Current Concepts Review Acute Ruptures of the Achilles Tendon
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Gulati V, Jaggard 1000, Al-Nammari SS, Uzoigwe C, Gulati P, Ismail N, Gibbons C, Gupte C. Management of achilles tendon injury: A current concepts systematic review.World J Orthop 2015; 6(four): 380-386 [PMID: 25992315 DOI: 10.5312/wjo.v6.i4.380]
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Vivek Gulati, Specialist Registrar, Section of Orthopaedic Surgery, Chelsea and Westminster Hospital, 369 fulham road, London SW10 9NJ, U.k..
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Earth J Orthop. May eighteen, 2015; six(4): 380-386
Published online May 18, 2015. doi: ten.5312/wjo.v6.i4.380
Direction of achilles tendon injury: A electric current concepts systematic review
Vivek Gulati, Matthew Jaggard, Shafic Said Al-Nammari, Chika Uzoigwe, Pooja Gulati, Nizar Ismail, Charles Gibbons, Chinmay Gupte
Vivek Gulati, Matthew Jaggard, Shafic Said Al-Nammari, Chika Uzoigwe, Pooja Gulati, Nizar Ismail, Charles Gibbons, Section of Orthopaedic Surgery, Chelsea and Westminster Hospital, London SW10 9NJ, United Kingdom
Chinmay Gupte, Academic Section of Orthopaedic Surgery, Charing Cross Infirmary, London W6 8RF, United Kingdom
ORCID number: $[AuthorORCIDs]
Writer contributions: Gulati 5, Jaggard G and Uzoigwe C were involved in the writing of the manuscript; Gulati V, Al-Nammari SS, Gulati P and Ismail N performed the literature search and collated the fabric; Gibbons C and Gupte C reviewed the manuscript, formed its structure and supplied editorial input.
Disharmonize-of-interest: The authors declare that are no conflicts of interest.
Open up-Admission: This article is an open-admission article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Artistic Commons Attribution Non Commercial (CC BY-NC iv.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on unlike terms, provided the original work is properly cited and the utilise is non-commercial. Encounter: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Vivek Gulati, Specialist Registrar, Department of Orthopaedic Surgery, Chelsea and Westminster Hospital, 369 fulham road, London SW10 9NJ, United Kingdom.
Phone: +44-7803-902595
Received: September 4, 2014
Peer-review started: September 4, 2014
Beginning conclusion: January xx, 2015
Revised: March 28, 2015
Accepted: April 16, 2015
Article in printing: April 18, 2015
Published online: May eighteen, 2015
Abstract
Achilles tendon rupture has been on the rise over recent years due to a variety of reasons. It is a debilitating injury with a protracted and sometimes incomplete recovery. Management strategy is a controversial topic and prove supporting a definite arroyo is express. Stance is divided between surgical repair and conservative immobilisation in conjunction with functional orthoses. A systematic search of the literature was performed. Pubmed, Medline and EmBase databases were searched for Achilles tendon and a diverseness of synonymous terms. A recent wealth of reporting suggests that conservative regimens with early weight bearing or mobilisation accept equivalent or improved rates of re-rupture to operative regimes. The application of dynamic ultrasound assessment of tendon gap may prove crucial in minimising re-rupture and improving outcomes. Studies employing functional assessments have institute equivalent part between operative and bourgeois treatments. Nevertheless, no specific tests in peak power, push button off strength or athletic performance have been reported and whether an advantage in operative treatment exists remains undetermined.
Core tip: Achilles tendon rupture is a common injury. Simmonds or Thomas' exam is a reliable diagnostic tool with a sensitivity of betwixt 0.89-0.93. Studies have not shown conclusive superiority of operative repair compared with non-operative and casting techniques. Non-operative direction has a more favourable complication contour. In that location is emerging evidence that the traditional perception that not-operative management is associated with higher re-rupture rates no longer holds truthful for the new management strategies which appraise tendon gap and utilise a dedicated "Achilles tendon management infrastructure". It is important that clinicians can recognize the injury and delayed diagnosis can lead to significant morbidity.
