Objectives. The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods. A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results. The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion. The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development. Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2

Background. Disability and slow return to sport and work after tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in laboratory conditions but evidence from adequately powered robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture. Methods. In a placebo-controlled, participant- and assessor-blinded, trial at 19 NHS hospitals we randomly assigned 230 adults starting acute Achilles rupture non-surgical management to PRP injection or dry-needle insertion (placebo) to the rupture gap under local anaesthetic. Patients with confounding or contraindicated concurrent medical conditions were excluded. The primary outcome was muscle-tendon function, assessed by the limb symmetry index (LSI, uninjured limb/injured limb × 100, higher scores better) of the work (Joules) performed during the heel-rise endurance test at 24 weeks. Secondary outcomes were: Achilles Tendon Rupture Score (ATRS, 0–100, higher scores better), quality of life (SF-12), pain, and goal attainment. Trial registration: ISRCTN54992179. Results. Participants were aged mean 46 years and 57 (25%) were female. 103/114 (90%) of the PRP group and all (n=116) in the placebo group received allocated treatment. At 24 weeks, mean LSI was 34.4 for the PRP group and 38.8 for placebo (adjusted mean difference −4.4 95% CI −11.2 to 2.5, n=201) and ATRS was mean 65.2 PRP vs 65.8 (adjusted mean difference −0.6, 95% CI −4.9 to 3.7, n=224). There were no differences between groups in the other secondary outcomes. Conclusion. We found no evidence of PRP efficacy for improving muscle-tendon function or patient-reported recovery after acute Achilles tendon rupture. Our findings challenge the increasing global use of PRP for acute tendon injury and indicate that robust evaluations are required in other applications

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. Methods. PROMs including the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS), EuroQol five-dimension (EQ-5D), satisfaction, net promoter score and data regarding re-rupture, and venous thromboembolic rates were collected for patients randomized to receive either operative or nonoperative treatment for acute Achilles tendon rupture in a previous study. Of the 80 patients originally randomized, 64 (33 treated surgically, 31 nonoperatively) patients were followed up at a mean of 15.7 years (13.4 to 17.7). Results. There was no statistically significant difference between operatively and nonoperatively treated patients, in SMFA Dysfunction Index (median 1.56 (interquartile range (IQR) 0 to 5.51) vs 1.47 (IQR 0 to 5.15); p = 0.289), SMFA Bother Index (2.08 (IQR 0 to 12.50) vs 0.00 (IQR 0 to 6.25); p = 0.074), ATRS (94 (IQR 86 to 100) vs 95 (IQR 81 to 100); p = 0.313), EQ-5D-5L (1 (IQR 0.75 to 1) vs 1 (IQR 0.84 to 1); p = 0.137) or EQ-5D health today visual analogue score (85 (IQR 72.5 to 95) vs 85 (IQR 8 to 95); p = 0.367). There was no statistically significant difference between operative and nonoperative groups in terms of satisfaction (84% vs 100%; p = 0.119) or willingness to recommend treatment to friends or family (79% vs 87%; p = 0.255). Four nonoperative patients and two in the operative group sustained a re-rupture (p = 0.306). Conclusion. Both patient groups reported good results at long-term follow-up. The findings give no evidence of superior long-term patient reported outcomes (as measured by the SMFA) for surgical treatment over nonoperative treatment. There was no demonstrable difference in other patient reported outcome measures, satisfaction, or re-rupture rates at long-term follow-up. Cite this article: Bone Joint J 2020;102-B(7):933–940

