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• Fractures of the anteromedial facet of the coronoid require addressing as combined osteoligamentous injuries. • With a rupture rate of 91.7% in this cohort, the MCL appears to be more frequently affected than previously suggested. • The presented systematic algorithm might save the lateral approach through the medial start of the procedure in subtype 2 and 3 fractures of the anteromedial facet in certain cases. Varus posteromedial rotational injury mechanisms lead to fractures of the coronoids process' anteromedial facet. As these fractures are often unstable, rapid fracture treatment is vital to prevent progressive osteoarthritis. Twelve patients with a fracture of the anteromedial facet treated surgically were enrolled in the study. Computed tomography images were used to classify the fractures according to the system by O'Driscoll et al. Clinical follow-up included each patient's medical record, surgical treatment algorithm, all complications encountered during the follow-up period, Disabilities of the arm, shoulder, and hand score, subjective elbow value, and pain. A total of 8 men (66.7%) and 4 women (33.3%) were treated surgically and followed-up after a mean period of 45 ± 23 months. The mean DASH score was 11.9 ± 12.9 points. One patient complained of transient neuropathy in the innervation area of the ulnar nerve, however, this existed already pre-operatively and resolved after less than three months. The presented patient cohort shows that AMF fracture of the coronoid process are unstable lesions according to the bony instability and the frequently ruptured collateral ligament complexes which need to be addressed. The MCL seems to be affected more frequently than previously appreciated. Level IV; Case Series; Treatment Study. [ABSTRACT FROM AUTHOR]

Historically, the segmental loss of the Achilles tendon with overlying soft-tissue defects had been frequently reconstructed with the composite anterolateral thigh (ALTP) flap, including the iliotibial tract or fasciae latae. This study aimed to present our modified combination using the bi-pedicled conjoined flap with vascularized fasciae latae, for the approximately total reconstruction of the Achilles tendon and extensive soft tissue. From May 2015 to March 2018, 15 patients (9 male and 6 female) with a mean age of 36 years (ranged, 18–52 years) underwent microvascular Achilles tendon reconstruction. Harvested on the abdomen and groin, the conjoined flap was chimeric with the vascularized fasciae latae. Primary donor-site closure was accomplished in all patients. A standard assessment of the functional and esthetical outcomes was completed. Mean follow-up time was 42 months (ranged, 32–48 months). The average dimension of the conjoined flap was 25 × 14 cm (ranged, 18 × 10–35 × 18 cm), and the average size of the folded fasciae latae was 15 × 6 cm (ranged, 12 × 5–25 × 8 cm). At the last follow-up, the Thompson test was negative in all patients. The mean American Orthopedic Foot and Ankle Society (AOFAS) score was 91.0. The mean Achilles tendon total rupture score (ATRS) was 18.5. The mean Vancouver Scar Scale (VSS) score was 3.0. The composite bi-pedicled flap including vascularized fasciae latae provides an alternative approach with great functional and esthetic outcomes, in selected patients who suffered severe Achilles tendon and skin defects. The one-stage procedure facilitates better rehabilitation postoperatively. [ABSTRACT FROM AUTHOR]

To determine the influence of gap distance and its location on clinical and radiological outcomes in patients with acute rupture of Tendo-Achilles (TA) treated non-operatively with functional rehabilitation. Twenty-six patients with acute complete TA rupture underwent ultrasound (US) scanning within a week of their injury. The measurements taken included the distance of the rupture from the enthesis and the gap distance between the tendon edges in varying degrees of ankle and knee positions. All patients were managed non-operatively in functional weight-bearing orthoses. Nineteen patients were then followed up at a mean of 6.1 years (range 5.8–6.5) to assess their clinical and radiological outcomes. The outcomes included ultrasound assessment of tendon healing, Achilles Tendon Rupture Score (ATRS) and modified Leppilahti Score (mLS). In the initial ultrasound, the mean distance of the rupture from the enthesis was 52 mm (range: 40–76). The mean gap distance with the foot plantigrade was 11.4 mm, which reduced to 4.8 mm with the foot in equinus. At final follow up, no re-ruptures had occurred. The mean ATRS and mLS were 86 and 71 respectively. There was a significant correlation between the distance of the rupture from the enthesis with the MLS total score (p = 0.02), mLS Fatigue domain score (p = 0.03), and the ATRS domains of strength (p = 0.04) and fatigue (p = 0.02). There was no significant correlation between the measured gap distance with respect to the mLS, ATRS or individual ATRS domain scores. Also, there was no significant difference in ATRS and mLS outcomes when comparing tendons with respect to healed tissue appearance and fibre orientation on ultrasound. The initial gap distance had no relationship with any of the measured clinical outcomes at the final follow up. The distance of the gap from the enthesis, however, may carry a greater prognostic value following non-operative treatment of Achilles tendon injuries. [ABSTRACT FROM AUTHOR]

