Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial. Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study. Percutaneous vs. open repair of the ruptured Achilles tendon--a prospective randomized controlled study. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Open versus minimal invasive repair with Achillon device. Augmented compared with nonaugmented surgical repair of a fresh total Achilles tendon rupture. A prospective randomized study. Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. End-to-end versus augmented repair in the treatment of acute Achilles tendon ruptures. Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study.
There is no agreement on the ideal type of surgical management for Achilles tendon rupture. The present randomized prospective study was performed to compare outcome data of open and percutaneous repair in the treatment of Achilles tendon rupture. Forty consecutive patients with acute rupture of Achilles tendon were recruited. Patients were randomized to receive open (group A) or percutaneous repair with Tenolig (group B). All patients followed the same rehabilitation protocol except for slight differences in the duration of immobilization. Follow-up included objective evaluation (at 4 and 12 months), subjective evaluation using the SF-12 questionnaire (at 24 months), and bilateral ultrasound scanning and isokinetic testing (at 12 months). The differences in the parameters evaluated clinically were not significant except for ankle circumference, which was significantly greater in group B. There were two minor complications in the open repair group and one case of failed repair in the percutaneous group. SF-12 questionnaire, ultrasound and isokinetic test data did not show significant differences between the groups. The present study demonstrates that the open and the percutaneous technique are both safe and effective in repairing the ruptured Achilles tendon and that both afford the same degree of restoration of clinical, ultrasound and isokinetic patterns. Medium-term results were substantially comparable. Percutaneous repair is performed on a day-surgery basis, it reduces cutaneous complications and operation times, and enables faster recovery, enhancing overall patient compliance. To us, these characteristics make it preferable to open repair in managing subcutaneous ruptures of Achilles tendon in non-professional sports practicing adults. Surgical repair of acute Achilles tendon ruptures is considered superior to nonoperative treatment, but complications other than rerupture range up to 34%. Nonoperative treatment by functional bracing seems a promising alternative.
                Nonoperative treatment of acute Achilles tendon rupture with functional bracing reduces the number of complications compared with surgical treatment with a minimally invasive technique.
                Randomized controlled clinical trial; Level of evidence, 2.
                Using concealed random allocation, 83 patients with acute Achilles tendon rupture were assigned to nonoperative treatment by functional bracing or minimally invasive surgical treatment followed by tape bandage. Patients were allowed full weightbearing, and follow-up was 1 year.
                Complications risk other than rerupture by intention-to-treat basis was 9 in 42 patients (21%) for surgical treatment and 15 in 41 patients (36%) for nonoperative treatment (risk ratio, 0.59; 95% confidence interval, 0.29-1.19). Reruptures risk was 5 in 41 patients after nonoperative treatment and 3 in 42 patients for surgical treatment (risk ratio, 0.59; 95% confidence interval, 0.15-2.29). The mean time to work was 59 days (SD, 82) after surgical treatment and 108 days (SD, 115) after nonoperative treatment (difference, 49 days; 95% confidence interval, 4-94; P < .05). The difference between treatments for return to sports (risk ratio, 0.55; 95% confidence interval, 0.23-1.29), pain, and treatment satisfaction did not reach statistical significance.
                There appears to be a clinically important difference in the risk of complications between minimally invasive surgical treatment and nonoperative treatment for acute Achilles tendon ruptures, but this was not statistically significant. One hundred and five consecutive patients with a closed acute rupture of the tendo achillis were assigned randomly for surgical or non-surgical treatment. After treatment, the patients were evaluated clinically and with static and dynamic measurements of plantar flexion strength. Only minor differences were noted between the final results in the two groups. Non-surgical treatment had the advantages of shorter morbidity and no hospital stay. The frequency of major complications was about the same in both groups of patients: two re-ruptures and two deep infections in patients who had operations as compared with five re-ruptures in the conservatively treated patients. I concluded that non-surgical treatment offers advantages over surgical treatment. A prospective randomized controlled trial comparing open and percutaneous repair of closed ruptured Achilles tendons was performed over a period of 30 months. Sixty-six patients from seven district general hospitals were entered into the study with 33 patients randomized into each group. A modification of the technique described by Ma and Griffith was used in the percutaneous group and a Kessler suture supplemented with interrupted sutures was used in the open group. Patients were followed up for a minimum of six months. The mean age was 38.5 years (26 to 53 years). Forty patients were male and 26 female. After the rupturing event but prior to surgery, it was noted that seven patients had paresthesia in the territory of the sural nerve. The mean duration