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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: Augmented and nonaugmented techniques have been used for the operative repair of a fresh complete Achilles tendon rupture. Augmented techniques have been favored for their stronger pullout strengths but have been avoided because of the risk of wound complications. If proven to be equally good, the nonaugmented technique would be the method of choice. In the present study, we hypothesized that augmentation with a down-turned gastrocnemius fascia flap would not provide better results than would end-to-end suture repair with use of the Krackow locking loop surgical technique., Methods: Sixty patients with an acute Achilles tendon rupture were randomized preoperatively to receive end-to-end suture repair with use of the Krackow locking loop technique either without augmentation (simple repair group) or with a down-turned gastrocnemius fascia flap as described by Silfverskiöld (augmented repair group). A brace allowed free active plantar flexion of the ankle postoperatively, whereas dorsiflexion was restricted to neutral for the first three weeks. Weight-bearing was limited for six weeks. The follow-up period was one year, and the patients were evaluated in terms of clinical measurements, an outcome score, isokinetic calf muscle performance tests, and tendon elongation measurements., Results: The mean operative time was twenty-five minutes longer and the incision was 7 cm longer in the augmented repair group as compared with the simple repair group (p < 0.001 for both). In the simple repair group, the overall ankle score was excellent for nineteen patients (63%) and good for eight patients (27%) and three patients (10%) had an early failure (all because of rerupture). In the augmented repair group, the ankle score was excellent for fourteen patients (56%) and good for six patients (24%) and five patients (20%) had a failure because of rerupture (three) or deep infection (two). The difference between the groups with regard to the overall result was not significant (p = 0.68). In the simple repair group the isokinetic calf muscle strength score was excellent for eleven patients (37%), good for fourteen patients (47%), and fair for two patients (7%), with three patients (10%) having a failure, whereas in the augmented repair group the score was excellent for nine patients (36%), good for seven patients (28%), fair for three patients (12%), and poor for one patient (4%), with five patients (20%) having an early failure. Achilles tendon elongation occurred in both groups, and elongation correlated significantly with isokinetic peak torque deficits (rho = 0.64, p = 0.001) and isometric strength deficits (rho = 0.48, p = 0.026) in the simple repair group. No significant differences were seen between the two groups at the three-month and twelve-month checkups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, overall outcome, isokinetic calf muscle strength, mean peak work-displacement relationships, or tendon elongation., Conclusions: Augmented repair of a fresh total Achilles tendon rupture does not have any advantage over simple end-to-end repair.