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Achilles tendon rupture- Minimally invasive repair

    Overview

    Learn the Achilles tendon rupture: Minimally invasive repair surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Achilles tendon rupture: Minimally invasive repair surgical procedure.
    The incidence of achilles ruptures is increasing, probably due to the increase in sports and exercise amongst an older population.
    Whether its treated surgically or conservatively, the recovery is prolonged and it will take 8-10 months to return to full activity and sports and over a year to reach maximum recovery. The goal of treatment is to achieve maximum function in the calf muscles and this requires intensive input from physiotherapy and from the patient to achieve this.
    We know from the original papers by Mason & Allen in 1948, that tendons heal quickest and strongest if they are immobilised for a short period and then mobilised within a protected environment. This is the focus of current achilles rupture management. We also know that early weightbearing is not detrimental if the ankle is protected in plantarflexion.
    It is important to know the severity of the injury and ultrasound is the investigation of choice – it will confirm the site of rupture and also the presence of any gap in the tendon ends. Ruptures at the proximal muscul0tendinous junction do not require surgery and should be treated conservatively (surgery may still be indicated in professional athletes). Ruptures or avulsions at the distal end usually require surgery as there is often a large gap. This will require open surgery (see achilles avulsion).
    Most ruptures occur in the midportion 6-7cm above the insertion and the ultrasound will confirm most importantly if the tendon ends appose in plantarflexion. Recent studies have shown that little or no benefit with surgery in patients where there is a gap <5mm and these can be successfully treated in a well structured rehabilitation programme with protection in an equinus cast or boot, with reducing equinus over several weeks. If there is a significant gap >5mm then, in my opinion, surgery is required although some surgeons use >10mm gap as the cut off.
    In professional athletes or where maximal achilles function is essential for work, I recommend surgical repair – long term function studies have confirmed significant benefits in plantarflexion torque with surgery.
    Ideally, the surgery should be performed using minimally invasive techniques – these have been shown to have significantly lower risks of wound and infective complications, when compared to open surgery. The technique described here is one method – there are others that use jigs to guide the suture placement (Achillon and PARS devices)
    Readers will also find the following OrthOracle techniques of interest:
    Achilles tendon rupture: Integra Achillon percutaneous repair.
    Achilles tendon rupture: Open repair technique.
    Achilles Reconstruction :Flexor Hallucis Longus tendon transfer using Arthrex Biotenodesis screw
    Achilles avulsion: Reattachment using an Arthrex Biocomposite anchor.

    Grassi et al. Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery. J Bone Joint Surg Am. 2018

    Indications

    INDICATIONS
    Acute rupture of the Achilles tendon, with a demonstrable gap of >5mm on ultrasound assessment, in full plantarflexion. It is not suitable for avulsion injuries.
    The technique is suitable for injuries 3 weeks old and potentially longer, although an open repair should be planned for too. If the tendon ends are too stuck down or retracted, it may not be possible to perform a percutaneous repair – in which case it’s necessary to extend the incision proximally and distally for an open reconstruction.
    In professional athletes or highly athletic patients, I preferentially recommend acute repair as there is strong evidence that power (plantarflexion torque) is better with surgery.

    SYMPTOMS & EXAMINATION
    The classic patient is a male between the ages of 25 and 55 years who is involved in a sports activity, commonly squash and tennis in the UK. The patient often feels as though they had been “hit from behind by another player” and may also have heard a large pop or rifle shot.
    The leg is instantly weak and the patient no longer able to play any sport and struggles to walk. Surprisingly it’s often quite painless.
    The most common site of rupture is in the mid portion 6-7cm above the insertion but its important to check for tears high up in the muscle tendon junction and low tears or avulsions as the treatment is very different and MI surgery not applicable.
    Examination is best performed with the patient lying prone on the couch, with the feet resting off the end of the couch. This allows a relaxed resting position and will demonstrate the natural tension in the calf. On the intact side, there will be 10-15 degrees of plantarflexion – on the rupture side the foot will hang vertically downwards. This is the Achilles Tendon Resting Angle (ATRA). There will also be loss of the normal outline of the tendon when compared to the normal side and there may be a clear gap visible. Gentle palpation may reveal a gap in the tendon, but this is often obscured by swelling. The achilles is often quite tender over a diffuse area and this is not specific.
    There are other tests used such as the Thompson test or calf squeeze test – Squeezing the calf muscle should cause plantarflexion, indicating an intact Achilles on the normal limb. On the injured side, there is no motion. I don’t find this as reliable as the resting posture test, as often its too painful to squeeze it as hard and often the injured side moves a little anyway.