Purpose: The treatment options of acute Achilles tendon rupture (AATR) remain controversial. This article aims to compare the efficacy of a new surgical procedure, the panda rope bridge technique (PRBT) with open surgery of AATR.Methods: Ninety-eight patients with AATR were recruited, 53 underwent the PBRT, and 45 underwent open surgery. The operation time, postoperative American Orthopaedic Foot and Ankle Score, Achilles Tendon Rupture Score, complications and time to return to work and restore exercise were documented.Results: The average operation time, intraoperative blood loss and complication rate were 35.1 min, 18.2 ml and 3.8%, respectively, in the PRBT group, which were significantly lower than those of the open surgery group (P<0.001). The post-operative American Orthopaedic Foot and Ankle Score of 99.6 and the Achilles Tendon Rupture Score of 97.5 in the PRBT group were significantly higher than that of the open surgery group (P<0.001). The time to return to work and return to exercise were shorter in the PRBT group (P<0.001).Conclusion: Compared to open surgery, PRBT is a better approach to the management of AATR. PRBT offers accelerated recovery, lower occurrence of post-operative complications and improved recovery of ankle joint function. [ABSTRACT FROM AUTHOR]

Background: Acute Achilles tendon rupture (AATR) is a common injury of the foot and ankle. So far, the optimal management of AATR remains controversial. The target of the present retrospective study was to describe a new operative technique for percutaneous repair of AATR and evaluate efficacy of the technique.Methods: In the present study, 32 patients were enrolled with AATR treated with the percutaneous oval forceps suture-guiding method with anchor nails from Jan 2014 to Jan 2017. The operation duration and length of incision were collected. The functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score, Achilles tendon total rupture score (ATRS), range of motion (ROM) of the ankle and plantar flexion strength ratio at the last follow-up. The postoperative sports activity level and complications were also recorded.Results: The mean operation duration and length of incision were 24.5 min and 2.0 cm. Whilst patient reported outcome questionnaires like AOFAS and ATRS showed good results, ROM of the ankle was quite low with only 16.5 degrees. Plantar flexion strength ratio was lower post surgery, as well. As for the postoperative sports activity level: 26/32 cases (81.3%) returned to former sports activity level; 4/32 cases (12.5%) showed a decline in sports activity level; 2/32 cases (6.2%) gave up on sports. The overall complication rate was 6.2%, one sural nerve damage and one fusiform thickening were found in the study.Conclusion: The percutaneous oval forceps suture-guiding method with anchor nails is a new considerable surgery method with adequate healing rates and an alternative to existing surgical procedures. [ABSTRACT FROM AUTHOR]

Purpose: The primary aim was to determine independent patient, injury and management-related factors associated with symptomatic venous thromboembolism (VTE) following acute Achilles tendon rupture (ATR). The secondary aim was to suggest a clinical VTE risk assessment tool for patients with acute ATR.Methods: From 2010-2018, 984 consecutive adults (median age 47yrs, 73% [n = 714/984] male) sustaining an acute ATR were retrospectively identified. Ninety-five percent (n = 939/984) were managed non-operatively in a below-knee cast (52%, n = 507/984) or walking boot (44%, n = 432/984), with 5% (n = 45/984) undergoing primary operative repair (<6wks post-injury). VTE was diagnosed using local medical records and national imaging archives, reviewed at a mean 5yrs (range 1-10) post-injury. Multivariate logistic regression was performed to determine independent factors associated with VTE.Results: The incidence of VTE within 90 days of ATR was 3.6% (n = 35/984; deep vein thrombosis 2.1% [n = 21/984], pulmonary embolism 1.9% [n = 19/984]), and the median time to VTE was 24 days (interquartile range 15-44). Age ≥50yrs (adjusted OR [aOR] 2.3, p = 0.027), personal history of VTE/thrombophilia (aOR 6.1, p = 0.009) and family history of VTE (aOR 20.9, p<0.001) were independently associated with VTE following ATR. These non-modifiable risk factors were incorporated into a VTE risk assessment tool. Only 23% of patients developing VTE (n = 8/35) had a relevant personal or family history, but incorporating age ≥50yrs into the VTE risk assessment tool (alongside personal and family history) identified 69% of patients with VTE (n = 24/35). Non weight-bearing for ≥2wks after ATR was also independently associated with VTE (aOR 3.2, p = 0.026).Conclusions: Age ≥50 years, personal history of VTE/thrombophilia and a positive family history were independently associated with VTE following ATR. Incorporating age into our suggested VTE risk assessment tool enhanced its sensitivity in identifying at-risk patients. Early weight-bearing in an appropriate orthosis may be beneficial to all patients in VTE risk reduction. [ABSTRACT FROM AUTHOR]

