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Achilles Tendon Sports Injuries
A Review of Classification and Treatment
Achilles tendon injuries are among the three most frequent sports-related injuries of the foot and ankle. Proper function of the Achilles tendon is critical to performance in sports. A thorough knowledge of the anatomy and biomechanical function of this tendon is essential to the effective treatment of these injuries. Distinguishing among the various pathologies of the Achilles tendon is an important first step toward successful treatment and return of the athlete to sports activity. The term Achilles tendinitis is a nonspecific diagnosis that does not accurately describe an actual injury. This review is intended to provide the sports medicine physician with a means of classifying Achilles tendon injuries and, thus, arriving at an accurate diagnosis and treatment plan. (J Am Podiatr Med Assoc 97(1): 37–48, 2007)
Fracture of an ossified Achilles tendon is a rare clinical entity. Reossification after removal of the bony fragment was reported in only one case previously. In this study, we present a 49-year-old man with a reossified Achilles tendon after the removal of a fractured and ossified Achilles tendon. Treatment of an ossified or fractured Achilles tendon should be selected on a patient-by-patient basis. Surgical treatment can be used when conservative treatment has failed. The possibility of reossification after surgical treatment, especially in patients with risk factors, should be kept in mind, and the patient should be informed about this possibility.
Abstract
Background: Ideal suture technique and type in tendon repair are remain unclear. This biomechanical study aimed to assess the biomechanical characteristics of three techniques, modified Kessler (mKE), modified Krackow (mKR), and modified tension Bunnell (mtBU), in sheep Achilles’ tendon tear repair using three suture types, polypropylene, polyester, and ultra-high molecular weight polyethylene (UHMWPE) sutures, which are also compared.
Methods: Sixty-three Achilles’ tendons harvested from sheep were transversely hacked as a replacement for rupture in a standardized measure and repaired using mKE, mKR, and mtBU techniques with No. 2 polypropylene, polyester, and UHMWPE sutures. Biomechanical parameters, such as Young’s modulus, ultimate strength, and strength to the 5-mm gap were recorded for statistical analysis.
Results: The mtBU technique with UHMWPE use resulted in increased ultimate strength, strenght to 5-mm gap, Young’s modulus, and quantity of specimens with low clinical failure modes compared to other techniques with other suture materials. Furthermore, mtBU has the lowest thickness at the repair side of the tendons. This approach showed tendon failure during maximal traction testing, whereas the mKE and mKR had polyethylene and polyester suture failures.
Conclusions: The UHMWPE suture was significantly superior to the other sutures in each suture techniques in terms of strength and durability. The mtBU technique using UHMWPE suture showed better biomechanical results, implying that this repair might be more appropriate to obtain early mobilization after tendon ruptures.
Cerebrotendinous xanthomatosis is a rare, autosomal recessive, lipid storage disease with accumulation of cholestanol in most tissues, particularly in the Achilles tendons. We described a 23-year-old female patient who had progressive painfull swelling of both Achilles tendons due to cerebrotendinous xanthomatosis. We performed surgery on both-side Achilles tendon tumors. Wide degenerative areas of the tendons were resected, and the flexor hallucis longus tendon was harvested and transferred to reconstruct motion function.
Treatment Algorithm for Chronic Achilles Tendon Lesions
Review of the Literature and Proposal of a New Classification
Chronic Achilles tendon lesions (CATLs) ensue from a neglected acute rupture or a degenerated tendon. Surgical treatment is usually required. The current English literature (PubMed) about CATLs was revised, and particular emphasis was given to articles depicting CATL classification. The available treatment algorithms are based on defect size. We propose the inclusion of other parameters, such as tendon degeneration, etiology, and time from injury to surgery. Partial lesions affecting less than (I stage) or more than (II stage) half of the tendon should be treated conservatively for healthy tendons, within 12 weeks of injury. In II stage complex cases, an end-to-end anastomosis is required. Complete lesions inferior to 2 cm should be addressed by an end-to-end anastomosis, with a tendon transfer in the case of tendon degeneration. Lesions measuring 2 to 5 cm require a turndown flap and a V-Y tendinous flap in the case of a good-quality tendon; degenerated tendons may require a tendon transfer. Lesions larger than 5 cm should be treated using two tendon transfers and V-Y tendinous flaps. A proper algorithm should be introduced to calibrate the surgical procedures. In addition to tendon defect size, tendon degeneration, etiology of the lesion, and time from injury to surgery are crucial factors that should be considered in the surgical planning.
