THE TREATMENT OF ACHILLES TENDON RUPTURES WITH A NEW METHOD OF REPAIR, EARLY RANGE OF MOTION, AND FUNCTIONAL REHABILITATION: A PROSPECTIVE STUDY
September 27th, 1993
Bert R. Mandelbaum, MD, Mark S. Myerson, MD,
and Robert Forster, RPT
We prospectively treated 29 athletes with Achilles tendon ruptures according to a functional rehabilitation protocol using a hinged orthosis. The 25 male and four female patients had a mean age of 35 years (range, 19 to 56 years). The repair was performed with a modified whip suture of #2 nonabsorbable polyfilament. Patients began range-of-motion exercise at 72 hours, used a posterior splint for 2 weeks, and then began ambulation in a hinged orthosis, which allowed full plantar flexion, with a block to dorsiflexion at 10o of equinus. At 6 weeks, the orthosis was discontinued, full weight-bearing was allowed, and progressive resistive exercises were initiated. Isokinetic strength and endurance testing was performed at 3, 6, and 12 months postsurgery.
There were no reruptures. Two patients developed superficial wound infections that responded to debridement and/or local wound care. One patient suffered a pulmonary embolism.
At 3 months, Cybex testing showed the mean functional deficit was 36 and 35% at 60 and 120 degree seconds, respectively. By 6 months, the mean deficit was 2.9 and 2.3% at 60 120 degree seconds, respectively. All patients returned to preinjury activity levels at a mean of 4 months (range, 3 to 7 months) after repair. By 12 months, there was no significant difference in ankle motion, isokinetic strength, or endurance as compared to the uninvolved side.
Although the first reported occurrence of Achilles tendon rupture was by Pare in 1575,4,28 the first sports-related description was by Maydl in 1882.28 More recent reports indicate that 75% of Achilles tendon ruptures occur in athletes,11-14,16,20 predominantly in males between 30 and 40 years old.17,19 The incidence of Achilles tendon rupture is more common in countries where work is generally sedentary and is markedly decreased in countries, such as China, where physical work is commonplace.32 Approximately 15% of all Achilles tendon ruptures are associated with symptoms of antecedent tendinitis.13,21
The etiology of Achilles tendon rupture is still unclear, but the literature abounds with theories, including repetitive microtrauma,16 inhibitor mechanism malfunction,17 a correlation of rupture with blood type O,20 hypoxic and mucoid degeneration,20,21 decreased perfusion that results in degenerative changes,18 and systemic or locally infiltrated corticosteroids.28
All treatment options -- nonoperative closed methods,15,16,19 open surgical procedures, or percutaneous methods of repair12,22,26,27 -- utilize a cast. Reports of the results of these differing treatment methods have emphasized rerupture rates, morbidity, and complications.11-14,16,17,19 Although many different methods of suture repair of the Achilles tendon are available, until recently none have been strong enough to allow early range of motion of the foot and ankle. In 1987, we began using a technique reported for patellar tendon repair10 to repair the Achilles tendon and instituted a postoperative protocol, based on the reports of Garrett and colleagues7,8,33 of collagen's response to loading, of early and aggressive motion and weight bearing to enhance tendon healing and strength. In addition, since treatment results are determined not only by the method of repair but also, and perhaps more importantly, by the functional rehabilitation during recovery, we established a protocol for rehabilitation after repair an Achilles tendon rupture. This study was designed to prospectively evaluate the results of this treatment protocol.
Materials and Methods
From 1987 to 1991, all consecutive patients with Achilles tendon rupture who were treated operatively were managed prospectively according to a protocol defined by functional rehabilitation.
The study group consisted of 29 patients (25 males, 4 females) with a mean age of 35 years (range, 19 to 56 years). Each patient had sustained an Achilles tendon rupture during an athletic event: basketball (14), tennis (7), volleyball (2), racquetball (1) gymnastics (1), dance (1), softball (1), bowling (1), jumping (1). All Achilles tendon ruptures were identified by standard history and physical examination. All ruptures were complete and occurred at the muscle tendon junction (9), mid substance 4 to 6 cm proximal to the insertion (17), or avulsions from the calcaneus (3). Three patients had experienced symptoms of chronic Achilles tendinitis prior to sustaining the rupture.
