Long term results of acute Achilles repair with triple-bundle technique and early rehabilitation protocol
Introduction
The best treatment for acute rupture of the Achilles tendon is still debated [1], [2]. Literature exists to support non-operative treatment [3], traditional open repair, percutaneous repair [4], [5], [6], and repair with a “mini-open” technique [7], [8]. Rehabilitation protocols also vary tremendously, with some data suggesting good success with early mobilization, particularly in young active patients [9], [10], [11]. In a systematic review of the literature, surgical treatment has been recommended as the optimal strategy based on an assessment of outcome probabilities with particular attention paid to re-rupture and complications [12]. It has been suggested that patients should be allowed to make an informed decision based upon the probability of success and complications. But there is no absolute consensus about the best type of surgical repair: there is some evidence to suggest that an end-to-end suture technique leads to more successful outcomes with a reduced rate of complications [13] when compared to approaches utilising tendon augmentation [13], [14]. Jaakkola et al. in 2000 [15] designed a study to compare the tensile strength of ruptured Achilles tendons repaired using either the triple bundle technique or the Krakow locking loop technique. Eight pairs of fresh frozen cadaver Achilles tendons were harvested. A simulated “Achilles tendon rupture” was created 4 cm from the calcaneal insertion in all sixteen tendons by transversely cutting the tendon with a scalpel. One Achilles tendon “rupture” of a pair was repaired using the triple bundle technique, while the other tendon of the pair was repaired using the Krakow locking loop technique. Then, using a servo-hydraulic testing machine, each tendon was tested to failure in tension. The difference in average rupture load for the triple bundle technique and the average rupture load for the Krakow locking loop technique represented a statistically significant superiority in favour of the triple bundle technique. Jaakkola et al. in 2001 [16], realised a study to evaluate the triple bundle technique for acute Achilles tendon rupture repair followed by early (14 days) postoperative ankle range of motion compared to non-operative treatment with delayed ankle range of motion. They retrospectively reviewed 73 patients with an acute Achilles tendon rupture treated with either a plantar flexed cast or with surgical repair. Operative treatment reduced immobilization time, allowed safe early return to weight bearing, and diminished risk of re-rupture compared to non-operative treatment. However, at an average follow-up greater than 3.5 years, there was no statistical difference in AOFAS hindfoot scores, strength, or patient satisfaction between the two groups. Significant complications were higher in the non-operative group manifested by three re-ruptures vs. one deep wound dehiscence in the operative group (3%).
The aim of this study was to present the clinical (Range of motion, AOFAS score, Leppilahti score, and circumference of tight, calf and ankle) and functional results (Isokinetic tests) at 36 months follow up obtained in 66 consecutive patients treated surgically by the same surgeon by the triple-bundle technique with end-to-end suture according to Marti et al. [17] and an early rehabilitation protocol.
Section snippets
Materials and methods
Sixty-six consecutive patients (56 men; 10 women) presenting with complete unilateral rupture of the Achilles tendon, treated by a single surgeon at our institution between February 1995 and December 2007, were included in this study. During this period, patients with a history of diabetes, hyperuricemia, vasculopathy, and systemic diseases requiring immunosuppressive agents were not treated surgically due to the higher potential for wound complications. All patients were previously evaluated
Results
At a 36 months follow-up, no re-ruptures, superficial infections, deep infections, or deep venous thrombosis were observed. All patients excluding two cases were satisfied: the first one was a 36-year-old recreational tennis player who experienced considerable pain in the postoperative period and developed calf atrophy. He returned for final follow-up evaluation at 6 years from surgery and reported that he was never able to return to his previous activity level. The second poor result occurred
Discussion
There is no single best treatment for every Achilles tendon rupture. Treatment should be individualised depending on the age, functional capacity, and additional co-morbidities of the patients. However, open surgical repair is still considered the best option for active and young people who want to return to daily and sports activities sooner. Numerous surgical techniques for the treatment of Achilles tendon rupture have been used and described, but which technique is the best option remains
Conclusion
In conclusion, we demonstrated good results in patients with acute Achilles rupture treated with the triple-bundle technique. This approach is recommended in young, active patients that want to return to sports as soon as possible, while minimising the potential risks of re-rupture or lengthening. In patients with a low activity level, poor skin conditions and inflammatory diseases we recommend a percutaneous repair. The indications for nonoperative treatment are patients who want to avoid
Conflicts of interest statement
None.
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