Introduction: To compare the strength between the Achilles tendons repaired with the "Giftbox" and the Krackow techniques in New Zealand white rabbits post six weeks of tendon healing.Materials and Methods: Eight rabbits were randomized into Giftbox and Krackow groups. Tenotomy was performed on the Achilles tendon of one side of the lower limb and repaired with the respective techniques. The contralateral limb served as control. Subjects were euthanized six weeks post-operative, and both repaired and control Achilles tendons were harvested for biomechanical tensile test.Results: The means of maximum load to rupture and tenacity in the Giftbox group (156.89 ± 38.49 N and 159.98 ± 39.25 gf/tex) were significantly different than Krackow's (103.55 ± 27.48 N and 104.91 ± 26.96 gf/tex, both p = 0.043).Conclusion: The tendons repaired with Giftbox technique were biomechanically stronger than those repaired with Krackow technique after six weeks of tendon healing. [ABSTRACT FROM AUTHOR]

The optimal treatment of Achilles tendon ruptures (ATRs) is a subject of some debate amongst orthopedic surgeons. Many patients' understanding of Achilles injuries is limited and may be more informed by popular culture than anything objective. We sought to assess patient perceptions of ATRs using a proprietary questionnaire and correlate that with demographic information and the health literacy of the patient. Patients presenting with an Achilles tendon injury were asked to fill out a demographic form, the Literacy in Musculoskeletal Problems (LiMP) survey, to assess musculoskeletal health literacy, and a 22-question survey on ATRs designed to assess patient knowledge and perception of ATRs. Seventy percent of patients responded that surgery with or without other modalities is the most appropriate treatment for ATRs, while only 20% of patients responded that nonoperative treatment is most appropriate. Perceptions of treatment were not associated with demographic data or LiMP scores and appear to be biased to some degree towards surgery. In a setting in which the optimal treatment has not been fully worked out by surgeons, it is difficult to tell what influence patient perceptions may have on treatment, although it is possible these patient perceptions may cause surgeons to be more surgically aggressive. [ABSTRACT FROM AUTHOR]

Introduction: Very distal tears of the Achilles tendon are uncommon, and poor quality tendinous tissue of the calcaneal stump can compromise healing. Little has been published about the characteristics and surgical management of such injuries. We present a surgical technique, developed by the senior author, to restore continuity of the gastrosoleus-Achilles tendon-calcaneus complex using a free ipsilateral semitendinosus graft, and clinical outcomes of a case series of 28 consecutive patients. Our hypothesis was that this is a safe technique, and patients can return to pre-injury occupation and athletic activities.Patients and Methods: A total of 28 patients (mean age 46 years) underwent minimally invasive reconstruction using a free ipsilateral semitendinosus graft for acute insertional rupture of tendo Achillis. The procedure required two small incisions along the course of the Achilles tendon, and one posteromedial incision at level of the ipsilateral knee to harvest the semitendinosus tendon. Patients were assessed at minimum 2 years (range, 2-2.5 years) following the index procedure.Results: The median Achilles tendon Rupture Score (ATRS) at the latest follow-up was 88. Two patients developed a superficial wound infection. All patients returned to their preinjury occupation, whilst 22 out of 28 patients (79%), returned to their preinjury level of physical activity at a mean of 6.7 months after surgery, reporting good or excellent overall satisfaction in 88.5% of cases.Conclusion: This minimally invasive technique was safe, and allowed most of patients to return to preinjury daily and sport activities within 9 months from surgery. [ABSTRACT FROM AUTHOR]

Benzyl alcohol (BnOH) is a natural colorless liquid organic compound that plays an important role in bacteriostatic and anesthetic processes. It is also used to relieve the nerve and ganglionic pain. In this study, we assessed the effect of topical application of BnOH on the Achilles tendon healing process. Sprague Dawley rats were subjected to an experimentally induced wound in the tendon area and then randomized into four groups. Normal saline (0.5 mL) was applied to rats in control group, and BnOH at the concentrations of 0.5 mL 0.075%, 0.15%, 0.3% were applied to the BnOH treatment groups, respectively. Wound treatment with BnOH led to significantly faster functional recovery than with saline. Moreover, treatment of wounds with 0.3% BnOH accelerated the healing process faster than with 0.075% and 0.15% BnOH. Histological analysis of healed wounds that had been treated with BnOH showed more collagen and blood capillaries and fewer inflammatory cells compared to the control. To study the mechanism of the process, the expression of mRNA of TGF-β1, Smad2/3 and Smad7 and protein of TGF-β1, p-Smad2/3 and Smad7 were quantified by real-time PCR and Western blotting, respectively. Results of this study showed that wounds treated with BnOH significantly enhanced the expression of TGF-β1 and Smad2/3 and reduced the expression of Smad7. In general, the current study demonstrated that BnOH improved the recovery process of tendon healing through the promotion of collagen with angiogenesis and showed that TGF-β plays a role in BnOH treatment of tendon healing. [ABSTRACT FROM AUTHOR]

Background: In recent years, primary Achilles tendon ruptures have increased due to the aging population's participation in physically demanding activities. These injuries commonly occur during recreational sports and frequently lead to a long-term reduction in activity despite treatment. Non-operative methods of treatment for Achilles tendon ruptures may result in the Achilles healing in a lengthened position compared to the pre-injury state. This study uses a cadaveric model that simulates static weight bearing to explore the effect of a lengthened Achilles tendon on ankle joint load distribution.Methods: Five lower limb cadaveric specimens were placed on a custom jig, where a 334 N (75 lb) load was applied at the femoral head, and the foot was supported against a plate to simulate static double-leg stance. A pressure mapping sensor was inserted into the ankle joint. A percutaneous triple hemiresection tendo-Achilles lengthening procedure (Hoke procedure) was performed on each specimen to simulate tendon lengthening after conservative treatment. Contact pressure, peak pressure, and center-of-pressure were measured for native and tendon-lengthened conditions.Results: Tendon rupture did not significantly alter average contact pressure, peak contact pressures, or center-of-pressure in the ankle joint compared with native tendon.Conclusion: Achilles lengthening does not significantly change contact pressures of the ankle joint in this model . This result suggests that the passive restraint on ankle joint translation imposed by the Achilles tendon is minimal without muscle activation. [ABSTRACT FROM AUTHOR]

Background: Open Giftbox repair of the Achilles tendon has good biomechanical advantages, but it is not minimally invasive. We designed a peritendon fixation technique, the "Locking Block Modified Krackow" (LBMK) technique, to meet minimally invasive needs. This study used a simulated protocol of early rehabilitation to compare the biomechanics of LBMK with those of the Giftbox technique.Methods: Twenty fresh bovine Achilles tendon specimens were randomly assigned to either the LBMK group or the Giftbox group. The LBMK technique and the Giftbox technique were used as the main suture configurations, and transverse sutures were used as secondary suture configurations in both groups. Each repaired specimen was subjected to two cyclic loading protocols (20-100 N, 20-190 N). The gapping between the tendon ends was measured after each stage of loading. Finally, all specimens underwent a load-to-failure test at a stretching rate of 25 mm/s.Results: After the first loading stage, the mean tendon gapping was 0.76±0.44 mm in the LBMK group and 0.86 ± 0.47 mm in the Giftbox group (p = 0.620). After the second loading test, the average gapping measures of the LBMK and Giftbox groups were 3.8 ± 1.9 mm and 4.2 ± 2.2 mm, respectively (p = 0.466). Finally, the catastrophic load to failure was 732.8 ± 138 N in the LBMK group and 645.5 ± 121 N in the Giftbox group. The difference was statistically significant (p = 0.023).Conclusion: Both the LBMK and Giftbox techniques meet the requirements of early rehabilitation, but the suture strength in the LBMK group was significantly higher than that in the Giftbox group. [ABSTRACT FROM AUTHOR]

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years. [ABSTRACT FROM AUTHOR]

Introduction: Post-traumatic injury of talus's posterior area and ankle joint with consequent scar formation is often complicated by an unhealing trophic ulcer. Aim of this paper is to evaluate the autologous fat graft effectiveness in treating Achilles tendon area wounds.Material and Methods: From October 2011 to March 2014 we treated with fat graft a total of 7 patients with post-surgical painful chronic ulcer of calcaneal area. Mean age was 38.6 years (range 22-64 years). One patient was a professional football player who was presenting a post-injury ulcer not respondant to advanced dressings.Results: Wound rehepitelization was observed in all cases treated within one month and fat grafting resolved pain related to the wound. All patient returned to their daily normal activities. In all cases treated we observed an increased softness of perilesional post-surgical scars. Our professional football player came back able to perform an usual training 5 days post-operation obtaining complete rehepitelization within 3 weeks.Discussion: Our surgical approach showed a therapeutic effect that relies on biological properties of adipose tissue; those properties are clear in both procedures of chronic ulcer's rehepitelization stimulation and perilesional tissue's enhancement obtaining pain control. The procedure is safe, with low rate of complication. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study is to present outcomes and objective measures of assessment for acute Achilles tendon (AT) ruptures treated with an eight-week functional dynamic treatment protocol in a VACOped® boot with immediate full weight bearing mobilisation, the Leicester Achilles Management Protocol (LAMP).Methods: A prospective study of all patients treated with the LAMP with minimum 12-month follow-up was performed. Patients completed the Achilles Tendon Rupture Score (ATRS) and in the latter part of the study, objective measures of the calf muscle girth and heel raise height were obtained.Results: 442 patients were treated with the LAMP. There were nine (2%) re-ruptures in the 442 non-operative treated group of patients throughout the study period. ATRS at twelve months or more were available in 234 patients and objective measures in 77 patients. The mean age was 50 years. The mean ATRS was 75.5 at an average of 23 months post injury. Men had a statistically significant higher ATRS score when compared to women (p < 0.05). There was statistically significant difference in the calf muscle girth and the heel raise height when compared to the uninjured side at 12-months post-injury (p < 0.05). These differences did not correlate with the ATRS (p > 0.05).Conclusions: The LAMP is a simple yet effective regime for the non-operative treatment of acute AT ruptures, which can be universally adopted without the need for many resources. Compared to other studies, the overall time in the boot is less with low complication rates and similar patient reported outcomes. [ABSTRACT FROM AUTHOR]

