Elsevier

Injury

Volume 45, Issue 8, August 2014, Pages 1268-1274
Injury

Long term results of acute Achilles repair with triple-bundle technique and early rehabilitation protocol

https://doi.org/10.1016/j.injury.2014.04.028Get rights and content

Abstract

Background

The best treatment for acute rupture of the Achilles tendon is still under debate. Our purpose was to evaluate surgical triple-bundle technique in selected patients with full subcutaneous rupture of Achilles tendon.

Methods

Sixty-six consecutive patients (56 men, 10 women; age range 20–61 years) with full unilateral rupture of the Achilles tendon were surgically treated by the triple-bundle technique. Seventy-four percent of the lesions occurred during sport activity. Each patient was assessed by: (1) The American Orthopaedic Foot and Ankle Society (AOFAS) score; (2) the Leppilahti score; (3) the range of movement measurement of ankle joint; (4) ipsilateral thigh, calf, and ankle circumferences compared to the contralateral limb; (5) functional evaluation with isokinetic dynamometry of both limbs.

Results

80.3% of the patients were fully satisfied (AOFAS ≥90) with treatment and resumed their previous level of sport. Concerning the outcomes, (1) the mean AOFAS score at 36 months was 93.9; (2) the mean Leppilahti score at 36 months was 91.8; (3) the mean difference in dorsiflexion and plantarflexion between the healthy side and the operated side was 4.3° and 6.9°, respectively. We observed calf muscle hypotrophy in two cases and scar complication in one. No re-ruptures occurred. Isokinetic tests performed 36 months after surgery showed a good restoration of plantarflexion. At univariate analysis AOFAS was influenced by age and difference between the healthy side and the operated side in dorsiflexion, plantarflexion, and circumference at all three levels and strenght at 60°/s. At univariate analysis, Leppilahti score confirmed the significant parameters of the AOFAS with the exception of age and difference of thigh circumference. The only predictive parameters in multivariate analysis were dorsiflexion difference (O.R. = 0.831; 95% C.I. 0.694–0.995; p = 0.044) and plantarflexion difference (O.R. = 0.777; 95% C.I. 0.631–0.958; p = 0.018).

Conclusion

In this case series the triple-bundle technique showed a low rate of complications and good functional restore tested with isokinetic tests. For these reasons afforded by biomechanical strength test reported in literature, this technique has to be considered a valid choice for the treatment of Achilles tendon rupture in young patients with a high level of sport activity.

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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