Achilles tendon repair

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Description

Achilles tendon rupture

The achilles tendon connects the calf muscles to the calcaneus (heel bone) and is one of the important tendons in the human body. The main action of the achilles tendon is foot plantar flexion. Common pathologies include: tendinopathy, tear or rupture. Examples of mechanisms of injury for rupture includes: falling from a height, forceful plantar flexion of the ankle (as in jumping with an extended knee), or using the foot to break a fall if you stumble.

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Conservative vs Surgical intervention:

There is much disagreement in the literature about treatment for ATR with the two options comprising of a conservative or surgical approach.Some literature suggests that nonoperative treatment is not the gold standard for Achilles tendon repair anymore ,Meta-analyses of studies have shown that the re-rupture rates are higher in cases of non-operative management: 13% for conservative management compared with 4% for surgically repaired Achilles tendons, so the surgical option a good option because it offers advantages over nonsurgical treatment in terms of clinical outcomes and recurrence [1]

Clinical Presentation and Assessment

In 2010, the American Academy of Orthopaedic Surgeons published clinical guidelines regarding ATR. They describe following a detailed history, a physical examination should include two or more of the following tests;

• Clinical Thompson test (Simmonds squeeze test) - The test is performed with the patient in prone. The tester gently squeezes the calf around the gastroc muscle bellies. The test is considered positive if there is little or no movement of the ankle into plantar flexion. The Sensitivity of this test is .96
• Decreased ankle plantar flexion strength
• presence of a palpable gap (defect, loss of contour)
• Increased passive ankle dorsiflexion
• Additional general clinical observations include: report of sharp onset of pain or the sound of a “gunshot” at the time of injury, and an inability to stand in plantar flexion.

Pre-op

Prior to surgery general edema reduction should be used (Rest, Ice, Compression, Elevation). The surgery will ideally occur within one week of the rupture.

Surgery Description

Many techniques exist for this surgery, including transverse, medial and longitudinal incisions. The ankle is placed in neutral position and the severed ends of the tendon are sutured together. The surgeon will then take the ankle through complete range of motion to look at the integrity of the repair. A cast is often applied, with the surgical technique determining how long the cast stays on. Many surgeons are now focusing on early weight bearing and passive motion to improve tendon healing. A new minimally-invasive technique involves utilization of the peroneus brevis via two para-midline incisions. The technique reportedly preserves skin integrity over the site most prone to breakdown in a vertical incision, open reconstruction. Another study recommended percutaneous repair in the recreational athlete and in patients concerned with cosmesis, and open repair for all high-caliber athletes who cannot afford any chance of rerupture."

Post-op

Early mobilization following Achilles tendon repair has been reported to be beneficial in terms of postoperative recovery and improved tendon vascularity. Dutton describes three phases of post-surgical rehabilitation following Achilles tendon repair. 

Phase I

Phase I typically lasts three weeks.

Goals of this phase are as follows:

• -Control edema and protect the repair site
• -Minimize scar adhesion and detrimental effects of immobilization
• -Progress to full weight bearing as tolerated/ indicated
• -Pain 5/10 or less, strength 4/5 all LE muscles except plantar flexors

Phase I interventions include:

• -Modalities for pain and edema
• -Stretching of large LE muscle groups, gastrocnemius/soleus added at week 3
• -AROM POD#2: plantar and dorsiflexion 3x5; 3 times daily; add inversion and
• eversion at week 2
• -Foot/ankle isometrics at week 2; band exercises week 3
• -Proprioceptive training for lower extremities; Gait training
• -Upper extremity cardiovascular exercise
• -Joint mobilization and soft tissue work, as indicated

Phase II

Phase II typically lasts from post op week 4-6.

Goals for this phase are as follows:

• -Normalized gait pattern
• -full ankle ROM
• -5/5 LE strength
• -Return to full ADL ability
• -Pain reported to be <2/10
• -Proprioceptive reactions equal to non-surgical side

Phase II interventions include:

• -Ankle flexibility at various knee angles
• -Progressive closed kinetic chain LE strengthening
• -Cardiovascular progression
• -Proprioceptive training on variety of surfaces
• -Manual resisted exercises and joint mobilization, as indicated

Phase III

Phase III typically lasts from post op week 6-15.

Goals for this phase are as follows:

• -Initiate running program
• -Improve balance and coordination
• -Increase velocity of activity
• -Return to sport

Phase III interventions include:
-Progressive ankle and LE strengthening
-Agility exercises
-Double heel raise/lower progressing to single leg heel raise at various speeds

Evidence Based Treatment Protocol

A recent systematic review by Brumann and colleagues (2014) identified the most up-to-date rehabilitation protocol for an Achilles tendon repair. They summarised their findings with the following guidelines;

Week 0 - 2

Nil ankle RoM

Orthosis fixed at 30° of PF

Progress to full weight bearing (FWB)

Week 3 - 6

FWB

Active ankle RoM 0-30°

Orthosis limited to plantargrade (0° DF) to 30° PF

Week 7+

Full RoM

Nil orthosis

Key Evidence

Calder J, Saxby T. Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Br J Sports Med. 2005;39(11):857-859.

Krueger-Franke M, Siebert CH, Scherzer S. Surgical treatment of ruptures of the Achilles tendon: a review of long-term results. Br J Sports Med. 1995;29(2):121-125.

Maffulli N, Longo UG, Gougolias N, Denaro V. Ipsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon. BMC Musculskelet Disord. 2008;9(100).

Metz R, Kerkhoffs G, Verleisdonk EJ, van der Heijden G. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial. BMC Musculoskelet Disord. 2007;8(108).

Metzl JA, Ahmad CS, Levine WN. The ruptured Achilles tendon: operative and non-operative treatment options. Curr Rev Musculoskelet Med. 2008;1(2):161-164.
Ramelli FD. Diagnosis, management and post-surgical rehabilitation of an Achilles tendon rupture: a case report. J Can Chiropr Assoc. 2003;47(4):261-268.

Shin D, Finni T, Ahn S, Hodgson JA, Lee HD, Edgerton R, Sinha S. Effect of chronic unloading and rehabilitation on human Achilles tendon properties: a velocity-encoded phase-contrast MRI study. J Appl Physiol. 2008;105(4):1179-1186.

Resources

AAOS Guidlines for diagnosis and treatment of Acute Achilles Tendon Rupture.

Vivek Gulati, Matthew Jaggard, Shafic Said Al-Nammari, Chika Uzoigwe, Pooja Gulati, Nizar Ismail, Charles Gibbons, and Chinmay Gupte. Management of achilles tendon injury: A current concepts systematic review World J Orthop. 2015 May 18; 6(4): 380–386