K, Thomee P, Faxen E, Eriksson BI, Karlsson J (2007) The Achilles tendon total rupture score (ATRS): development and validation. Am J Sports Med 35:421–426

    PubMed  Article  Google Scholar 

  22. Ozaki J, Fujiki J, Sugimoto K, Tamai S, Masuhara K (1989) Reconstruction of neglected Achilles tendon rupture with Marlex mesh. Clin Orthop Relat Res 238:204–208

    PubMed  Google Scholar 

  23. Pajala A, Kangas J, Ohtonen P, Leppilahti J (2002) Rerupture and deep infection following treatment of total Achilles tendon rupture. J Bone Joint Surg Am 84-A:2016–2021

    PubMed  Google Scholar 

  24. Perez Teuffer A (1974) Traumatic rupture of the Achilles Tendon. Reconstruction by transplant and graft using the lateral peroneus brevis. Orthop Clin North Am 5:89–93

    PubMed  CAS  Google Scholar 

  25. Pintore E, Barra V, Pintore R, Maffulli N (2001) Peroneus brevis tendon transfer in neglected tears of the Achilles tendon. J Trauma 50:71–78

    PubMed  CAS  Article  Google Scholar 

  26. Porter DA, Mannarino FP, Snead D, Gabel SJ, Ostrowski M (1997) Primary repair without augmentation for early neglected Achilles tendon ruptures in the recreational athlete. Foot Ankle Int 18:557–564

    PubMed  CAS  Google Scholar 

  27. Saltin B, Grimby G (1968) Physiological analysis of middle-aged and old former athletes. Comparison with still active athletes of the same ages. Circulation 38:1104–1115

    PubMed  CAS  Google Scholar 

  28. Silbernagel KG, Gustavsson A, Thomee R, Karlsson J (2006) Evaluation of lower leg function in patients with Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 14:1207–1217

    PubMed  Article  Google Scholar 

  29. Silfverskiöld N (1940) Uber die subcutane totale Achillessehnenruptir und deren Behandlung. Acta Chir Scand 84:393–413

    Google Scholar 

  30. Takao M, Ochi M, Naito K, Uchio Y, Matsusaki M, Oae K (2003) Repair of neglected Achilles tendon rupture using gastrocnemius fascial flaps. Arch Orthop Trauma Surg 123:471–474

    PubMed  Article  CAS  Google Scholar 

  31. Turco VJ, Spinella AJ (1987) Achilles tendon ruptures––peroneus brevis transfer. Foot Ankle 7:253–259

    PubMed  CAS  Google Scholar 

  32. Wapner KL, Hecht PJ, Mills RH Jr (1995) Reconstruction of neglected Achilles tendon injury. Orthop Clin North Am 26:249–263

    PubMed  CAS  Google Scholar 

  33. White RK, Kraynick BM (1959) Surgical uses of the peroneus brevis tendon. Surg Gynecol Obstet 108:117–121

    PubMed  CAS  Google Scholar 

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Acknowledgments

The authors thank the Swedish National Centre for Research in Sports (CIF) and the local Research and Development Council of Halland, Sweden, for financial support.

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Affiliations

  1. Department of Orthopaedics, Kungsbacka Hospital, Göteborg University, Gamla Göteborgsvägen, 434 40, Kungsbacka, Sweden

    Katarina Nilsson-Helander

  2. Department of Orthopaedics, Sahlgrenska University Hospital, Göteborg University, Göteborg, Sweden

    Leif Swärd, Bengt I. Eriksson & Jon Karlsson

  3. Lundberg Laboratory for Orthopaedic Research, Sahlgrenska University Hospital, Göteborg University, Göteborg, Sweden

    Karin Grävare Silbernagel & Roland Thomeé

Authors
  1. Katarina Nilsson-Helander
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  2. Leif Swärd
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  3. Karin Grävare Silbernagel
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  4. Roland Thomeé
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  5. Bengt I. Eriksson
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  6. Jon Karlsson
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Correspondence to Katarina Nilsson-Helander.

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Nilsson-Helander, K., Swärd, L., Silbernagel, K.G. et al. A new surgical method to treat chronic ruptures and reruptures of the Achilles tendon . Knee Surg Sports Traumatol Arthr 16, 614–620 (2008). https://doi.org/10.1007/s00167-008-0492-3

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  • DOI: https://doi.org/10.1007/s00167-008-0492-3

Keywords

  • Achilles tendon
  • Rerupture
  • Chronic rupture
  • Free flap
  • Augmentation