Aims

Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation.

Background. Conservative treatment of acute AT ruptures with functional rehabilitation has demonstrated superior results with equal reported re-rupture rates but without the added complications of surgical treatment. There is no consensus on the duration and method of treatment using functional rehabilitation regimes. The purpose of this paper is to define our treatment regime, the Leicester Achilles Management Protocol (LAMP), supported with patient reported outcomes and objective measures of assessment. Methods. All patients with an acute achilles tendon rupture were treated with the same non-operative LAMP functional rehabilitation regime in a VACOped boot for 8 weeks. 12 months post rupture ATRS scores and objective measures of calf muscle girth and heel raise height were obtained and analysed. Venous thromboembolic rates and rates of re-rupture were recorded. Results. 442 patients were treated with this regime between February 2011 and December 2015. The incidence of a thromboembolic event was 5.9% and a re-rupture rate of 2%. The ATRS score at 12 months was available in 200 patients. Objective measures were available in 50 patients. The average age was 50 years (range 21–82). The average ATRS score was 75.3 (SD 22, 95% CI 72.2 – 78.4) at an average follow up of 25 months post injury. Men had better ATRS than women (P< 0.05). The calf muscle girth and heel raise height were significantly different from the uninjured side. However, these did not correlate with the ATRS (P>0.05). Conclusions. The LAMP is a simple effective regime which is very easy to adopt and involves a VACOped boot for 8 weeks. Compared to other studies, the overall time in the boot is less with similar patient reported outcomes. Implications. Simple non-operative functional rehabilitation regime that can be applied to ALL patients with acute achilles tendon ruptures

Introduction. Active patients may benefit from surgical repair of the achilles tendon with the aim of preserving functional length and optimising push-off power. A mini-open device assisted technique has the potential to reduce wound complications, but risks nerve injury. We present the largest published series of midsubstance achilles tendon repairs using the Achillon® device. Methods. A prospective cohort study was run at the Princess Royal Devon & Exeter Hospital between 2008 and 2015. We included all patients who presented with a midsubstance Achilles tendon rupture within 2 weeks of injury, and device assisted mini-open repair was offered to a young active adult population. All patients in the conservative and surgical treatment pathway had the same functional rehabilitation protocol with a plaster for 2 weeks, and a VACOped boot in reducing equinus for a further 8 weeks. Results. 354 patients presented with a midsubstance achilles tendon rupture over a 7-year period, of which 204 had conservative treatment and 150 patients had surgical repair with the Achillon device. Patients were assessed clinically for a minimum of 10 weeks, with long-term notes surveillance for late complications. The rerupture rate for conservative treatment was 1.5%, with no reruptures in the Achillon group. Infections in the surgical group were superficial in 2 cases (1.3%) and deep in 3 cases (2%). Pulmonary embolus occurred in 2 Achillon cases (1.3%), and 1 conservatively managed case (0.5%). There was 1 case of temporary sural nerve irritation in each group. Discussion. Our series show encouraging results for the Achillon® repair with no reruptures and a low complication profile. Functional rehabilitation is likely to have contributed to the low rerupture rate. Studies are emerging that show earlier and improved calf muscle strength in those having surgical repair, suggesting a role for device assisted mini open repair in a selected population

The Swansea Morriston Achilles Rupture Treatment (SMART) programme was introduced in 2008. This paper summarises the outcome of this programme. Patients with a rupture of the Achilles tendon treated in our unit follow a comprehensive management protocol that includes a dedicated Achilles clinic, ultrasound examination, the use of functional orthoses, early weight-bearing, an accelerated exercise regime and guidelines for return to work and sport. The choice of conservative or surgical treatment was based on ultrasound findings.

The rate of re-rupture, the outcome using the Achilles Tendon Total Rupture Score (ATRS) and the Achilles Tendon Repair Score, (AS), and the complications were recorded. An elementary cost analysis was also performed.

Between 2008 and 2014 a total of 273 patients presented with an acute rupture 211 of whom were managed conservatively and 62 had surgical repair. There were three re-ruptures (1.1%). There were 215 men and 58 women with a mean age of 46.5 years (20 to 86). Functional outcome was satisfactory. Mean ATRS and AS at four months was 53.0 (sd 14), 64.9 (sd 15) (n = 135), six months 67.8 (sd 16), 73.8 (sd 15) (n = 103) and nine months (72.4; sd 14) 72.3 (sd 13) (n = 43). The programme realised estimated cost savings exceeding £91 000 per annum.

The SMART programme resulted in a low rate of re-rupture, a satisfactory outcome, a reduced rate of surgical intervention and a reduction in healthcare costs.

Cite this article: Bone Joint J 2015; 97-B:510–15.

There are longstanding debates regarding surgical versus conservative management of Achilles tendon ruptures, however there is limited focus on rehabilitation. A specific rehabilitation programme was initiated in 2008 to unify management and improve patient outcomes. We present the results at three and a half years. In October 2008 management was streamlined under the foot and ankle surgeons and a dedicated physiotherapy service. Operative management used mainly the Achillon device (Integra) and VACOped boot with a specific rehabilitation protocol. We prospectively collected data on all patients with Achilles tendon ruptures from October 2008 to March 2012. There were 246 patients in total with four lost to follow up. 80 were treated with the Achillon system, 18 had an open repair and 144 were treated conservatively (of which 56 were partial or musculocutaneous junction tears). Three patients sustained re-rupture (1.2%), all initially treated conservatively. There were two operative complications (2%), both wound breakdowns. Two patients suffered PE's (0.8%), confirmed on VQ scan or CTPA (one operative, one conservative). One non-compliant patient healed functionally long and required a shortening procedure. The authors experience has been that using the VACOped boot with our custom rehabilitation programme in dedicated physiotherapy clinics has produced excellent results

We undertook a prospective study to analyse the outcome of 48 malunited pronation-external rotation fractures of the ankle in 48 patients (25 females and 23 males) with a mean age of 45 years (21 to 69), treated by realignment osteotomies. The interval between the injury and reconstruction was a mean of 20.2 months (3 to 98).

In all patients, valgus malalignment of the distal tibia and malunion of the fibula were corrected. In some patients, additional osteotomies were performed. Patients were reviewed regularly, and the mean follow-up was 7.1 years (2 to 15).

Good or excellent results were obtained in 42 patients (87.5%) with the benefit being maintained over time. Congruent ankles without a tilted talus (Takakura stage 0 and 1) were obtained in all but five cases. One patient required total ankle replacement.