Aims. To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture. Methods. A randomized multicentre two-arm parallel-group, participant- and assessor-blinded superiority trial was undertaken. Recruitment commenced on 28 July 2015 and two-year follow-up was completed in 21 October 2019. Participants were 230 adults aged 18 years and over, with acute Achilles tendon rupture managed with non-surgical treatment from 19 UK hospitals. Exclusions were insertion or musculotendinous junction injuries, major leg injury or deformity, diabetes, platelet or haematological disorder, medication with systemic corticosteroids, anticoagulation therapy treatment, and other contraindicating conditions. Participants were randomized via a central online system 1:1 to PRP or placebo injection. The main outcome measure was Achilles Tendon Rupture Score (ATRS) at two years via postal questionnaire. Other outcomes were pain, recovery goal attainment, and quality of life. Analysis was by intention-to-treat. Results. A total of 230 participants were randomized, 114 to PRP and 116 to placebo. Two-year questionnaires were sent to 216 participants who completed a six-month questionnaire. Overall, 182/216 participants (84%) completed the two-year questionnaire. Participants were aged a mean of 46 years (SD 13.0) and 25% were female (57/230). The majority of participants received the allocated intervention (219/229, 96%). Mean ATRS scores at two years were 82.2 (SD 18.3) in the PRP group (n = 85) and 83.8 (SD 16.0) in the placebo group (n = 92). There was no evidence of a difference in the ATRS at two years (adjusted mean difference -0.752, 95% confidence interval -5.523 to 4.020; p = 0.757) or in other secondary outcomes, and there were no re-ruptures between 24 weeks and two years. Conclusion. PRP injection did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo. The evidence from this study indicates that PRP offers no patient benefit in the longer term for patients with acute Achilles tendon rupture. Cite this article: Bone Joint J 2022;104-B(11):1256–1265

Abstract. Objectives. This study aims to evaluate the functional outcomes of early weight-bearing in a functional orthosis for conservatively managed, complete AT ruptures. Also we tried to evaluate the patient reported outcome with this form of treatment. Design. In this prospective study, we have analysed data from 41 patients with ultrasound diagnosed compete AT ruptures, with a gap of less than 5 cm. Every patient was treated in a functional weight-bearing orthosis (VACOped®) for 8 weeks with early weight-bearing following a specific treatment protocol, followed by rehabilitation with a trained physiotherapist. Methods. Patients were followed up with foot and ankle trained physiotherapist for at least 1 year post-injury. At final follow up, the followings were measured: calf girth, single-leg heel raise height and repetitions. Furthermore, ATRS score and a patient feedback were taken on this final visit. Result. The mean ATRS score was 82.1, with a re-rupture rate of only 2% as compared to 5% in normal orthosis. The average calf bulk difference was 1.6 cm, the average heel raise height difference was 1.8cm and a heel raise repetition difference of 6. There was a statistically significant correlation between ATRS score and calf muscle girth (p=0.02). However, there was no significant correlation between ATRS and heel raise height or heel raise repetitions. Conclusion. Early weight-bearing in a functional orthosis provides excellent functional outcomes for conservatively managed, complete AT ruptures, and is associated with very low re-rupture rates. A multidisciplinary approach with a guided rehabilitation programme is essential for optimising functional outcome

Background. Patients presenting with an acute tendoachilles (TA) rupture are managed in a dedicated clinic led by a Foot & Ankle Consultant and specialist physiotherapist. The diagnosis is made clinically and no ultrasound scan is performed. All management, rehabilitation and follow-up is undertaken within this clinic by the specialist physiotherapist, with Consultant support as required. Patients are offered a choice of conservative or surgical management (percutaneous TA repair). Both groups undergo a standardised functional rehabilitation regimen. Methods. All patients treated through our dedicated clinic between May 2010 and April 2016 were identified. Patient outcomes were reported using the validated Achilles Tendon Repair Score (ATRS). ATRS scores were collected at 3, 6 and 12 months post-injury. Re-rupture and complication rates were also documented. Results. 167 patients were identified. 79 patients underwent a percutaneous repair and 88 patients opted for conservative management. Mean age of patients undergoing percutaneous repair was 46 years (21–77 years) and 52 years (19–88 years) in the conservatively managed group. Male to female ratios were equal between both groups. Mean ATRS scores at 3, 6 and 12 months were 41.6, 69.5 and 85.3 respectively for the percutaneous repairs and 45.4, 69.0 and 77.1 respectively for the conservatively managed group. The re-rupture rate was 4.2% (3 patients) in the conservative group and 0% in our surgical group. In the surgical group, 1 patient developed a PE and 1 had a wound complication. Discussion. Our dedicated clinic for managing TA ruptures has proved popular with patients, with a patient satisfaction score of 98.7%. By standardising our rehabilitation regimen we believe our outcomes have improved. Our percutaneous repair group has an improved ATRS score compared to our conservative group at 12 months post injury. We believe that any fit active individual should be offered a percutaneous repair irrespective of age