Background: The purpose of this article was to introduce calcaneal lengthening for partial traumatic loss of the calcaneus. Effectiveness with the use of the technique was also assessed.Methods: From January 2013 to May 2016, calcaneal lengthening was performed in 15 patients who sustained a partial traumatic loss of the tuberosity portion of calcaneus. There were 13 men and 2 women with an average age of 36 years (range, 19-53 years). Combined Achilles tendon rupture was noted in 7 patients, and the tendon was reinserted to the calcaneus before calcaneal lengthening. Calcaneal lengthening was performed using an Ilizarov frame. Clinical outcome was assessed based on the American Orthopedic Foot and Ankle score.Results: The mean loss of calcaneus was 27% (range, 19%-35%). Calcaneal lengthening (mean total time is157 days; range, 111-226 days) included three periods, i.e., latency (mean 7 days; range, 7-9 days), distraction (mean 43 days; range, 32-57 days), and consolidation (mean 108 days; range, 84-162 days). The mean amount of lengthening was 28% (range, 19%-38%). The mean follow-up duration was 25 months (range, 24-27 months). Based on the American Orthopaedic Foot and Ankle, there were 8 excellent, 6 good, and 1 fair result.Conclusions: For the treatment of partial traumatic loss of the calcaneus, calcaneal lengthening using an Ilizarov frame is a preferable technique to restore the length of calcaneus and foot function. [ABSTRACT FROM AUTHOR]

Meticulous skin closure is required to avoid wound problems after Achilles tendon surgery. The purpose of our study was to compare postoperative complication rate, operation time, clinical outcome and patient satisfaction with the wound among two topical skin adhesives (2-octyl cyanoacrylate and n-butyl cyanoacrylate) and conventional nylon skin sutures in Achilles tendon repair surgery. We retrospectively reviewed the records 122 consecutive patients (40 patient in nylon skin suture, 43 patients in 2-octyl cyanoacrylate and 39 patients in n-butyl cyanoacrylate) who underwent surgical repair for acute Achilles tendon rupture between 2012 and 2016. The primary outcome measure was the development of complications in the wound. Secondary outcome measures included the operative time, the Achilles Tendon Total Rupture Score (ATRS) and patient satisfaction with the wound. There was no difference in complication rate in the wound (p = 0.694) and in ATRS (p = 0.824) among patients in the three groups. Mean operative time in nylon skin suture group was significantly longer than in the 2-octyl cyanoacrylate group and n-butyl cyanoacrylate group (p = 0.018 and p = 0.002, respectively). Patient satisfaction in the 2-octyl cyanoacrylate and n-butyl cyanoacrylate groups was significantly higher than in the nylon skin suture group (p = 0.015 and 0.018, respectively). The use of 2-octyl cyanoacrylate and n-butyl cyanoacrylate topical skin adhesives for skin closure following repair of Achilles tendon rupture has equivalent effectiveness and safety compared to conventional nylon skin suture, but higher patient satisfaction. Despite its higher cost, these topical skin adhesives are viable alternatives for wound closure in patients who regard cosmetic outcomes as important. [ABSTRACT FROM AUTHOR]

Introduction: Acute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures.Methods: Between June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved.Results: We recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5-39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21-63) and 28 (IQR 15-28). Nevertheless, a difference of 10 points is considered clinically relevant.Conclusion: The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed. [ABSTRACT FROM AUTHOR]

Objective: Acute closed spontaneous Achilles tendon rupture often occurs in elderly individuals and is usually accompanied with many complications. Conventional surgical approaches to remove the tendon lesions and enthesophytes are highly traumatic and cause complications. In this study, a previously established minimally invasive surgical approach was modified and combined with a Kazakh exercise therapy to reduce trauma, improve wound healing, and promote tendon regeneration in the management of acute closed spontaneous Achilles tendon rupture.Methods: Fifty-two patients with acute closed spontaneous Achilles tendon rupture were randomly classified into 2 groups. Group A included 23 patients that were treated with the novel approach. Group B included 29 patients that were treated with a continuous medial oblique surgical approach. Follow-up examinations were performed at post-operative weeks 12 and 24, and year 2. Outcomes were assessed by Achilles tendon rupture score (ATRS), a heel-rise endurance test, and ultrasonographic and multislice spiral computerized tomography.Results: Mean ATRS in Group A was 68.6 and 86.0 at post-operative week 12 and 24, respectively, significantly higher than that in Group B (55.9 and 72.0, respectively). Recovery of patients in Group A was significantly better compared to Group B (p < 0.01), allowing them to participate in early rehabilitating kinesiotherapy. Patients in Group A rarely experienced complications after surgery, such as infection and Achilles tendon exposure, while in Group B, the wound healing was slower, the inside flaps were prone to necrosis and infection, and Achilles tendon exposure occurred in 10% of patients.Conclusions: The novel minimally invasive surgery is more advantageous in the treatment of acute closed spontaneous Achilles tendon rupture over previous approaches by promoting wound healing and tendon regeneration. [ABSTRACT FROM AUTHOR]