- Commendation: Gulati V, Jaggard Thou, Al-Nammari SS, Uzoigwe C, Gulati P, Ismail N, Gibbons C, Gupte C. Management of achilles tendon injury: A current concepts systematic review.Globe J Orthop 2015; 6(4): 380-386
- URL: https://www.wjgnet.com/2218-5836/full/v6/i4/380.htm
- DOI: https://dx.doi.org/ten.5312/wjo.v6.i4.380
INTRODUCTION
The Achilles tendon is the well-nigh ofttimes ruptured tendon in the human body[1]. The incidence of rupture is on the rise and has been so since the 1980s. The yearly incidence of Achilles tendon rupture is rising and reported as 4.seven/100000 in 1981 to 6/100000 in 1994 from a Scottish accomplice, and 22.1/100000 in 1991 to 32.six/100000 in 2002 from a Danish cohort. The nearly rapid increase was noted in the male 30 to 39 historic period grouping[1,2]. The near hazardous sport appears to be badminton with 83% occurring in males. The hateful age of presentation is 35 years with a male:female person ratio of twenty:1[3,4]. The classical patient is the novice sportsmen in his fourth decade engaging in unaccustomed sport.
The commonest site of rupture is in a region three to 6 cm to a higher place the os calcis which corresponds to a watershed region of poor vascularisation[five]. Perfusion in this region is farther compromised during stretching and contraction[6,7]. With increasing age there is decreased collage-crosslinking and weakening of the tensile forcefulness of the tendon. Maffulli et al[8] and Järvinen et al[9] histologically observed significant collagen degeneration in patients with Achilles tendon rupture. Ruptured Achilles tendon have histologically demonstrated collagen degeneration with a greater content of collagen III and less collagen I[8,9].
Both oral and intratendinous injection of steroids have been implicated in spontaneous tendon rupture[10]. Other run a risk factors for rupture of the Achilles tendon include steroid therapy, hypercholesterolemia, gout, rheumatoid arthritis, long-term dialysis, and renal transplantation[two,xi-xv].
PRESENTATION
The patient typically presents with pain, inability to weight bear and a clear popping sensation or audio afterwards an episode of activity during which they sustain a forced dorsiflexion of the ankle. The injury can too be sustained during eccentric wrinkle. The patient frequently describes the sensation of being kicked, shot or even bitten on the back of the heel.
Acute Achilles tendon rupture can readily be detected on physical test. Plantarflexion of the foot is understandably weak[sixteen]. The Achilles tendon is best examined with the patient kneeling and the anxiety hanging over the edge of the chair. In this position soft tissues hang off the Achilles tendon similar a tent ridge pole and defects can be readily visualised (Figure 1). There is frequently a visible defect in the Achilles tendon. This is accompanied by swelling due to peritendinous haemotoma.
Figure i View of the correct and left Achilles tendon with the patient decumbent. The left is ruptured. The right Achilles tendon is well defined and soft tissues hang off it similar a tent. The suspension of the soft tissues off the Achilles tendon is not visible on the left side as the tendon is ruptured.
The defect in the Achilles tendon is typically palpable with a sensitivity of 0.71 and specificity of 0.89. Maffulli compared the sensitivity and specificity of the main clinical tests designed to decide Achilles tendon rupture[17]. Specific tests include Simmonds or Thompsons' test with sensitivity of 0.98 and specificity of 0.93. Lesser known are the O'Brien and Copeland tests both with a sensitivities of 0.8. Early reports suggest that up to 20% of Achilles tendon injuries tin can exist missed by clinical assessment alone[18].
RADIOLOGY
In patients with equivocal clinical signs diagnostic imaging is required.
Ultrasound is readily available, cheap, non-invasive but user dependant. Ultrasound has a diagnostic reported sensitivity, specificity and accuracy of 100%, 89.9% and 94.four% respectively[19].