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

Background. The PATH-2 trial found no evidence of a benefit of Platelet Rich Plasma (PRP) injection versus a placebo after Achilles tendon rupture (ATR) at six-months. ATR often leave longer-term functional deficiencies beyond six-months. This study aim is to determine if PRP affect tendon functional outcomes at two-years after rupture. Study design. Randomised multi-centre two-arm parallel-group, participant- and assessor-blinded, superiority trial. Methods. Adults with acute ATR managed non-surgically were recruited in 19 UK hospitals from 2015 to 2019. Exclusions were insertion or musculotendinous injuries, leg injury or deformity, diabetes, haematological disorder, corticosteroids and anticoagulation therapy. Participants were randomised via an online system 1:1 to PRP or placebo. Primary outcome was Achilles Tendon Rupture Score (ATRS) at two-years. Secondary outcomes were pain, Patient-Specific Functional Scale (PSFS), SF-12 and re-rupture. Assessors were blinded. Intention-to-treat and Compliance Average Causal effects (CACE) analyses were carried out. Consistency of effects across subgroups age, BMI, smoking and gender were assessed using Forest plots. Pearson's correlation was used to explore ATRS correlation with blood and growth factors. Results. 216/230 (94%) participants completed the 6-months follow-up were contacted. 182/216 (84%) completed the two-year follow-up. Participants were aged mean 46 (SD 13.0), 57 female/159 male. 96% received the allocated intervention. Two-years ATRS scores were 82.2 (SD 18.3) in the PRP group (n=85) and 83.8 (SD 16.0) in the placebo group (n=92). There was no evidence of a difference in the two-years ATRS (adjusted-mean difference −0.752 95%CI −5.523 to 4.020, p=0.757), or in any secondary outcome, and no re-rupture between at two-years. Neither PRP cellular or growth factors correlated with the two-year ATRS. Conclusion. PRP did not improve patient-reported function or quality of life two-years after acute Achilles tendon rupture, compared with placebo, indicating that PRP offers no patient benefit in the longer term

A total of seven patients (six men and one woman) with a defect in the Achilles tendon and overlying soft tissue underwent reconstruction using either a composite radial forearm flap (n = 3) or an anterolateral thigh flap (n = 4). The Achilles tendons were reconstructed using chimeric palmaris longus (n = 2) or tensor fascia lata (n = 2) flaps or transfer of the flexor hallucis longus tendon (n = 3). Surgical parameters such as the rate of complications and the time between the initial repair and flap surgery were analysed. Function was measured objectively by recording the circumference of the calf, the isometric strength of the plantar flexors and the range of movement of the ankle. The Achilles tendon Total Rupture Score (ATRS) questionnaire was used as a patient-reported outcome measure. Most patients had undergone several previous operations to the Achilles tendon prior to flap surgery. The mean time to flap surgery was 14.3 months (2.1 to 40.7). At a mean follow-up of 32.3 months (12.1 to 59.6) the circumference of the calf on the operated lower limb was reduced by a mean of 1.9 cm (. sd. 0.74) compared with the contralateral limb (p = 0.042). The mean strength of the plantar flexors on the operated lower limb was reduced to 88.9% of that of the contralateral limb (p = 0.043). There was no significant difference in the range of movement between the two sides (p = 0.317). The mean ATRS score was 72 points (. sd. 20.0). One patient who had an initial successful reconstruction developed a skin defect of the composite flap 12 months after free flap surgery and this resulted in recurrent infections, culminating in transtibial amputation 44 months after reconstruction. . These otherwise indicate that reconstruction of the Achilles tendon combined with flap cover results in a successful and functional reconstruction. Cite this article: Bone Joint J 2015;97-B:215–20