The surgery was performed on an outpatient basis for 14 patients, and with a one-day hospital stay for 15 patients.
With the patient in the prone position using general (13), spinal (1), or local (15) anesthesia, the repair was performed with a #2 nonabsorbable polyfilament suture using a previously described technique10 (Fig. 1). The peritenon was repaired using absorbable sutures of 4-0 vicryl, achieving a tight closure over the tendon. To accomplish this, a posterior release of the fascia between the superficial and deep compartments of the leg was performed in 14 patients. Skin closure was performed with a dermal mattress suture of 4-0 nylon, and the lower leg was immobilized with a below-the-knee posterior splint with the ankle in slight equinus.
Between 48 and 72 hours after surgery, the bandages were changed to a removable posterior splint, and an early range of motion program was initiated. The patient was instructed to comfortably move the ankle passively four to five times a day through 10 to 20o of plantarflexion and dorsiflexion. The splint was worn when passive exercises were not being performed. At 2 weeks, the sutures were removed and if the wound had fully healed, early weight bearing, coupled with range of motion exercises, was initiated. Patients were fitted with hinged walking boots that permitted full plantar flexion but blocked dorsiflexion at 10o of equinus. At 4 weeks, 14 patients used cowboy boots for ambulation and the remaining 15 patients continued using the walker boot, which was adjusted to a block of dorsiflexion at neutral. The postoperative physical therapy protocol is listed in Table 1.
All patients were examined at 6 and 12 weeks, and at 3, 6, 12, and 24 months after surgery. Subjective parameters, including pain, functional deficit, and return to sport or athletic activities were evaluated. Objective outcome and performance parameters, including toe raise, range of motion, and Cybex dynamometry, were recorded. Cybex testing was performed through motions of dorsiflexion and plantarflexion, and analyzed as a percentage deficit relative to the opposite limb normalized for body weight. At 60 degree seconds, these correlated with strength and at 120 degree seconds with power parameters. Endurance parameters were not utilized in this study. To have a full return to sport, the patient should be able to participate, train, and complete sports activities with no significant functional deficit.
Ninety-two percent of the patients had a full return to sports by 6 months, and 100% returned to sport by 12 months. From a functional standpoint, 90% had a full range of motion by 6 weeks and 87% were able to perform a single limb toe raise by 3 months. Cybex results are presented by plantar flexion deficit. At 3 months the mean functional deficit was 36% at 60 degree seconds (+/- 9.3) and 35% (+/- 9.6) at 120 degree seconds. By 6 months, the mean deficit was 2.9% (+/- 10.3) at 60 degree seconds and 2.3% (+/- 8.1) at 120 degree seconds.
Two patients developed superficial wound problems, characterized by local inflammation and minimal drainage with no specific positive wound culture, and healed without the use of long-term antibiotics. A pulmonary embolus occurred in one patient. There was no rerupture, recurrent pain, deep infection, or skin necrosis in this group of patients.
Achilles tendon rupture in the athletic population is becoming increasingly common. The etiology of these ruptures can be simple or multifactorial, and theories include microtrauma, degeneration of the tendon, loss of vascularity, and inhibitor mechanism maladaptation. Regardless of the etiology, this injury occurs in a wide range of individuals, from the recreational/weekend sports participant to the elite athlete. The goals of the sports medicine physician caring for these problems are to minimize the morbidity and to optimize the rapid return to full functional performance.
Although Nistor29 equates nonsurgical management with operative intervention, other clinicians have determined that operative intervention is required to obtain the stated goals. Operative options include percutaneous repair,26,27 gastrocnemius flap,25 simple suture,29 pullout wire,31 fascial reinforcement,1 polylactate implant,5 and carbon fiber. Whatever the technique, the cast has been the standard postoperative regimen.
The rationale for using a cast is that immobilization (for approximately 8 weeks) will achieve tendon healing through hematoma to collagen proliferation and maturation. Unfortunately, immobilization is associated with many complications, including muscle atrophy and long-term weakness, articular cartilage weakening and degeneration, skin necrosis, deep vein thrombosis, and joint stiffness. In addition, from a functional standpoint, cast immobilization never allows full rehabilitation of the extremity, regardless of what operative or nonoperative protocols are used. With a cast as part of the treatment, Nistor29 reported at least a 10% deficit regardless of protocol use, Bradley and Tibone4 demonstrated a 13 to 20% deficit, and Inglis and Sculco23 described a deficit of 12 to 15% as standard. On the other hand, in a rat animal model, Enwemeka et al6 demonstrated a significant increase in tendon strength after early mobilization of repaired tendons. Cumulatively, these studies indicate that the there was never less than a 10% power or strength deficit with protocols utilizing immobilization. Thus, it can be concluded that immobilization, used in conjunction with reparative techniques, may cause increased morbidity. Therefore, there was a need to develop a stable internal fixation technique for soft-tissue and tendon repairs.
Several studies demonstrated that mobilization is optimal for connective tissue: Booth2,3 showed that muscle atrophy can be minimized, Pepples et al30 demonstrated a decreased time of fibril polymerization to collagen, and Gelberman et al9 reported that mobilized extremities enhanced the orientation and organization of collagen. As a consequence, we instituted a preliminary study to examine using a suture technique described by Krackow24 for Achilles tendon ruptures. With this repair technique, we have obtained a rigid and stable fixation that allows early range of motion, strengthening, and functional rehabilitation. (It should be stated that good internal fixation allows an early effective range of motion rehabilitative protocol.) Krackow's initial presentation of the suture in 198624 demonstrated this technique as a rigid internal fixation without resultant fascial or tendon necrosis. This technique, coupled with complete repair of the peritenon, results in progressive healing of the Achilles tendon during the postinjury and postoperative period. In a pilot study, 4 patients treated by this protocol were followed-up postoperatively using magnetic resonance imaging to evaluate in vivo healing of tendons, and all showed complete continuity by 6 months. Functionally, Cybex dynamometry indicated a 2 to 3% power and strength deficit with this protocol, which compares favorably to the more than 10 to 15% cumulative deficit in all previous studies using immobilization techniques.
In conclusion, repair of the Achilles tendon utilizing this suture technique is an efficacious method demonstrating no postsurgical ruptures and, most importantly, a return to 94% of the preinjury functional level by 6 months. In addition, this method is cost effective and the complication rate is clearly acceptable. In general, athletes managed with this technique showed no cast-related morbidity and they were rapidly able to obtain their athletic goals with minimal or no deficits.
1. Abraham E, Pankovich AM: Neglected rupture of Achilles tendon treatment by V-Y tendinous flap. J Bone Joint Surg 57:253, 1975
2. Booth FW: Effect of limb immobilization on skeletal muscle. J Appl Physiol 52:1113-1118, 1982
3. Booth FW: Physiologic and biomechanical effects of immobilization on muscle. Clin Orthop 219:15-20, 1987
4. Bradley JP, Tibone JE: Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study. Am J Sports Med 18(2):188-195, 1990