Introduction: Although nonsurgical methods and many surgical techniques have been developed for repairing a ruptured Achilles tendon, there is no consensus on its best treatment. In this article, a novel minimally invasive technique called the Panda Rope Bridge Technique (PRBT) is described.Methods: Patient with acute Achilles tendon rupture was operated on in the prone position. The PRBT begin with making the proximal bridge anchor (Krackow sutures in the myotendinous junction), the distal bridge anchor (two suture anchors in the calcaneus bone) and the ropes (threads of the suture anchors) stretched between the anchor sites. Then a small incision was made to debride and reattach the stumps of ruptured tendon. After the surgery, no cast or splint fixation was applied. All patients performed enhanced recovery after surgery (ERAS), which included immediate ankle mobilisation from day 1, full weight-bearing walking from day 5 to 7, and gradually take part in athletic exercises from 8 weeks postoperatively.Results: PBRT was performed in 11patients with acute Achilles tendon rupture between June 2012 and June 2015. No wound infection, fistula, skin necrosis, sural nerve damage, deep venous thrombosis or tendon re-rupture was found. One year after the surgery, all patients reported 100 AOFAS ankle-hindfoot score points and the mean ATRS was 96.6.Conclusion: The PRBT is a simple, effective and minimally invasive technique, with no need for immobilisation of the ankle, making possible immediate and aggressive postoperative rehabilitation. [ABSTRACT FROM AUTHOR]

Objective: To determine the role of imaging in the diagnosis and monitoring of the Achilles tendon rupture (ATR).Study Design: Systematic review.Data Sources: PubMed and EMBASE in November 2016.Eligibility Criteria: Clinical studies providing information on the methods and role of imaging in the diagnosis and monitoring of the ATR were included.Results: Fifty-six studies were included, most concerning the use of ultrasound (n=37) or MRI (n=18). Seven studies provided data on the diagnostic accuracy of imaging. Most ultrasound studies used a 7.5MHz probe (19/32 studies) and scanned the patient bilaterally in prone position, with recent studies tending to use higher frequency probes (r=0.42). Sensitivity [for detecting a rupture] ranged from 79.6 to 100%; the spread in specificity was large but two studies showed perfect (100%) data. Negative and positive likelihood ratios ranged from 0 to 0.23 and 1.0 to 10 respectively. MRI examination was generally performed with 1.5Tesla (T) MRI (6/12 studies) with a strong trend for higher T strength in more recent studies (r=0.71). One study reported a sensitivity of 90.9% and one a specificity of 100%. Although imaging can visualize structure and healing, these results were generally not related to the clinical picture. Overall, ultrasound was recommended over MRI for diagnosis and monitoring. Results of other imaging modalities remain inconclusive.Conclusion: The adjunct role of imaging, especially of ultrasound and MRI, in the diagnosis and monitoring of ATRs was established. It is therefore recommended to rely primarily on the clinical examination and evaluation and to use imaging for ruling out other injuries and providing additional clinical information. More high-quality research is warranted into the diagnostic accuracy of imaging as well as less conventional imaging modalities' diagnostic and monitoring capabilities. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to elucidate whether body mass index (BMI), activity level, and other risk factors predispose patients to Achilles tendon ruptures.Materials and Methods: A retrospective review of 279 subjects was performed (93 with Achilles tendon rupture, matched 1:2 with 186 age/sex matched controls with ankle sprains). Demographic variables and risk factors for rupture were tabulated and compared.Results: The rupture group mean BMI was 27.77 (95% CI, 26.94-28.49), and the control group mean BMI was 26.66 (95% CI, 26.06-27.27). These populations were found to be statistically equivalent (p=0.047 and p<0.001 by two one-sided t-test). A significantly higher proportion of those suffering ruptures reported regular athletic activity at baseline (74%) versus controls (59%, p=0.013).Conclusion: There was no clinically significant difference found in BMI between patients with ruptures and controls. Furthermore, it was found that patients who sustained ruptures were also more likely to be active at baseline than their ankle sprain counterparts. [ABSTRACT FROM AUTHOR]

Background: The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time.Methods: Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies.Results: The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI.Conclusion: Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years.Level Of Evidence: Level III; Retrospective cohort study. [ABSTRACT FROM AUTHOR]

Purpose: As outdoor activities participation increase, Achilles tendon rupture incidence also tends to increase. There are a number of treatment and rehabilitation options for a ruptured Achilles tendon. However, the optimal rehabilitation protocols are still under debate. The purpose of this study is to determine whether early rehabilitation is more effective than conventional rehabilitation.Methods: Medical records of 56 patients who had been treated with open repair after a ruptured Achilles tendon were retrospectively reviewed. 24 patients were treated postoperatively with below knee cast immobilization for four weeks, and they started tolerable weight-bearing rehabilitation at four weeks' follow-up. The remaining 32 patients were managed postoperatively with short leg splint immobilization for two weeks and started the tolerable weight-bearing at two weeks' follow-up. We evaluated the patients several times to identify when the single heel raise was possible and measured the American Orthopedic Foot and Ankle Society (AOFAS) scores and Achilles tendon total rupture scores (ATRS) as a functional outcome.Results: The single heel raise test was positive in all patients at the last assessment. But there were no statistically significant differences between the groups (p=0.137). The patients in the Cast group took significantly more time to return to work than did the patients in the Splint group (p=0.032). And AOFAS scores and ATRS were slightly higher in the Splint group than in the Cast group. There were statistically significant differences (p=0.042, p=0.028) between the two groups.Conclusion: The early rehabilitation did not lead to greater endurance, but it showed better results in the return to work and the Achilles functional score. Early rehabilitation after open repair for patients with a ruptured Achilles tendon is helpful for functional recovery. Type of study / Level of evidence: Therapeutic, Level III. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess the functional outcomes after a combined FHL transfer and a gastrocnemius recession for treatment of chronic ruptures of Achilles tendon with a gap and to investigate the patient's satisfaction about the great toe function after transfer.Material and Methods: 19 patients with chronic rupture of the Achilles tendon with a gap were treated with a flexor halluces longus tendon transfer combined with a gastrocnemius recession, Clinical diagnosis depends on the presence of gap in the tendon on examination, inability of tip toe walking on the affected side and positive calf-squeeze test, MRI was used to confirm the clinical diagnosis. American Orthopedic Foot & Ankle Society hind foot score was used for assessment of the results.Results: The AOFAS score improved significantly from a mean of 65 preoperatively to 94 at the last follow up (p<0.001), there was no significant difference in the final outcome between patients with FHL tendon weaved through the stump of the Achilles tendon and those with trans osseous tunnels, the mean AOFAS score at the last follow up was 94.2, 93.8 respectively, no patient complained of big toe dysfunction.Conclusion: Management of chronic rupture of the Achilles tendon with a gap with flexor halluces longus tendon transfer combined with a gastrocnemius recession is a safe and reliable method with a significantly improved functional outcome, muscle advancement through gastrocnemius recession decreases the length of the gap without affecting the muscle function, flexor halluces longus tendon transfer doesn't harm the big toe function. [ABSTRACT FROM AUTHOR]

Background: Surgical management of Achilles tendon rupture is still controversial: open techniques have a higher rate of soft tissue complications but a lower incidence of re-rupture than percutaneous tenorrhaphies. The aim of our retrospective study was to analyze and compare clinical and functional results in patients treated with either the conventional open or minimally invasive suture treatment with the Achillon® system.Methods: A retrospective review of 140 patients was performed; 72 were treated with open tenorrhaphy, 68 with the minimally invasive Achillon® suture system.Results: With a comparable re-rupture rate, there was a statistically significant reduction in surgical time, incidence of minor complications, time required to return to sport activities and return to work in the minimally invasive group.Conclusions: Achillon® mini-invasive suture system is a reliable tool for the Achilles tendon ruptures, able to reduce the incidence of soft tissues complications if compared to the classic open tenorrhaphy, while maintaining strength of the suture and leading to superimposed functional outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Incidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient's health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon.Methods: Two hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers.Results: At 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D-3L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period.Conclusions: Overall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to compare the efficiency of non-operative and surgical procedures in the treatment of ruptured Achilles tendon in athletes (professional and amateur).Methods: Ninety professional or amateur athletes with rupture of the Achilles tendon were included in the study between 1998 and 2013. The athletes were aged between 25 and 40 years (mean 34.83±4.65). A total of 30 athletes underwent an open procedure, 30 were treated with a percutaneous method and 30 were treated non-operatively. All operated patients were tested one year after the surgical procedure.Results: An isokinetic dynamometer was used to compare the open and percutaneous methods. The results for the patients who were treated using the percutaneous method were 15% better than those for the patients who underwent the open procedure; the results for the group treated conservatively were 20% better than those for the group treated percutaneously.Discussion and Conclusion: The percutaneous method was easier technically than the open method. Time spent in hospital was 14.5 times shorter with the percutaneous procedure compared with the open procedure (percutaneous procedure: range 0.5-2 days, mean 0.79±0.36; open procedure: range 10-24 days, mean 11.46±2.70; p<0.00). Return to sport activities was twice as fast with the percutaneous procedure compared with the open procedure. There were no postoperative infections or reruptured Achilles tendon in the group treated with the percutaneous procedure. One patient in the group treated with the open procedure had postoperative infection (4.2%). In the non-surgical (conservatively treated) group, there were three reruptures of the Achilles tendon within one year, and one patient developed adhesions that resulted in loss of function and had to undergo an operation. The percutaneous method is the best method of surgical treatment for Achilles tendon rupture. [ABSTRACT FROM AUTHOR]