of immobilization was 12.4 weeks (10 to 14). The complications in the open group included seven wound infections (21%), two adhesions (6%) and two cases of re-rupture (6%). In the percutaneous group there were three cases of wound puckering (9%), one re-rupture (3%) and one case with persistent paresthesia in the sural nerve territory (3%). The difference in infective wound complications between the two groups was statistically significant (Fisher's exact test P = 0.01). Percutaneous repair is advocated on the basis of the low rate of complications and improved cosmetic appearance. One hundred eleven patients with acute rupture of the Achilles tendon were included in a prospective trial and randomly assigned to groups for operative (56 patients) or nonoperative (55 patients) treatment. All of the patients were followed with clinic evaluations at 4 months and 1 year after the rupture. The major complications in the operative treatment group were three reruptures and two deep infections as compared with seven reruptures, one second rerupture, and one extreme residual lengthening of the tendon in the nonoperative group. There were fewer minor complications in the nonoperative group than in the operative group. The operatively treated patients had a significantly higher rate of resuming sports activities at the same level, a lesser degree of calf atrophy, better ankle movement, and fewer complaints 1 year after the accident. The conclusion we reached through this randomized prospective study is that operative treatment of ruptured Achilles tendons is preferable, but nonoperative treatment is an acceptable alternative. Comparisons of surgically and nonsurgically treated Achilles tendon ruptures have demonstrated that those treated with surgery allow earlier motion and tend to show superior results. However, early motion enhances tendon healing with or without surgery and may be the important factor in optimizing outcomes in patients with Achilles tendon rupture.
                There is no difference in the outcome of acute Achilles tendon rupture treated nonoperatively or operatively if controlled early motion is allowed as part of the rehabilitation program.
                Randomized, controlled clinical trial; Level of evidence, 1.
                Patients with acute rupture of the Achilles tendon were randomized to surgery or no surgery, with both groups receiving early motion controlled in a removable orthosis, progressing to full weightbearing at 8 weeks from treatment. Both groups were followed prospectively for 12 months with measurements of range of motion, calf circumference, and the Musculoskeletal Functional Assessment Instrument (MFAI) outcome score; any reruptures and any complications were noted.
                Both groups were comparable for age and sex. There were no significant differences between the 2 groups in plantar flexion, dorsiflexion, calf circumference, or the MFAI scores measured at 2, 8, 12, 26, or 52 weeks. One patient in each group was noncompliant and required surgical rerepair of the tendon. There were no differences in complications and a similar low number of reruptures in both groups.
                This study supports early motion as an acceptable form of rehabilitation in both surgically and nonsurgically treated patients with comparable functional results and a low rerupture rate. There appears to be no difference between the 2 groups, suggesting that controlled early motion is the important part of treatment of ruptured Achilles tendon. We prospectively analyzed and compared the functional and clinical results of patients with standard open and minimally invasive repair with the Achillon suture system at mid-term followup.
                From February 2004 to May 2007, 40 consecutive patients were operated for the treatment of acute Achilles tendon rupture with two different methods. None of the cases required adjunctive procedures like plantaris, flexor hallucis longus or gastrocnemius augmentation (Lindholm, Bosworth) to allow for acceptable end to end apposition. The patients were divided equally into two groups. In Group 1, only Krakow end-to-end suturing technique and in Group 2, Minimal invasive repair with Achillon suture system (Integra Life Sciences Corporation, Plainsboro, NJ) was used respectively. The average age of the patients was 40 years. Patients in study groups were followed up at mean of 22.4 (range, 10 to 48) months after surgery. At the end of the followup time, functional outcome scores and complications were evaluated.
                The AOFAS hindfoot clinical outcome scores were 98.7 in Group 1, 96.8 in Group 2. Although there was a numerical increase in AOFAS Scores in Group 1, there was no significant difference. The surgical outcome concerning local tenderness, skin adhesions, scar and tendon thickness was better in Group 2 than in Group 1 with statistical significance.
                Although functional outcomes of both treatment groups were the same, minimally invasive repair with the Achillon suture system provided safe, reliable and practical treatment with low risk of complications in the treatment of acute Achilles tendon ruptures. Augmented and nonaugmented techniques have been used for the operative repair of a fresh complete Achilles tendon rupture. Augmented techniques have been favored for their stronger pullout strengths but have been avoided because of the risk of wound complications. If proven to be equally good, the nonaugmented technique would be the method of choice. In the present study, we hypothesized that augmentation with a down-turned gastrocnemius fascia flap would not provide better results than would end-to-end suture repair with use of the Krackow locking loop surgical technique.