5. Clemow AJT, Chen EH: Induction of neo-tendons using a resorbable polymeric scaffold. Presented at the 32nd Annual Meeting of the Orthopaedic Research Society, New Orleans, LA, February 17 -- 20, 1986
6. Enwemeka CS, Spielholz NI, Nelson AJ: The effect of early functional activities on experimentally tenotomized Achilles tendons in rats. Am J Phys Med Rehabil 67(6):264-269, 1988
7. Garrett WE, Jr., Nikolaou PK, Ribbeck BM, Glisson RR, Seaber AV: The effect of muscle architecture on the biomechanical failure properties of skeletal muscle under passive extension. Am J Sports Med 16:7-12, 1988
8. Garrett WE, Jr., Safran MR, Seaber AV, Glisson RR, Ribbeck BM: Biomechanical comparison of stimulated and nonstimulated skeletal muscle pulled to failure. Am J Sports Med 15:448-454, 1987
9. Gelberman RH, Manske PR, Van de Berg JS, Lesker PA, Akeson WH: Flexor tendon repair in vitro: a comparative histologic study of the rabbit, chicken, dog, and monkey. J Orthop Res 2:39-48, 1984
10. Hidalgo DA, Shaw WW: Anatomic basis of plantar flap design. Plast Reconstr Surg 78(5):627-636, 1986
11. Hoaglund FT, States JD: Factors influencing the rate of healing in tibial shaft fractures. Surg Gynecol Obstet 124:71-76, 1967
12. Hodgkinson DJ, Irons GB: Newer applications of the cross-leg flap. Ann Plast Surg 4(5):381-390, 1980
13. Hofmann AA, Dahl CP, Wyatt RW: Experience with acetabular fractures. J Trauma 24(8):750-752, 1984
14. Hogden JT: On the treatment of gunshot fractures of femur and tibia. Am Med Times 7:169-170, 1863
15. Hogh J, Mikkelsen P: Hansen-Street nailing of fractures of the femoral shaft. A study of 70 consecutive cases. Injury 4(5):440-446, 1983
16. Hohl M: Surgical treatment and technique. J Bone Joint Surg 47A(1):179-190, 1965
17. Holcroft JW, Trunkey DD: Pathophysiology of shock and adult respiratory distress syndrome. Surg Annu 15:1-12, 1983
18. Holden CEA: The role of blood supply to soft tissue in the healing of diaphyseal fractures. An experimental study. J Bone Joint Surg 54A(5):993-1000, 1972
19. Holden CEA: Bone-grafts in the treatment of delayed union of tibial shaft fractures. Injury 4:175-179, 1972
20. Holden CEA: Compartmental syndromes following trauma. Clin Orthop 113(Nov-Dec):95-102, 1975
21. Holden CEA: The pathology and prevention of Volkmann's ischaemic contracture. J Bone Joint Surg 61B(3):296-300, 1979
22. Holdsworth FW: Dislocation and fracture-dislocation of the pelvis. J Bone Joint Surg 30B(3):461-466, 1948
23. Inglis AE, Scott WN, Sculco TP, et al : Ruptures of the tendo Achilles -- an objective assessment of surgical and nonsurgical treatment. J Bone Joint Surg 58A:990-993, 1976
24. Krackow KA, Thomas SC, Jones LC: A new stitch for ligament-tendon fixation. Brief note. J Bone Joint Surg 68(5):764-766, 1986
25. Lindholm A: A new method of operation for subcutaneous rupture of the Achilles tendon. Acta Orthop Scand 117:261, 1959
26. Ma GW, Griffith TG: Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop 128:247-255, 1977
27. Ma GWC, Griffith TG: Percutaneous repair of acute closed ruptured Achilles tendon: a new technique, in Moore TM (ed): Symposium on Trauma to the Leg and Its Sequelae. St. Louis, Mosby-Year Book, 1982, pp 358-370
28. Mahler F, Fritschy D: Partial and complete ruptures of the Achilles tendon and local corticosteroid injections. Br J Sports Med 26(1):7-14, 1992
29. Nistor L: Surgical and non-surgical treatment of Achilles tendon rupture. J Bone Joint Surg 63A:394-399, 1981
30. Pepples WRJ, Plasmans CMT, Sloof TJH: The course of healing of tendons and ligaments. Acta Orthop Scand 54:952, 1983
31. Ralston E, Schmidt ER, Jr.: Repair of the ruptured Achilles tendon. J Trauma 11:15, 1971
32. Sun Y-S, Yen T-F, Chie LH: Ruptured Achilles tendon: report of 40 cases. Zhonghua Yixue Zazhi 57:94-98, 1977
33. Taylor DC, Dalton JD, Jr., Seaber AV, Garrett WE, Jr.: Viscoelastic properties of muscle-tendon units. The biomechanical effects of stretching. Am J Sports Med 18:300-309, 1990