Background Achilles tendon ruptures are becoming more common. Complications after open or minimally invasive surgery are: recurrent rupture (2–8%), wound breakdown, deep infections, granuloma, and fistulas. The authors expose their experience with a personal technique. Materials In 8 patients with acute rupture of Achilles tendon the surgery was performed at least 25 days after trauma. Clinical exam and MR demonstrated in all case a total lesion of tendon. After a posterolateral skin incision the tendon stumps were debrided and suture in end-to-end fashion. A tendon flap was harvested from the proximal part of the tendon, in order to protect and reinforce the suture itself. A plaster cast was applied for 3 weeks and the patients started the rehabilitation protocol. Results After 4 months all patients returned to pre-injury daily activities. The mean follow up was 13 months (ranged between 6 and 24 months). No major complications occurred. Conclusion The posterolateral skin incision, not above the tendon, preserves the vascularity of the soft tissues, allows identifying and not accidentally injuring the sural nerve, and prevents the cutaneous scar is overlapped the tendon. In this way is favoured physiological tendon sliding. The preparation of the flap tendon does not weaken the overall strength of the tendon and protects the tendon suture. The tension on sutured stumps is less than being spread over a larger area. In our sample of 8 patients the absence of short-and long-term complications and the rapid functional recovery after surgery suggest that the technique used is safe and effective. [ABSTRACT FROM AUTHOR]

The acute rupture of the Achilles tendon is a protracted injury. Surgery is only the beginning of a long rehabilitation period. Therefore, the rehabilitation protocol is an integral aspect to restore the pre-injury activity level. Despite several trials available comparing different treatment regimes, there is still no consensus regarding the optimal protocol. Consequently, the aim of our study was to systematically search the evidence available and define a precise rehabilitation programme after operative repair of acute Achilles tendon rupture based on the trials with the highest level of evidence. We performed a systematic literature search in Medline, Embase and Cochrane library. We identified twelve randomized controlled trials comparing different treatment regimes after operative repair of the Achilles tendon. Five trials compared full to non weight bearing, all applying immobilization in equinus. Immediate full weight bearing led to significant higher patient satisfaction, earlier ambulation and return to pre-injury activity. Four trials compared early ankle mobilization to immobilization. All trials found mobilization to be superior as it shortens time to return to work and sports significantly. Three trials compared the combination of full weight bearing and early ankle mobilization to immobilization. This combination was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced atrophy and tendon elongation. No study found an increased rerupture rate for the more progressive treatment. In conclusion, the rehabilitation protocol after Achilles tendon repair should allow immediate full weight bearing. After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied. [ABSTRACT FROM AUTHOR]

Abstract: Background: Considering the 3Rs principle in animal experiments, there is a demand to perform research experiments with the fewest number of animals possible while warranting the welfare of the animals. Orthopaedic experimental studies involving operations on the hind legs of rabbits are either performed on one hind leg with the second hind leg serving as control or on both hind legs simultaneously (control: rabbits with no operations at all). Methods: The Achilles tendon of rabbits was transected and sutured, and the two-dimensional motion pattern of animals having only one leg operated was compared to rabbits having both hind legs operated (control: non-treated animals). Step length, maximum ankle angle, minimum ankle angle and the resulting range of motion of both hind legs were determined weekly over a time span from 3 weeks to 12 weeks post-operation. The results were fitted by a linear mixed effects model including time dependency. Moreover, all tendon specimen were analysed histologically. Tenocyte and tenoblast density, tenocyte and tenoblast nuclei width, inflammation level and collagen fibre alignment were determined. Results: Statistically significant differences in the motion pattern were found when one-leg treated and two-leg treated animals were compared. However, the absolute differences were on average less than 20%. Histologically, 1-leg treated animals had tendon tissue with higher cell density, but lower inflammation and less ondulated collagen fibres compared to 2-leg treated animals; the nuclei width was the same for both groups. With regard to welfare, all animals were fine during the experiments. Conclusions: While comparative studies should be performed with one-leg treated animals due to interaction effects, for proof-of-principle studies, operating two legs per animal may be justified as the welfare of the animals is warranted. This is a great benefit in the sense of the 3Rs because up to 50% of animals can be spared. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]