Spontaneous Achilles tendon rupture associated with long-term oral steroid use is not uncommon, particularly in older patients who use these drugs daily to treat systemic diseases. Rupture often results in a large defect, which complicates surgical repair. The authors review Achilles tendon rupture associated with systemic and local steroid use and present a case of rupture due to chronic oral steroid use in a patient with Addison’s disease. (J Am Podiatr Med Assoc 92(6): 355-358, 2002)
Xanthomas are described as deposits in the skin and subcutaneous tissues. Mostly known as pseudotumors, xanthomas consist of connective tissue containing mainly cholesterol, triglycerides, and numerous foamy macrophages. Bilateral Achilles tendon xanthomata is pathognomonic for cerebrotendinous xanthomatosis in the case of normal cholesterol levels but increased cholestanol levels in serum. In this article, we present findings regarding bilateral xanthomas of Achilles tendons in a patient with cerebrotendinous xanthomatosis. (J Am Podiatr Med Assoc 103(2): 152–155, 2013)
The Percutaneous Surgical Approach for Repairing Acute Achilles Tendon Rupture
A Comprehensive Outcome Assessment
Background: Treatment modalities for acute Achilles tendon rupture can be divided into operative and nonoperative. The main concern with nonoperative treatment is the high incidence of repeated ruptures; operative treatment is associated with risk of infection, sural nerve injury, and wound-healing sequelae. We assessed our experience with a percutaneous operative approach for treating acute Achilles tendon rupture.
Methods: The outcomes of percutaneous surgery in 29 patients (25 men; age range, 24–58 years) who underwent percutaneous surgery for Achilles tendon rupture between 1997 and 2004 were retrospectively evaluated. Their demographic data, subjective and objective evaluation findings, and isokinetic evaluation results were retrieved, and they were assessed with the modified Boyden score and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale.
Results: All 29 patients demonstrated good functional outcome, with no- to mild-limitations in recreational activities and high patient satisfaction. Mean follow-up was 31.8 months. Changes in ankle range of motion in the operated leg were minimal. Strength and power testing revealed a significant difference at 90°/sec for plantarflexion power between the injured and healthy legs but no difference at 30° and 240°/sec or in dorsiflexion. The mean modified Boyden score was 74.3, and the mean Ankle-Hindfoot Scale score was 94.5.
Conclusions: Percutaneous surgery for Achilles tendon rupture is easily executed and has excellent functional results and low complication rates. It is an appealing alternative to either nonoperative or open surgery treatments. (J Am Podiatr Med Assoc 100(4): 270–275, 2010)
Background
The purpose of this study was to report the management and outcomes of ten patients with chronic Achilles tendon rupture treated with a turndown gastrocnemius-soleus fascial flap wrapped with a surgical mesh (Hyalonect).
Methods
Ten men with neglected Achilles tendon rupture were treated with a centrally based turndown gastrocnemius fascial flap wrapped with Hyalonect. Hyalonect is a knitted mesh composed of HYAFF, a benzyl ester of hyaluronic acid. The Achilles tendon ruptures were diagnosed more than 1 month after injury. The mean patient age was 41 years. All of the patients had weakness of active plantarflexion. The mean preoperative American Orthopaedic Foot and Ankle Society score was 64.8.
Results
The functional outcome was excellent. The mean American Orthopaedic Foot and Ankle Society score was 97.8 at the latest follow-up. There were significant differences between the preoperative and postoperative scores. Ankle range of motion was similar in both ankles. Neither rerupture nor major complication, particularly of wound healing, was observed.
Conclusions
For patients with chronic Achilles tendon rupture with a rupture gap of at least 5 cm, surgical repair using a single turndown fascial flap covered with Hyalonect achieved excellent outcomes.
Wound Complications from Surgeries Pertaining to the Achilles Tendon
An Analysis of 219 Surgeries
Background: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon.
Methods: We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation.
Results: A total of 219 surgical cases were available for review (140 males and 70 females; mean ± SD age at the time of surgery, 46.5 ± 12.6 years; age range, 16–75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after their wound complications; some had simple granuloma excision, and one necessitated a flap. Patients with risk factors such as diabetes mellitus, smoking, and rheumatoid arthritis necessitating corticosteroid therapy were more likely to have a wound complication (Fisher exact test, P = .03).
Conclusions: Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed manner. Absorbable and nonabsorbable sutures can be implicated. (J Am Podiatr Med Assoc 98(2): 95–101, 2008)