    IMAGING
    Determination of the site of rupture is essential because ruptures proximal to the myotendinous junction do not require operative intervention and distal avulsions need a different reconstruction.
    Ultrasound is the investigation of choice. It allows assessment of the tendon quality (revealing underlying tendinopathy), the site of the rupture (the distance from the insertion on the calcaneus) and especially whether or not the tendon ends can be opposed. It will confirm if the injury is suitable for a minimally invasive repair – that it is not an avulsion injury or rarely when there is a large longitudinal injury.
    MRI is also very helpful, especially for determining the height of the rupture – in proximal / musculotendinous tears non-operative treatment may be preferred. However it is not possible to be dynamic and so no assessment of the tendon approximation can be made.
    Often an MRI has been organised by the referring team already – I use ultrasound much more than MRI, but I do use it in cases of extensive swelling, where the nature of the injury is unclear.
    In general, I use ultrasound to confirm that the tendon ends come together, in patients that I am considering treating non-operatively. I use MRI in patients when I am not confident about the type of the rupture or when I suspect that the quality of the tendon may be poor and not suitable for surgery.

    ALTERNATIVE OPERATIVE TREATMENT
    Open achilles repair.
    This is the old gold standard and is used less and less now, due to the increased risks of wound problems and nerve injury.

    Percutaneous operative repair techniques:
    Several techniques have been described with no particular technique gaining widespread use (Achillon / PARS device). The Achillon jig, passes transverse sutures across the tendon and the PARS is similar but with a locking loop mechanism. I have used both devices and had issues with poor suture hold in the proximal tendon, with the sutures pulling out easily. Although small, there is an incidence of sural injury with these transverse sutures.
    Because of these issues, I use a percutaneous medial locking suture instead. In my hands, the suture fixation is better and it less invasive – the primary incision is much smaller. Also, the incisions are away from the sural nerve.

    Achilles reconstruction procedures
    Used for delayed presentation of more than 6 weeks. These are used when the tendon gap cannot be brought together primarily.
    The V-Y plasty or Achilles turn-down technique involve mobilising part of the proximal muscle / tendon unit to bridge the gap.
    FHL tendon transfer – either long or short. This uses the powerful FHL muscle to provide plantarflexion of the ankle by transferring it to the heel. Either by direct implantation into the calcaneum (Short FHL transfer) or passing it through the heel and proximally to attach to the proximal achilles (Long FHL transfer).

    NON-OPERATIVE MANAGEMENT
    Recent studies in the literature support the treatment of closed acute Achilles tendon ruptures with opposable tendon ends in a weight bearing walker boot. The boots either have adjustable hinges at the ankle to vary the degree of equinus or, more commonly, removable wedges can be applied within the boot to adjust the foot position.

    CONTRAINDICATIONS
    The absolute contraindication for surgical repair of an Achilles rupture is in patients with poor lower limb vascularity and active infections. Patients with underlying neuropathy and diabetes should also be preferentially managed non-operatively. Any patient taking medications that compromise the immune response to trauma (steroids, DMARDS etc) should avoid surgical repair.
    The quality of the skin also needs to be considered carefully for increased risks of infective complications. Any signs of skin disease or infection indicates that surgery may not be safe.

    Setup

    The surgery is performed under general or spinal anaesthesia, with a thigh tourniquet (300 mmHg) and the patient in the semi-prone position.
    The semi-prone position is really useful for surgery on the achilles or the posterior ankle – it is much less complicated for the anesthetist and also easier for the theatre team to set up than fully prone.
    The patient is placed in the lateral position with the injured leg on the bottom and just off the end of the table. The patient is then rolled forwards onto a large pillow or bolster and the back supported. The lower leg is then pulled behind gently to allow it to roll in. Remember to put the tourniquet on before your turn the patient!
    One dose of IV antibiotics given at induction.

    Operation – 1

    Achilles Tendon Resting Angle (ATRA)
    I find this test the most reliable. With the patient lying prone and fully relaxed, the injured side (1.) has no natural tension and rests completely vertically.
    On the uninjured side (2.) the natural tension in the achilles provides 10-15′ of plantarflexion.
    In the acute setting and if relaxed, there can be no other cause for this posture.
    Note: There is no need for an ultrasound to confirm the diagnosis – but there may be a need for one to assess the tendon gap.

    Ultrasound is the main investigation of choice, but as a moving image the still images can be hard to interpret.
    This image shows the proximal stump to the left (1.) , with haematoma separating it (2.) from the distal stump (3.)
    The great benefit of USS is that it will show clearly how closely the gap can be closed and the height of the rupture above the calcaneum. Especially if the tears are at the muscle tendon junction, as these should be treated conservatively, in the main.

    MRI is indicated when the diagnosis is not clear.
    In this case, the achilles can be seen clearly ruptured, with the proximal stump very visible (1.) and complete detached from the calcaneum (2.).
    This is an avulsion injury – it is not suitable for minimally invasive surgery. The tendon will need pulling back onto the heel with multiple bone anchor points.

    Positioning: The surgery is performed in the Semi-prone position.
    This is quicker and easier for the anaesthetic team than positioning fully prone. It still provides excellent access to the posterior ankle.
    The thigh tourniquet needs to be put on first before turning.
    The patient is initially in a lateral position, with the injured leg underneath and the feet off the end of the table.
    A large gel demi-roll is placed next to the abdomen and chest and the patient rolled forwards on to this, with a back support behind.
    The top leg is bent forwards and the lower leg is rotated externally to bring the achilles more vertical.

    Identify the site of the rupture and palpate and mark the proximal tendon end.The position of the main incision in relation to the tendon rupture is very important.
    Palpate the rupture site and feel where the ends of the tendon are, especially proximally.
    If the rupture has already started healing, then tendon ends will masked – In which case, dorsiflex the ankle to “re-rupture” the achilles and to form a gap again.

    In this image the proximal and distal tendon ends have been marked
    The proximal tendon is not very mobile and if the incision is too far away from the tendon end, your needle won’t reach the tendon.
    Ideally the sutures should transfix the tendon 2-3 cm above the rupture site, into healthy undamaged tendon.
    The distal tendon is very mobile and can easily be brought up to the incision by plantarflexing the foot.

    The main incision is a small transverse incision 5-10mm long at the level of the proximal ruptured tendon endIt is essential to place this incision at the proximal end.
    Place the incision medial to the midline to avoid the sural nerve. This classically runs in the midline proximally, deviating laterally in the lower ½ of the tendon, but the position is often variable. If there is a worry about the nerve, it’s best to stay on the medial side.
    Even though it’s a small incision, the sheath can be clearly seen with minimal retraction. Form a small window in the sheath, with scissors or a scalpel. This will often release some haematoma.

    The proximal tendon is grasped with an Alice or small grabber.Place the Alice directly through the sheath and avoid picking up an subcutaneous tissues (nerves) on the way.
    Pull the tendon down to the wound, and keep under tension.
    Often, the tendon is very frayed at the rupture site and only some of the frayed ends can be grabbed – this is fine as the first suture will pick up better tissue proximally.
    Once the first suture is in place, it will provide better tension than the Alice, which can be removed.

    After years of repairing achilles tendons, I find that No.2 Ethibond works best. There is a long curved needle, which is ideal for passing through the tendon a good distance from the rupture. Its a strong suture that doesn’t snap easily and ties well without slipping.
    It is non-absorbable and despite concerns over possible infection and prominent knots, I have not had an issue with this.
    The only downside is that it doesn’t pull through the tendon so easily , when tensioning the knots. Therefore its important to draw it through the tendon maximally before tying off.

    The first suture is passed through the window in the sheath, to pick up the proximal tendon and come out percutaneously on the medial sidePass the suture as far up the tendon as possible – Ideally 2-3cm proximal to the rupture site and into healthy “solid tendon”.
    The tendon is kept on traction throughout, and the needle directed to pass out of the skin just medial to the midline, to avoid the sural nerve.


    The first step is to pass a suture through the proximal tendon, exiting through a “portal” on the medial side.

    The tendon should feel firm and you should feel some resistance on passing the suture. This is not always the case, especially in very frayed tendons.
    In this photo, my assistant is using the Alice to pull the tendon distally, so that the suture can pass as proximally as possible into healthy proximal tendon.

    Fashion a first small proximal ‘portal’ in the skin before the needle is fully exited.It’s important to make a “portal” through the skin and sheath so that the sutures can be passed without picking up the local tissues.
    Do not pass the needle all the way through – Once the needle is visible, make a small full thickness cut around the needle of 2-3mm. Cut down onto the needle.
    Note: Its best to make this incision before the needle is pulled through, otherwise it’s very easy to cut the suture.





    Continue the portal through the sheath, to allow clear passage of the suture for the locking stitch.
    This is an important step, otherwise the locking sutures will catch the sheath instead of the tendon. If this happens, it will stop the tendons ends being pulled together at the end and will leave a gap!
    I use a single side of a clip to do this, keeping the portals as small as possible. When starting, it’s probably easier to make a larger portal and perforate the sheath with the whole clip or similar instrument.

    Pass the suture back through the first proximal portal, into the Achilles for a further bite and then come out medially, with the tip of the needle, then fashion a further portal.

    Pass the suture back through the first proximal portal, into the Achilles for a further bite and then come out medially, with the tip of the needlePass the suture back through the proximal portal, and bring the suture out on the medial side. The sural nerve will be safe, lying laterally.
    The tendon is usually too narrow to pass this suture directly out at the side and it has to be angled distally to exit close to the achilles.
    Remember not to take the need all the way through yet, as a portal needs fashioning.

    Fashion a second proximal medial suture portal here using the same technique, make a 2-3mm incision onto the needle, then enlarge with a clipAgain, cut onto the needle not the suture!

    Pull the suture through and then perforate the sheath. Use the clip to do this again – I’m using only one side of the clip, but a small mosquito clamp or dolphin-nosed scissors would do.

    Pass the suture back though the second medial portal, through the tendon, and out at the primary proximal incision..The locking stitch is vital in gaining a strong repair – the tendon is made up of longitudinal fibrils and it is easy for the suture to slip along or “comb” through these parallel fibres.
    The locking stitch produces a perpendicular segment of suture that grasps the tendon much better. It will make it harder for the stitch to be pulled tight though.
    Again, take care to pass the suture cleanly and not to pick up the sheath on the way out.


    The suture is passed back through the medial portal, in an arc exiting at the main incision, to form the first locking stitch in the tendon.

    Test the suture strength and fixation in the proximal tendon.Pull on both ends of the suture firmly to ensure it has a good grasp of the tendon and to check there is no tethering to the skin or sheath.
    There should be an elastic feel to the tendon when it is tested and pulled – if not one then the stitch must be tethered somewhere.
    The skin shouldn’t be pulled in or puckered, when tested. If it is, carefully release the tether without cutting the suture!
    Occasionally, this suture pulls out completely – dont worry, this happens. Simply repeat the process.

    Pass two more proximal locking sutures using the same portals and again test their strength of holdOnce the first stitch is locked in place, this can be used to pull on the tendon and the Alice can be removed.
    Repeat the proximal locking suture two more times, taking care to use the portals and avoid picking up the skin / sheath.
    Occasionally, a following suture passes through a previous suture, locking both up. Its not common – try and remove the last suture and repeat it. Both can get caught, in which case they will both need removing.
    Clip and secure each suture. Test the suture hold each time as occasionally one will pull through.

    I like to check that the proximal sutures are holding well, by lifting the whole leg with them.
    Any weak or incompetent ones will pull through. Its not that unusual for one of the sutures to not hold well and this can simply be redone, using the same technique.

    Before starting distal tendon fixation maximally plantarflex the ankle to deliver the tendon as close to the incision as possible and use the Alice to grab the tendon.Next, the same three sutures are used to transfix the distal tendon, using the same technique.
    Firstly,The sutures are then passed in a similar fashion.

    Through the primary midline incision, pick up the tendon 2-3cm from the rupture with the same suture as used proximally, but now directed distally.The distal tendon should feel much more dense and tougher to pass the suture through.

    Operation – 2

    Distally, the first suture is passed through the main incision and exiting at a midline portal.

    The distal suture is passed to exit in the midline (avoiding the sural nerve at this level) and a first distal, but central portal is created with the same technique as used proximally.Again, fashion another skin/sheath portal here for clear passage of the sutures.
    Cut down onto the needle, pass the suture all the way through and then perforate the sheath with a clip.

    The distal locking stitch is sewn back into a good bite of Achilles through the first distal midline portal.The first distal suture is passed back through the first distal midline portal and out medially.
    The tendon should feel “solid” and much harder to pass the needle through, compared to the proximal ones.

    A Distal locking suture is formed, passing back through the distal portal and exiting at a medial (distal) portal

    A second, and medially located, distal portal is fashioned in the same fashion, through which the first distal suture is exited.Cut down onto the needle, pass the suture all the way through and then perforate the sheath with a clip.

    A distal locking suture is formed by passing the suture back through the medial portal, exiting at the main incision.

    The distal suture is passed back through the medial portal (distal) to exit at the primary incision, having taken a good bite of tendon.Clip and secure both ends of the suture, and place the clip / sutures off to one side , out of the way for the passage of the next suture.
    Repeat this step with the 2 other sutures – always checking for clear passage of the sutures through the skin and sheath each time.
    Again, the tendon should feel quite tough to pass the needle through.


    A further two distal sutures are passed in the same fashion and then the strength of these sutures is tested.Again, lift the whole leg by the three distal sutures. It very uncommon for these to pull through, as the tendon is much firmer and the sutures lock around the tendon very well.
    If any do slip, simply repeat suture and follow the steps proximally and distally.

    Advancing the sutures to provide maximal tension.Once all three sutures are passed and checked, the foot is maximally plantarflexed.
    The next step is to take up an slack in the sutures, before tying. The ethibond locking sutures need to be pulled tight within the tendon, so that there are no areas of laxity to allow early gapping.
    This takes a little bit of care and is best done by repeatedly pulling and relaxing each individual suture, advancing them through the tendon.

    Getting the tension right and tying the sutures in maximal tension.When tying the knots, it’s important not to catch any of the sheath or local fat – this will stop the knot bedding down tightly and tension will be lost. If needed, use your assistant with small retractors (e.g. cats paw) to retract the subcutaneous tissues.
    I use a double throw “slip knot” and pull it tight in stages. This allows me to tighten, and re-tighten several times. Only when I am happy with the tension and my suture hold, will I lock the knot.
    When pulled tight, the knots will disappear deep inside the tendon and sheath and won’t be palpable.

    The final assessment should show, good plantarflexion with the natural contours of the achilles reformed and restoration of the natural ‘bounce” of the muscle tendon unit. Aim to repair the achilles in more plantarflexion than the normal side – often this is not far from full plantarflexion.
    We know from Lepillahti’s excellent studies, using RSA beads, that the repair lengthens and stretches by several millimeters during rehabilitation – therefore over-tightening and more plantarflexion is better than less.

    Note: It is not possible to over tighten it.

    This image shows the achilles repair is tensioned well, with good restoration of the natural contour above the heel. The ankle is plantarflexed and in a good position.
    The incision and portals are healthy and have not been caught up with no sign of puckering or tethering.
    At this stage I will do a final assessment of my repair. Check for obvious gaps, check for loss of tension or inadequate tension and check that the proximal muscle moves and tightens with dorsiflexion.
    If the repair does not feel satisfactory and is either a little lax or there is a gap, then I will redo the whole repair. Its much quicker to do now the portals are present.

    The sheath is closed with 3/0 vicryl rapide – it’s a small incision and so only one stitch is possible. I like closing the sheath, as it gives a nice gliding layer between the skin and the repair / sutures.
    The skin is closed with interrupted sutures and protected with steristrips.
    Release the tourniquet now , if used.

    Application of plastercast backslab with the ankle in equinus.Further gauze dressings / wool and a backslab is applied, to protect the wound and tendon repair for 2 weeks.
    I use a 10cm roll of synthetic cast for the backslab, rolled out and folded to the correct length. Its clean, light and very strong.

    Post Operative

    There are many advantages to minimally invasive achilles repair, with very low risks of infection, nerve injury and rerupture. The post operative rehabilitation follows other well published regimens, with protection in a backslab plastcast for 2 weeks to promote good wound healing and avoid infection. This is followed by a period of partial, then full weightbearing in a specialised Achilles boot with reducing equinus over 8 -10 weeks.
    I use the Vacoped Achilles boot which provides dynamic equinus in a protected range of plantarflexion. I prefer this , as it allows greater movement and potentially faster healing. My colleagues use a long leg orthopaedic boot with static equinus wedges, with equal success.
    The first 2 weeks are non-weightbearing in the plastercast with strict elevation above hip height for 45mins/hour. Clinic review is at 2 weeks and the immobilisation changed to the vacoped achilles boot, locked in full plantarflexion. Partial weightbearing (50% body weight) is started. The boot is worn day and night but can be taken off for short periods when resting or for physiotherapy.
    Physiotherapy starts at 2 weeks – initially this is simple soft tissue mobilisation and massage with minor unresisted dorsiflexion / plantarflexion exercises.
    Note: Dorsiflexion will come naturally and its extremely important the physiotherapists do not perform dorsiflexion stretches!
    There is a significantly increased risk of Deep Vein Thrombosis (DVT) with achilles tendon rupture and also with surgical repair. Therefore oral anticoagulation is given for the first 4 weeks to reduce the risk of DVT.
    At 4 weeks full weightbearing is started and the boot can be taken off at night and at rest. An increasing physiotherapy loading programme is started.