Acute Achilles tendon (AT) rupture management remains debatable but non-operative functional regimes are beginning to dominate current treatment algorithms. The aim of this study was to identify predictors of functional outcome in patients with AT ruptures treated non-operatively with an immediate weight bearing functional regime in an orthosis. Analysis of prospectively gathered data from a local database of all patients treated non-operativelyat our institution with anAT rupture was performed. Inclusion criteria required a completed Achilles Tendon Rupture Score (ATRS) at a minimum of 8 months post rupture. The ATRS score was correlated against age, gender, time following rupture, duration of treatment in a functional orthoses (8- and 11-week regimes) and complications. 236 patients of average age 49.5 years were included. The mean ATRS on completion of rehabilitation was 74 points. The mean ATRS was significantly lower in the 37 females as compared to the 199 males, 65.8 vs 75.6 (p = 0.013). Age inversely affected ATRS with a Pearsons correlation of −0.2. There was no significant difference in the ATRS score when comparing the two different treatment regime durations. There were 12 episodes of VTE and 4 episodes of re-rupture. The ATRS does not change significantly after 8 months of rupture. Patients with AT ruptures treated non-operatively with a functional rehabilitation regime demonstrate good function with low re-rupture rates. Increasing age and female gender demonstrate inferior functional outcomes

Introduction:. The treatment of acute rupture of the tendo-achilles remains controversial. There is good evidence to suggest that outcomes are the same for both operative and non-operative treatment when a functional rehabilitation program is utilised. However, debate continues as to whether the radiological gap-size between the proximal and distal remnants of the tendon has an influence on the suitability for non-operative management. Methods:. All adult patients who attended the emergency department with a clinically suspected tendo-achilles rupture were place in a plantarflexed cast, and underwent MRI scanning to confirm the diagnosis. They were then counselled on the risks and benefits of operative versus non-operative treatment. Patients opting for non-operative treatment were asked to take part in the study and treated using a functional rehabilitation programme. Gap sizes were determined using a standardised protocol by a single musculoskeletal radiologist blinded to the clinical outcomes. Results:. A total of 69 patients have been recruited into the study, 40 have complete their one year review. There were two re-ruptures. The average age was 42.4 years (range 19–70). The average gap size recorded by MRI was 40.4mm (range 6–110). The average ATRS score was 80 (range 17–100) and the single limb heel raise percentage of contralateral side was 64.8% (range 4–115). The Spearman rank correlation coefficient comparing gap size and ATRS score was 0.272 (p=0.045) and for gap size and strength was 0.158 (p=0.165). Conclusion:. This study shows a weak positive correlation between MRI measured gap size of the ruptured tendo-achilles and the Achilles tendon Total Rupture Score at one year. No correlation could be demonstrated between gap size and strength at one year. These results suggest that the MRI measured gap size is unimportant in predicting outcome and hence suitability for non-operative treatment of tendo-achilles rupture using functional rehabilitation

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

Background. Operative fixation of acute tendo-achilles ruptures remains controversial. Standard surgical exposure is associated with and increased risk of wound breakdown and infections. The mini-open technique was developed to minimise these risks and provide anatomical reduction/apposition of the tendon rupture. Methods. We present a retrospective case series of 27 patients who were treated operatively for acute Achilles tendon rupture in the hands of 1 surgeon, between 4–6 years post operatively, using Achillon instrumentation. Post operatively they were treated with an air cast boot and 3 wedges, bringing the foot into neutral by 6 weeks followed by a rehabilitation programme. The patients were contacted via telephone and consent was obtained. The complications, Leppilahti score and ATRS score were then calculated. Results. 2 patients underwent a further operation (one for a retained suture and another for a re-rupture in an uncompliant patient), in total there were 2 re-ruptures (another patient sustained a partial rupture which was treated conservatively). There were no patients who sustained a wound problem or infection (other than the patient already mentioned). There were 3 patients who complained of ongoing altered sensation in the sural nerve distribution, and 4 who had paraesthesia post operativeley that completely resolved within 3 months. There were no DVT/PE reported and the average Leppilahti score was 85.7/100 (excellent outcome) and ATRS 93.3/100 (excellent outcome). Conclusion. This study shows that the mini-open technique can be used successfully to treat acute tendo-Achilles ruptures with excellent long term outcome

Introduction:. Historically the incidence of Achilles re-ruptures has been described as around 5% after surgical repair and up to 21% after conservative management. In 2008 we commenced a dedicated Achilles tendon rupture clinic for both conservative and surgically managed patients using new standardised operating procedures (SOP). We have evaluated the impact of this new service, particularly with regard to re-rupture rate. Materials and methods:. The SOP was stage dependent and included an initial ultrasound examination, functional orthotics with early weight bearing, accelerated exercise and guidelines for the return to work and sport. Evaluation included re-rupture rate, complication rate, and outcome measured by the Achilles Tendon Total Rupture Score (ATRS) and Achilles Tendon Repair Score (AS). A basic cost evaluation was performed to assess any potential savings. Results:. A total of 213 patients (151 treated conservatively and 62 surgically) were included. Re-rupture occurred in two patients (1 conservative and 1 surgically managed). There were 16 major complications e.g. DVT, wound infection. The mean ATRS was 54.79, 67.66 and 71.05 at 4, 6 and 9 months respectively and the mean AS was 64.67, 73.96 and 71.05 at 4, 6 and 9 months respectively. The reduction in re-rupture compared to the literature was 4.1% and 19.1% for surgical and conservatively treated patients respectively. Cost savings achieved were £50,000 each annum. This was due to both a decrease in the number of re-ruptures as well as a decrease in the number of patients being managed operatively. Conclusion:. A dedicated follow up Achilles clinic treating acute Achilles tendon ruptures using monitored SOP's, provides an exceptionally low re-rupture rate (0.9%), excellent patient outcome and potential cost savings compared to a traditional fracture clinic approach. The reduction in re-rupture rate, and therefore cost savings, is greater in conservatively managed patients