It can discriminate betwixt partial and complete tears except those located at the proximal pole or musculotendinous junction of the tendon where sensitivity and specificity drop to 0.5 and 0.81 respectively[20]. An additional advantage in ultrasound in the dynamic observation of tendon gaps which have been shown to correlate strongly with those observed during operative repair[21]. Some authors contend that if the gap betwixt the tendon ends is greater than 5 mm as assessed by ultrasound in full equinus than surgical intervention is indicated[22].
Magnetic resonance imaging remains the gold standard for the diagnosis of the Achilles tendon rupture with a sensitivity of 100% and a specificity of 0.03[23].
Treatment
There is a dichotomy of therapeutic options: operative and bourgeois. Both are accepted forms of management for acute rupture and the optimal regimen remains contentious. The article discusses cases of astute tendoachilles rupture. In cases of delayed diagnosis the likely success of conservative management may be limited by a lack of apposition of the tendon ends due to scarring and retraction. Therefore, surgical repair is advocated[24]. Cases of chronic rupture of the tendoachilles by their very nature will not reply to conservative treatment and therefore will require repair utilising graft[25].
Conservative
The aim of not-operative means of treatment is to restore and maintain contact between the two ends of the ruptured Achilles tendon to facilitate healing. Conservative treatment regimens vary greatly but commonly involve immobilisation with rigid casting or functional bracing. The human foot is initially placed in full equinus (30° namely full plantarflexion). The foot is then brought into neutral sequentially over a catamenia of 8-12 wk. Once ankle position permits it, weight begetting is allowed. At that place is currently no clinical consensus on whether the cast should extend above the genu or if a below knee bandage is sufficient. The above knee plaster is applied with the articulatio genus in slight flexion which serves to defunction gastrocnemius, having an origin over the posterior aspect of the femora condyles. However, one study shows the position of the knee does not influence gap between the torn ends of the Achilles tendon[26].
Little evidence exists to recommend one regimen over some other. The current evidence is summarised in Tabular array 1. These studies demonstrate that patients can be immune to weight-conduct early in an off-the-shelf orthosis/CAM walker/Sheffield splint with no detriment in whatsoever long term outcomes[27,28]. This has obvious practical advantages compared to the traditional handling of prolonged non weight-bearing in a beneath knee joint equinus cast. This is particularly true for delicate or elderly patients where non-operative treatment tends to be preferred. Petersen et al likewise advise that this may also actually subtract the take chances of re-rupture although this was not institute to be significant (P = 0.066). Saleh et al[29] also suggested that their splint allowed patients to regain mobility significantly more than quickly and that patients preferred the splint to the bandage. These findings are in keeping with the literature on operatively managed acute Achilles tendon ruptures which suggests that early weight bearing and mobilisation improve outcomes.
Table 1 Summary of show for non-operative management of astute tendo-achilles rupture.
| Ref. | Patient group | Written report type (level of bear witness) | Outcomes | Key results | Study weaknesses |
| Costa et al[27] | 48 developed patients with astute achilles tendon rupture who chose to have non-operative treatment. Randomised to either half dozen weeks in an off-the-shelf, carbon-fibre orthosis with three one.5 cm heel raises that were encouraged to mobilise fully weight-bearing and move the talocrural joint within the orthosis (trial group) or to half dozen weeks in a below articulatio genus gravity equinus cast that were non weight-bearing (control group). This was followed by serial removal of heel raises or casting in increasing dorsiflexion over 6 further weeks. Immobilisation was discontinued at 12 wk. Reviews at 3, 6 and 12 mo | PRCT | Numbers returning to sport | No meaning difference found (P = 1.0); 56% trial group vs 52% control group | Of the original 48 patients but 40 were bachelor for review at one twelvemonth. All patients who presented out of hours were initially placed in below-articulatio genus equinus plaster backslab |
| Time to return to normal activities | No significant differences found. Sport- (P = 0.631) xviii wk trial group vs 21 wk control group. Walking- (P = 0.765) 16 wk trial group vs 22 wk control grouping. Stair climbing- (P = 0.484) 16 wk trial grouping vs 22 wk command group. Work- (P = 0.370) xiii wk trial grouping vs 17 wk control group | ||||
| EuroQol wellness status questionnaire- EQoL Domain | No significant differences found. 3 mo- (P = 0.372) eighty trial group vs 85 command grouping. 6 mo (P = 0.598) 89 trial group vs 88 command group. 12 mo- (P = 0.122) 85 trial group vs 91 command grouping | ||||
| EuroQol health condition questionnaire- E5D Domain | No significant differences establish. 3 mo- (P = 0.450) 0.73 trial grouping vs 0.69 command group. 6 mo- (P = 0.810) 0.eighty trial group vs 0.80 control group. 12 mo- (P = 0.888) 0.85 trial group vs 0.85 control grouping | ||||
| Arrears in calf diameter in mm | No meaning difference plant (P = 0.634). 1.37 trial group vs 1.11 command group | ||||
| Loss of movement in degrees | No significant differences found. Dorsiflexion (P = 0.879) -0.7 trial group vs 0.27 control group. Plantarflexion (P = 0.248) 4.xiii trial group vs vii.27 control group | ||||
| Arrears in total concentric and eccentric work | No significant differences establish | ||||
| Complications | one re-rupture in trial group vs 1 re-rupture, ane failure of tendon healing and 1 PE in control group | ||||
| Petersen et al[28] | fifty adult patients with astute achilles tendon ruptures. Randomised to either a CAM walker and were encouraged to weight bear (trial group) or to a below articulatio genus full equinus cast and were non-weight bearing (command group). Both groups were immobilised for eight wk. Reviews at iv and 12 mo | PRCT | Re-rupture rate | No pregnant difference found (P = 0.066) just suggestive of a trend towards increased re-rupture in the control group. The hazard of a type II error was 44% and it was thought likely that should the numbers of patients recruited have been larger this may have become a significant divergence. 0% trial grouping, vs 17% control group | Number lost to follow-up: 8. Length of time between injury and treatment not stated although delayed presentations were excluded |
| Patient satisfaction | No pregnant difference | ||||
| Saleh et al[29] | 40 developed patients with acute achilles tendon ruptures. Randomised to either a below human knee full equinus cast for 2 wk followed past, a mid equinus bandage for ane wk and then controlled early mobilisation in a Sheffield splint with full weight-begetting (trial grouping) or to a full-leg cast, with the ankle in total equinus, for four weeks, followed past two weeks in a below-knee bandage with the ankle in mid-equinus, and then two more weeks with the ankle in the neutral position with weight-bearing allowed during the final two weeks simply (control grouping). Review at 3, 6 and 12 mo. The Sheffield splint is an ankle-pes orthosis which holds the ankle at fifteen degrees of plantar flexion, but allows some motility at the metatarsophalangeal joints. The orthosis is used in conjunction with an insole inside an extra-depth shoe. It is removed to let controlled movement during physiotherapy | PRCT | Strength of plantar flexion | No significant difference found at three, 6 or 12 mo | Randomisation method not stated |
| Range of plantar flexion (degrees) | No significant difference found at 3, half-dozen or 12 mo | ||||
| Range of dorsiflexion (degrees) | Significantly more than in trial grouping at 3, 6 and 12 mo (P < 0.001) | ||||
| Time to walking indoors | Significantly quicker in trial group (P < 0.001). 6 wk trial group vs 11 wk control group | ||||
| Time to walking outdoors | Significantly quicker in trial grouping (P < 0.001). 9 wk trial group vs 15 wk control group | ||||
| Complications | ane re-rupture in each grouping | ||||
| Patient preference | All patients in the trial grouping preferred the time spent in the Sheffield splint to the time spent in the bandage |
Newer splints for immobilisation have been developed with encouraging initial results. The Vacoped© is a cast in which the patient's talocrural joint is supported by an air absorber which is then inflated. The absorber is encased in a robust shell. The blueprint of the cast allows the degree of equinus to be dialled from thirty° (total) to 15° (mid) and 0° (neutral). In improver there is latch which allows users the facility to perform a restricted range (-ten°-10°) of plantar and dorsiflexion. The Vacoped regimen recommends 2 wk in full equinus followed past a further 2 wk in partial equinus. Then the ankle is held in neutral for 1 wk and then restricted (10°) dorsi- plantar flexion for the terminal week. The Vacoped allows the patient to impact weight conduct for 2 weeks, and partial weight carry from for 1 week later that. Full weight-bearing is commenced at 3 wk[30]. In addition the periodic insufflations and deflation of air facilitates venous drainage theoretically reducing the chance of deep vein thrombosis. Furthermore, the support is buoyant and supple avoiding the risk of pressure areas.
Operative
There are a diversity of approaches to the surgical management of this injury. Contention exists over the surgical approach (open or percutaneous), suture repair method and suture type.
In addition to isolated direct tendon repair, various means of augmentation of the tendon accept been described. Gastrocnemius augmentation involves raising a flap 2 cm broad past 8 cm long which is reflected beyond the repair and sutured. The Plantaris tendon tin can also be used (Figure 2). It is either weaved around the tendon or may be expanded into a membrane which is sutured effectually the repair. The evidence supporting augmentation is weak. Pajala et al[31] performed a large prospective study of tendoachilles repair and found no benefits between augmented and simple end-to-cease repair.
Figure ii Achilles tendon repair with plantaris tendon reinforcement.
Percutaneous repair has been described involving minimally invasive stab incisions on the medial and lateral attribute of Achilles tendon and a suture passer. Reduced infection rates have been shown compared to open up repair[32]. Increased rates of Sural nerve injury take been demonstrated with this technique[33].
Patient factors accept been demonstrated to influence post-operative wound breakdown and infection rates. These included diabetes mellitus, steroid therapy, smoking and rheumatoid disease[34].
Post-operative regime: Postoperatively the patient can progressively increment the extent of weightbearing. Typically, at vi wk the patient commences active and assisted movement of the ankle. Isokinetic strengthening is commenced 2 to 4 wk. The patient can ordinarily expect full force and endurance 4 mo later surgery. Although this represents the standard post-operative regimen, the optimum mail service-operative rehabilitation remains to be determined. Suchak et al[35] explored the effect of early weight bearing at 2 wk vs weight bearing at vi wk in their randomised controlled trial. They observed that early weight-begetting had statistically significant improvement in quality of life indices (such every bit social performance), vitality scores and physical operation[35]. However, past half dozen mo postoperatively there was no difference in the groups. Other sources of clinical controversy include post-operative early mobilisation versus rigid immobilisation for 6 wk. Kangas et al[36] explored this in a randomised controlled trial. They reported that early mobilisation was associated with improved isokinetic dogie strength at 60 wk. The re-rupture charge per unit was higher in the immobilisation cohort. Nevertheless, the difference did not accomplish statistical significance[36]. Mortenson'south group observed that patients who were allowed to perform early on restricted motion had a shorter rehabilitation time when compared to a below knee joint cast for viii wk[37].
Conservative or operative: which is amend?
No published studies conclusively demonstrate the definitive superiority of one modality over another. Meta-analyses of studies have shown that the re-rupture rates are higher in cases of non-operative management: 13% for conservative management compared with 4% for surgically repaired Achilles tendons[31,38]. Meta-analyses report a re-rupture rate of 2% for percutaneous reparative techniques.
Tendon elongation and weaker plantar flexion are also associated with not-operative direction. However, recent studies suggest that these benefits of operative repair over conservative management in plaster are simply brusk-lived. Keating and collaborators in the recent prospective randomised trial found that operative repair was associated initially with increased range of ankle movement and plantarflexion power when compared with cast management[39]. Yet by 26 wk in that location was no difference between the two groups.
Plaster or simple immobilisation alone avoids the inherent risks of surgery. These include wound infection (4%), fistula formation, skin necrosis, suture granuloma and damage to the sural nervus[31,37]. The peel necrosis tin can outcome in pregnant morbidity and crave extensive plastic soft tissue procedures to ensure coverage of the tendon. Operative repair is associated with more rapid rehabilitation and return to work.
Percutaneous operative techniques accept been found to have a complication contour superior to that of both conservative and open operative techniques. Meta-analysis study a re-rupture rate of 2%[31,37]. Studies involving functional bracing suggest that the disparity between surgical and bourgeois management may not exist every bit marked every bit originally suspected. More contempo studies show that re-rupture rates in patients treated operatively vs functional bracing are comparative[xix,40-42]. In a recent report the upshot of percutaneous operative management were compared with those achieved by functional bracing using the Vacoped. Investigators plant that the incidence of re-rupture to be three.ix% for percutaneous repair and 3.iv% for functional bracing with the Vacoped[43]. The departure did not accomplish statistical significance. The Vacoped allows early weight-bearing. The protective effect of early weight-begetting appears to be reproduced when patients are allowed early ankle movements. A contempo prospective randomised controlled trial observed no deviation in rupture rates between operative and non-operatively managed Achilles tendon rupture when both groups are permitted early on move in a functional brace[29].
Cess of the gap between the ends of the tendon as determined past magnetic resonance imaging or ultrasound may influence re-rupture rates in patients managed conservatively. Kotnis et al[22] elected to manage conservatively just those patients whose gap in full equinus was less than 5 mm. All others were managed operatively. They observed no statistically significant divergence in re-rupture rates between the groups[22]. Wallace et al[44] based in Belfast, Ireland and Sheffield, Uk studied 875 non-operatively treated Achilles tendon ruptures. The conclusion to manage patients non-operatively was based on the presence of opposition of the tendon ends on dorsiflexion. The observed re-rupture rate was 2.nine%. A recent series studied past the Swansea and Maudsley group used a protocol of dynamic ultrasound and a tendon gap of less than ane cm in full equinus. Furthermore, a dedicated clinic and service was established to treat and rehabilitate the patients. They constitute simply a single example of re-rupture (< one%) in 151 conservatively treated patients since 2008. This was comparable to the single case in the operative group of 63 patients[45]. In 2 of these series the re-rupture rate is superior to any anything achieved in a published operative series.
In Wallace'southward published series of fantabulous non-operative results patients were managed in a dedicated "Tendo Achilles" clinic. Patients were placed in an equinus non-weight bearing cast for the first four weeks. For the side by side four weeks they were place placed in a pneumatic walker with heel-raises, which were sequentially removed over a period of iv wk. The combined fourth dimension in the equinus bandage and boot walker was 8 wk. Later this patients engaged in a specialist physiotherapy programme involving gait training, strength and mobility grooming. Concluding assessment and belch was at 14 wk from injury or six wk from the time of removing the walking boot. Information technology is uncertain how much the dedicated Achilles tendon clinic contributed to the favourable outcome. Patients were attended to by a specialist physiotherapist and were merely discharged when the latter deemed that ankle strength was satisfactory.
Some authors would contend the merits of operative intervention in loftier performing athletes. The rationale for this argument is the potential loss of ability or push button off force with conservative direction which is lessened by operative repair. The most recent studies quoted using specific treatment and rehabilitation regimes exercise not identify a functional do good to operative repair. Information technology is possible that the accomplice may not reflect the athlete grouping. Furthermore, the measurement tools and assessments may non be sensitive enough to detect a deficit at the loftier operation sporting level. For this reason the authors would exercise circumspection in treating this cohort every bit it is difficult to draw definitive conclusions.
Decision
Tendoachilles rupture causes significant burden. Recovery is slow and potentially incomplete. Simmonds is a sensitive and reliable examination. Avoiding missed diagnosis is imperative in good outcome. Both MRI and Ultrasound take potential diagnostic value. The argument of bourgeois vs operative treatment volition no doubt continue; show is outset to shift towards underpinning the benefits of non-operative handling. Tendon gap assessment may be an important tool in deciding handling modality. Intensive and specific postal service-operative regimes are being employed with seemingly positive results. The relative impacts of these factors in not known but certainly it has been demonstrated that favourable re-rupture rates are achievable in the non-operative group.
Footnotes
P- Reviewer: Chen YK, Mohseni-Bandpei MA, Yamakado G S- Editor: Qi Y L- Editor: A E- Editor: Lu YJ
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