    WEEKS 2-4: Partial Weight Bearing in Vacoped Boot
    Partial WB of 50% of body weight allowed – test how this feels like on a bathroom scales.
    CHANGE TO VACOPED ACHILLES BOOT
    locked in full plantarflexion.
    wear 24 hrs a day.
    can take off when sitting.
    ↑ df range by 1 notch per week (5 per week)
    PHYSIOTHERAPY STARTS – NO DORSIFLEXION STRETCHES AT ANY STAGE
    Soft tissue massage
    Gentle Active
    Work on Achilles gliding
    WEEKS 4-8: Fully Weight Bearing in Vacoped boot
    remove walker at night.
    ↑ dorsiflexion by 1 notch per week.
    discard crutches when able
    zero position at 8 weeks – change to flat sole
    PHYSIOTHERAPY
    Active Plantarflexion with Theraband
    Compex muscle stimulation if available
    Seated heel raises
    Full PF, inversion and eversion
    At 6 weeks start light NWB aerobic exercises –
    e.g. cycling (push with heel, not toes)
    WEEKS 8-12: Vacoped to Shoes with heel raise
    discard vacoped at +10’
    change to flat shoe with 1cm heel raise for 4 weeks
    PHYSIOTHERAPY
    Proprioception/balance work
    Gait re-education
    Ecc/Con loading (bilat to single. Emphasise ecc phase)
    Single stairs
    Progress to upslope and downslope.

    WEEKS 12-16: NORMAL SHOES.
    PHYSIOTHERAPY
    Progressive exercises
    Full NWB work eg Xtrainer / Bike
    WEEKS 16-24+
    PHYSIOTHERAPY
    Progress to Jogging then fast acc. & deceleration.
    Directional running / cutting
    Pylometrics. e.g. toe bouncing upwards / forwards /directional

    Recommended Reading

    Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis.
    Ochen et al BMJ. 2019
    A meta-analysis of 10 randomised controlled trials and 19 observational studies with over 16,000 patients. In conclusion, re-rupture is less with operative repair although this included low risks of surgical complications. Early weightbearing (less than 4 weeks) was not harmful.
    The Rate of Healing of Tendons – An experimental study of tensile strength Mason, M & Allen, H
    Annals of Surgery 1941
    The original and classic paper on tendon healing performed on dogs. There were 3 groups, each with surgically cut flexor tendons and differing rehabilitation methods. The dogs were then sacrificed at different stages and the tendon strength examined. Group A were repaired and the limb left unprotected, Group B were temporarily immobilised and Group C were immobilised throughout. The findings showed that a period of immobilisation and protection for 2-3 weeks followed by active movement provided the greatest repair strength and healing.
    The treatment of a rupture of the Achilles tendon using a dedicated management programme. P Williams et al. BJJ 2015
    The SMART trial – A controlled trial of conservative (211) versus surgically treated (62) achilles ruptures. This concluded that closely monitored non-operative management (in patients with <10mm gap on ultrasound) had a comparable re-rupture rate to surgical cases and in an smaller group of patients (incomplete participation), there was no functional difference. This a good paper and has a very nice rehabilitation protocol outlined but its conclusion is perhaps misleading regarding the outcome as only a small number (103) were able to complete functional assessment.
    The treatment of a rupture of the Achilles tendon using a dedicated management programme. P Williams et al. BJJ 2015
    The SMART trial – A controlled trial of conservative (211) versus surgically treated (62) achilles ruptures. This concluded that closely monitored non-operative management (in patients with <10mm gap on ultrasound) had a comparable re-rupture rate to surgical cases and in an smaller group of patients (incomplete participation), there was no functional difference. This a good paper and has a very nice rehabilitation protocol outlined but its conclusion is perhaps misleading regarding the outcome as only a small number (103) were able to complete functional assessment.

    A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Juhana Leppilahti et al. AJSM 2016
    A randomised controlled trial of operative vs non operative achilles ruptures (60 patients). Strength, as measured by peak torque was 10-18% greater in the operative group at 18 months. This is a good paper written by Leppilahti who is an under-recognised expert on the achilles.

    Reference

    • orthoracle.com

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