The percutanous repair of the Achilles tendon is a cost efficient method of restoring early limb function and may offer reduced risk of re-rupture and wound infection. This technique has been described in the elderly population and elite athletes; we present an evaluation of this technique in a District General Hospital setting. We have prospectively audited the outcome of 56 patients who have elected to have percutaneous repair for Achilles tendon rupture from 2009–2011. The majority were males (44) with mean age of 46 years (range 27–80). Twenty nine patients ruptured the right tendon and 27 the left. 82% (46) of injuries were sustained whilst exercising: e.g. football (22), badminton (7), running (5). All but 2 patients were managed on a Day Case basis and 4 requested general anaesthesia. Patients were immediately weight bearing in a brace following surgery and commenced physiotherapy at 2 weeks. Functional outcome was measured using a modified Achilles Tendon Rupture Score (ATRS) at 3, 6, 9 and 12 months: 100 score equals maximal limitation. The mean ATRS scores a 3, 6, 9 and 12 months were 53 (7–82), 31 (0–74), 30 (0–67) and 15 (1–52) respectively. We have had 4 complications: 2 sural nerve injuries, 1 poor wound healing and 1 re-rupture at 8 weeks. Overall complication rate was 7.1%, comparable to other studies. We have shown a good outcome following percutaneous Achilles tendon repair. The majority of patients show good restoration of function by 3 months and a minor limitation at 6 months. The majority of the improvement in function occurred between 3 and 6 months following surgery. Two patients reported ongoing tendinopathic pain following repair increasing mean scores. We believe this technique can be introduced in District General Hospitals to give good outcome on a cost effective basis

Introduction: Current evidence for treatment of Achilles tendon rupture suggests that open surgical repair reduces the re-rupture rate compared to conservative treatment, but with a higher risk of infection. Modern non-surgical treatment and surgical aftercare involves early weight-bearing in functional orthoses. It is therefore appropriate to measure the re-rupture rates and outcomes in patients treated in this manner. Materials and methods: Between 2002 and 2008 our unit prospectively collected data on 80 patients treated with a below-knee functional orthoses for complete Achilles tendon rupture. Patients made their own choice of treatment following evidence-based counselling. The patients were treated either surgically or conservatively and entered the appropriate arm of the standard orthotic and early weight-bearing treatment protocol. Patients were contacted by telephone or post for follow-up and completed a VISA-A and Achilles Total Rupture Score (ATRS) questionnaire. Results: There were 61 Males, 19 Females with an age range of 24–80 (median 42). The median time in the functional brace was eight weeks. 51 patients were treated conservatively and 29 patients surgically. The conservative group were a decade older (median age 47y, range 27–80) than the surgical group (median age 37y, range 24–55y). In the non-operative treatment group the re-rupture rate was 3.9% (2/51, 95% confidence interval 0.5–13.5%). In the surgical group it was 3.4% (1/29, 95% confidence interval 0–17.8%), in this group the wound infection rate was 6.8% (2/29, 95% confidence interval 0.9–22.8%) with no nerve injuries reported. The median ATRS was 82 in the conservative group and 95 in the surgical group. The median VISA-A scores were 57 and 92 respectively. Discussion: Our case series shows comparable low re-rupture rates in both groups. Functional scores, using the newly validated ATRS score, were lower in the non-surgical, older group. Conclusion: Functional care after surgical and non-surgical treatment of Achilles rupture produces similar re-rupture rates

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.

Aims

The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial.

Aims

Patients with an acute Achilles tendon rupture (ATR) take a long time to heal, have a high incidence of deep vein thrombosis (DVT) and widely variable functional outcomes. This variation in outcome may be explained by a lack of knowledge of adverse factors, and a subsequent shortage of appropriate interventions.

Aims

Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment of the neglected tendo Achillis (TA) rupture.