                Sixty patients with an acute Achilles tendon rupture were randomized preoperatively to receive end-to-end suture repair with use of the Krackow locking loop technique either without augmentation (simple repair group) or with a down-turned gastrocnemius fascia flap as described by Silfverskiöld (augmented repair group). A brace allowed free active plantar flexion of the ankle postoperatively, whereas dorsiflexion was restricted to neutral for the first three weeks. Weight-bearing was limited for six weeks. The follow-up period was one year, and the patients were evaluated in terms of clinical measurements, an outcome score, isokinetic calf muscle performance tests, and tendon elongation measurements.
                The mean operative time was twenty-five minutes longer and the incision was 7 cm longer in the augmented repair group as compared with the simple repair group (p < 0.001 for both). In the simple repair group, the overall ankle score was excellent for nineteen patients (63%) and good for eight patients (27%) and three patients (10%) had an early failure (all because of rerupture). In the augmented repair group, the ankle score was excellent for fourteen patients (56%) and good for six patients (24%) and five patients (20%) had a failure because of rerupture (three) or deep infection (two). The difference between the groups with regard to the overall result was not significant (p = 0.68). In the simple repair group the isokinetic calf muscle strength score was excellent for eleven patients (37%), good for fourteen patients (47%), and fair for two patients (7%), with three patients (10%) having a failure, whereas in the augmented repair group the score was excellent for nine patients (36%), good for seven patients (28%), fair for three patients (12%), and poor for one patient (4%), with five patients (20%) having an early failure. Achilles tendon elongation occurred in both groups, and elongation correlated significantly with isokinetic peak torque deficits (rho = 0.64, p = 0.001) and isometric strength deficits (rho = 0.48, p = 0.026) in the simple repair group. No significant differences were seen between the two groups at the three-month and twelve-month checkups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, overall outcome, isokinetic calf muscle strength, mean peak work-displacement relationships, or tendon elongation.
                Augmented repair of a fresh total Achilles tendon rupture does not have any advantage over simple end-to-end repair. In a prospective, randomised, multicentre study, 112 patients (99 men and 13 women, aged between 21 and 63 years) with acute, complete rupture of tendo Achillis were allocated either to surgical treatment followed by early functional rehabilitation, using a brace, or to non-surgical treatment, with plaster splintage for eight weeks. The period of follow-up was for two years. Evaluation was undertaken by independent observers and comprised interviews, clinical measurements, isokinetic muscle performance tests, heel-raise tests and an overall outcome score. The rate of rerupture was 20.8% after non-surgical and 1.7% after surgical treatment (p < 0.001). Surgical and non-surgical treatment produced equally good functional results if complications were avoided. However, the rate of rerupture after non-surgical treatment was unacceptably high. We prospectively analyzed the functional and clinical results of patients who underwent a single end-to-end suture and an augmented tendon repair with plantaris tendon at middle-term follow-up. From January 2003 to May 2005, 30 consecutive patients were operated on for the treatment of acute Achilles' tendon rupture by means of 2 different methods. No cases required adjunctive procedures to allow for acceptable end-to-end apposition. All ruptures were acute and repairable. The patients were divided into 2 groups. In group 1, augmentation with plantaris tendon was performed in addition to the Krakow end-to-end suturing technique in 16 patients, and in group 2, only the Krakow end-to-end suturing technique was used in 14 patients. The average age of the patients was 40.6 years. Patients in the study groups were followed up at a mean of 17.8 months after surgery. At the end of the follow-up, functional and subjective outcome scores were evaluated. The American Orthopaedic Foot and Ankle Society hindfoot clinical outcome scores were 96.7 in group 1 and 98.8 in group 2. Although there was a numerical increase in group 2, no significant difference was determined between the 2 study groups statistically. The surgical outcome concerning local tenderness, skin adhesion scar, and tendon thickness was better in group 2 than in group 1 without a statistical significance. Although functional outcomes of both treatment groups were the same, the end-to-end suturing technique provided a safer and more reliable treatment with a low risk of complications in the treatment of acute Achilles' tendon ruptures compared with the plantaris tendon augmentation technique. Fifty-seven patients treated for an acute rupture of the Achilles tendon were studied. The patients were randomized into a Mason suture technique or a reinforced continuous six-strand suture technique, and markers were attached to each tendon end perioperatively. The postoperative separation of the markers was studied by repeat radiographic examination. Despite immobilization, separation developed after a biphasic course, and after 7 weeks the mean separation was 10.5 mm. No difference was found between the two techniques. We attempt to correlate the separation to the clinical outcome, examined at 1 year follow up.
Open surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with non-surgical treatment, but produces significantly higher risks of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously.