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Tendo Achilles Rupture

Introduction

Acute ruptures or tears of the Achilles tendon affect mainly middle-aged adults, and its incidence in the British Isles has increased steadily over the last two decades. Men in their 3rd or 4th decade who intermittently participate in sporting activity are affected more commonly. The left tendon is reported to rupture more commonly than the right, though the side - to - side difference is not as pronounced as originally described.

Most ruptured tendons are thought to have pre-existing degenerative change or inflammation, and up to 25% of patients with acute ruptures experienced pain and swelling. Also, ruptured tendons show evidence of pre-rupture changes when looked at under the microscope. Some antibiotics (such as ciprofloxacin), steroid tablets, mechanical abnormalities of the foot, gout and some other rare medical conditions all increase the risk of Achilles tendon rupture.

Although the most commonly ruptured tendon in the body, the ideal management of acute ruptures of the Achilles tendon is widely debated. Several contentious issues can be summarised into conservative versus operative management, early versus late mobilisation and, if operative management is selected, percutaneous versus open repair.

Diagnosis

An acute Achilles tendon rupture can usually be diagnosed on clinical examination. The patient will have weakness and pain on flexing the affected foot down and there may be a palpable gap in the tendon associated with tenderness and swelling. The patient may still retain some active downward flexion, as some other tendons are still intact.

The tendon tends to rupture 2-6 cm above its insertion on the heel bone. Diagnosis is usually made using the calf squeeze test. The patient lies face down with the feet sticking over the end of the examining couch. Both calves are squeezed. There is usually an obvious difference, with the affected ankle not flexing down as much as the normal one. Clinical tests are highly predictive of a rupture, and even in relatively inexperienced hands, scanning is not routinely required.

Management

Both surgical and non-surgical approaches have been used. Several clinical trials have compared these two management types of treatment. These studies have been fairly consistent in two findings: re-rupture is more common after non-operative management, and infections and skin healing complications are confined primarily to patients undergoing surgical repair. Both types of treatment aim to get the torn ends of the tendon together to regain the normal resting length.

Ultrasound guided management

Ultrasound may be used to determine which patients with acute ruptures should undergo surgery. If the gap in the tendon is 5 mm or less with the ankle in full downward flexion, the patient is advised to undergo closed management. If the gap is greater than 5 mm, surgery is recommended. When this approach is used, the re-rupture rate is low in both groups.

Operative Management

There are two broad surgical treatment options: open and percutaneous repair. Both have improved in the past decades with the main advantage being a lower re-rupture rate.

Percutaneous surgical repair techniques have evolved considerably, and both British and European groups have shown that new configurations allow excellent results, comparable to that achieved with open repairs, with fewer complications.

Postoperative rehabilitation

Postoperative rehabilitation falls into two broad categories: plaster immobilisation and functional bracing. An analysis of studies comparing the two methods shows that functional bracing is associated with a significantly lower rate of complications.

Non Operative Management

There is a definite trend towards more active treatment regimes. Recent studies show excellent results without a cast, but using a functional brace instead. With appropriate patient selection functional outcomes can be comparable with those of open surgery.

Conclusion

The management of acute ruptures of the Achilles tendon continues to evolve. Current evidence still points to operative repair as the gold standard, having the lowest re-rupture rates. However, this must be balanced against the higher rates of complications reported, especially poor wound healing, nerve injury and adhesions.

Non-operative management still plays a role in acute ruptures. Advances in this method, especially with regards to functional bracing where the tendon ends are well opposed on ultrasound examination, has shown encouraging results.

Early weight bearing and functional bracing hasten recovery and return to normal activity, and have obvious practical benefits for patients, without increasing the risk of re-rupture.

Ultimately, the method of management is left up to the treating clinician. The best regime for any particular patient may be different. However, current evidence indicates that early weight bearing and mobilisation, whichever regime (conservative or operative) one opts for gives the best results, provided that the tendon ends are kept in contact.

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