Best Surgical Management of Chronic Achilles Tendon RupturesWhether you are a young adult or in the older adult category (50 years old or older), active in sports or a nonathlete, rupture of the Achilles tendon is possible. A simple event like running to catch a bus, stumbling on the floor, or playing with children can lead to this type of injury in the nonathletic adult. For athletes, any sport or activity that involves running and/or jumping (e.g., jogging, soccer, dancing, biking) can result in the same problem.
It is estimated that one-fourth of all acute Achilles tendon ruptures are missed resulting in a delayed diagnosis. Eventually, the acute problem becomes a chronic one that can no longer be repaired (by sewing the two ends of the tendon back together). Instead, tendon reconstruction is required.
The torn end of a tendon is referred to as a "stump." In chronic ruptures, the ruptured end of the tendon pulls away or "retracts" from the bone. There is a large gap between the end of the torn tendon and the place where it is supposed to attach to the bone. By now, the ruptured tendon stump is thin and atrophied. It can no longer be pulled back up and reattached. That's when reconstruction surgery becomes the necessary treatment approach. But which surgical technique (there are several) works the best remains unknown.
In this study, surgeons at a single-center reviewed the results of their 28 patients. The patients ranged in age from 28 years old up to 66 years old. Two-thirds of the group were men and the remaining one-third were women.
Each patient was treated for chronic closed rupture of the Achilles tendon. The surgeons chose to use a tendon graft from the hamstring muscle (the semitendinosus portion of the hamstrings). Details of the operative technique are provided using written description, photos taken during the procedure, and drawings showing the final reconstruction. The postoperative rehabilitation program was also described.
Patients in the case series were followed for two to three years. The mid-term results were reported based on improvement of overall function and rate of complications. Calf circumference and strength were also measured and compared from before surgery to after surgery. Outcomes of surgical management are summarized in a table. Twenty of the 28 patients had no pain after surgery. The remaining eight people had mild to moderate pain; no one reported severe pain.
Daily activities were resumed by all but two patients. Some patients reported limited recreational activity. Only two people were bothered by shoes (usually the more fashionable, less supportive type of footwear). And in the end, 22 of the 28 patients were satisfied with the results. No one was dissatisfied; a few were happy with the results but had a few reservations.
In terms of post-operative problems, there were no infections, nerve injuries, reruptures, or blood clots to complicate matters. There was significant overall improvement of symptoms and function. But the authors also reported that calf circumference of the affected side did not fully return and ankle plantarflexion strength (pointing toe downward or rising up on toes) did not recover fully either. It should be noted that the loss of full strength did not affect patients' ability to walk normally, rise up on toes, or return to work and recreational activities.
In summary, the best approach to the surgical management of chronic Achilles tendon ruptures remains unknown. This study added some perspective on the subject by showing that using hamstring tendon grafts results in good clinical outcomes. The hamstring tendon is long enough to bridge the wide Achilles tendon gap. It is easy to harvest with quick recovery for the patient. The knee does not suffer significant loss of function in terms of strength and power. And the semitendinosus can grow back in time. The entire procedure can be done with minimally invasive techniques and few (if any) complications.
Nicola Maffulli, MD, MS, PhD, FRCS(Orth), et al. Minimally Invasive Reconstruction of Chronic Achillles Tendon Ruptures Using the Ipsilateral Free Semitendinosus Tendon Graft and Interference Screw Fixation. In The American Journal of Sports Medicine. May 2013. Vol. 41. No. 5. Pp. 1100-1108.
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