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Background: In this prospective study, we used magnetic resonance imaging (MRI) to assess long-term Achilles tendon length, calf muscle volume, and muscle fatty degeneration after surgery for acute Achilles tendon rupture., Methods: From 1998 to 2001, 60 patients at our center underwent surgery for acute Achilles tendon rupture followed by early functional postoperative rehabilitation. Fifty-five patients were reexamined after a minimum duration of follow-up of 13 years (mean, 14 years), and 52 of them were included in the present study. Outcome measures included Achilles tendon length, calf muscle volume, and fatty degeneration measured with MRI of both the affected and the uninjured leg. The isokinetic plantar flexion strength of both calves was measured and was correlated with the structural findings., Results: The Achilles tendon was, on average, 12 mm (95% confidence interval [CI] = 8.6 to 15.6 mm; p < 0.001) longer (6% longer) in the affected leg than in the uninjured leg. The mean volumes of the soleus and medial and lateral gastrocnemius muscles were 63 cm (13%; p < 0.001), 30 cm (13%; p < 0.001), and 16 cm (11%; p < 0.001) lower in the affected leg than in the uninjured leg, whereas the mean volume of the flexor hallucis longus (FHL) was 5 cm (5%; p = 0.002) greater in the affected leg, indicating FHL compensatory hypertrophy. The median plantar flexion strength for the whole range of motion ranged from 12% to 18% less than that on the uninjured side. Finally, the side-to-side difference in Achilles tendon length correlated substantially with the strength deficit (ρ = 0.51, p < 0.001) and with medial gastrocnemius (ρ = 0.46, p = 0.001) and soleus (ρ = 0.42, p = 0.002) muscle atrophy., Conclusions: Increased Achilles tendon length is associated with smaller calf muscle volumes and persistent plantar flexion strength deficits after surgical repair of Achilles tendon rupture. Strength deficits and muscle volume deficits are partly compensated for by FHL hypertrophy, but 11% to 13% deficits in soleus and gastrocnemius muscle volumes and 12% to 18% deficits in plantar flexion strength persist even after long-term follow-up., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: This prospective randomized trial with a mean fourteen-year follow-up compared simple end-to-end repair with fascial flap-augmented repair for acute Achilles tendon ruptures., Methods: From 1998 to 2001, sixty patients with acute Achilles tendon rupture were randomized to receive simple end-to-end repair or augmented repair; both groups were treated with postoperative bracing allowing free active plantar flexion. After a follow-up of thirteen years or more, fifty-five patients (twenty-eight in the nonaugmented-repair group and twenty-seven in the augmented-repair group) were reexamined. Outcome measures included the Leppilahti Achilles tendon score, isokinetic plantar flexion strength (peak torque and the work-displacement deficit at 10° intervals over the ankle range of motion), tendon elongation, and the RAND 36-item health survey., Results: After a mean of fourteen years of follow-up, the mean Leppilahti score was 87.1 points for the nonaugmented repairs and 91.5 points for the augmented repairs, with a mean difference of 4.3 points (95% confidence interval [CI], -0.1 to 8.8 points). The surgical technique did not have an impact on strength parameters, with a mean peak torque of 112.6 Nm after the nonaugmented repairs and 107.3 Nm after the augmented repairs (mean difference, 5.3 Nm [95% CI, -22.2 to 11.6 Nm]) and a median work-displacement deficit of 6.7% to 20.3% after the nonaugmented repairs and 12.8% to 18.0% after the augmented repairs (p = 0.9). Strength did not significantly change between the twelve-month and fourteen-year follow-up examinations. At a mean of fourteen years, the injured side showed a 12.2% to 18.0% median work-displacement deficit compared with the unaffected side (p < 0.001). RAND-36 scores indicated no between-group difference in health domains., Conclusions: Augmented repair of total Achilles tendon ruptures provided no advantage over simple end-to-end repair. Achilles tendon ruptures result in a permanent calf muscle strength deficit, but its clinical relevance remains unclear., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: This prospective diagnostic study assessed the utility of MRI (magnetic resonance imaging) findings for the deep aspect of the deltoid ligament in evaluating the stability of the ankle mortise in patients who have an SER (supination-external rotation)-type lateral malleolar fracture with no widening of the medial clear space., Methods: Sixty-one patients with a unilateral lateral malleolar fracture resulting from an SER mechanism were enrolled. Two surgeons assessed the stability of the ankle mortise with use of an external-rotation stress test. The anterior and posterior parts of the deep deltoid ligament were investigated with 3.0-T MRI and were graded (as normal, edematous, partial tear, or complete tear) by two musculoskeletal radiologists. The medial clear space was measured and compared with the MRI findings for the deep deltoid ligament in stable and unstable injuries. Interobserver reliability was calculated for both external-rotation stress testing and MRI assessment., Results: Thirty-three patients had a medial clear space of ≥ 5 mm in the external-rotation stress test. According to MRI, all of these patients had an injury involving the deep deltoid ligament (an edematous ligament in five, a partial tear in twenty-six, and a total tear in two). Twenty-eight patients had a medial clear space of <5 mm, and MRI indicated a deep deltoid ligament injury in all of these patients as well (an edematous ligament in nine and a partial tear in nineteen). The medial clear space increased according to the severity of the deep deltoid ligament injury as indicated by MRI (p < 0.001). The interobserver agreement of the external-rotation stress test was excellent (94% agreement; kappa = 0.87), whereas the interobserver reliability of the MRI assessments by the two musculoskeletal radiologists was fair to moderate (72% agreement for the posterior part of the deep deltoid ligament and 56% for the anterior part; kappa = 0.46 and 0.22, respectively)., Conclusions: On the basis of the study results, we do not recommend the use of MRI when choosing between operative and nonoperative treatment of an SER-type ankle fracture., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)