Aims. Although absorbable sutures for the repair of acute Achilles tendon rupture (ATR) have been attracting attention, the rationale for their use remains insufficient. This study prospectively compared the outcomes of absorbable and nonabsorbable sutures for the repair of acute ATR. Methods. A total of 40 patients were randomly assigned to either braided absorbable polyglactin suture or braided nonabsorbable polyethylene terephthalate suture groups. ATR was then repaired using the Krackow suture method. At three and six months after surgery, the isokinetic muscle strength of ankle plantar flexion was measured using a computer-based Cybex dynamometer. At six and 12 months after surgery, patient-reported outcomes were measured using the Achilles tendon Total Rupture Score (ATRS), visual analogue scale for pain (VAS pain), and EuroQoL five-dimension health questionnaire (EQ-5D). Results. Overall, 37 patients completed 12 months of follow-up. No difference was observed between the two groups in terms of isokinetic plantar flexion strength, ATRS, VAS pain, or EQ-5D. No re-rupture was observed in either group. Conclusion. The use of absorbable sutures for the repair of acute ATR was not inferior to that of nonabsorbable sutures. This finding suggests that absorbable sutures can be considered for the repair of acute ATRs. Cite this article: Bone Joint J 2022;104-B(8):938–945

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

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. . Patients and Methods. A total of 111 patients (95 men, 16 women; mean age 40.3, standard deviation 8.4) with an acute total ATR were prospectively assessed. At one year post-operatively a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining three validated, independent, outcome measures: Achilles tendon Total Rupture Score, heel-rise height test, and limb symmetry heel-rise height. Predictors of ACOS included treatment; gender; age; smoking; body mass index; time to surgery; physical activity level pre- and post-injury; symptoms; quality of life and incidence of DVT. . Results. There were three independent variables that correlated significantly with the dichotomised outcome score (ACOS), while there was no correlation with other factors. An age of less than 40 years old was the strongest independent predictor of a good outcome one year after ATR (odds ratio (OR) 0.20, 95% confidence interval (CI) 0.08 to 0.51), followed by female gender (OR) 4.18, 95% CI 1.01 to 17.24). Notably, patients who did not have a DVT while immobilised post-operatively had a better outcome (OR 0.31, 95% CI 0.12 to 0.80). . Conclusion. Over the age of 40 years, male gender and having a DVT while immobilised are independent negative predictors of outcome in patients with an acute ATR. . Cite this article: Bone Joint J 2016;98-B:1635–41

Introduction/Aim. Thromboembolism is a significant cause of patient morbidity and mortality, the risk of which increases in orthopaedic patients with lower limb immobilisation. It was therefore, our aim to identify a difference in symptomatic thromboembolism by treating acute Achilles tendon rupture patients with conventional non- weight bearing plaster versus functional weight bearing mobilisation. Methodology. The notes of 91 consecutive patients with acute Achilles tendon rupture were reviewed. The patients' demographics, treatment modality (non- weight bearing plaster versus weight bearing boot), and predisposing risk factors were analysed. From the 91 patients, 50 patients with acute Achilles tendon rupture were treated conservatively in a non- weight bearing immobilisation cast. From these 50 patients, 3 then underwent surgery and were therefore excluded from the results. 41 patients were treated with functional weight bearing mobilisation. Patients who did have a symptomatic thromboembolic event had an ultrasound scan to confirm a deep vein thrombosis of the lower limb, or a CT-scan to confirm pulmonary embolism. Results. Out of the 47 patients who were treated conservatively in a non-weight bearing plaster cast, 9 patients (19.1 %) had a thromboembolic event. Out of the 41 patients who were treated with functional weight bearing mobilisation, 2 patients (4.8%) had a thromboembolic event. Thus, patients who were treated in a non-weight bearing plaster had a significantly higher risk of developing thromboembolism (p value of <0.05) and an increased risk ratio of 24% compared to those who were treated with functional weight bearing mobilisation. Conclusion. There is a significant decrease in the clinical incidence of thromboembolic events in patients treated conservatively with early mobilisation in the functional weight bearing boot compared to those treated in a non- weight bearing cast

Introduction

Achilles tendon rupture (ATR) account for 10.7% of all tendon and ligament injuries and causes lasting muscular deficits and have a profound impact on patients’ quality of life^1,2. The incidence, characteristics and management of ATR in the United Kingdom is poorly understood.

Aim

To determine the influence of tendo achilles (TA) rupture gap distance and location on clinical outcome managed with accelerated functional rehabilitation.

Introduction. The dichotomy between surgical repair and conservative management of acute Achilles tendon ruptures has been eliminated through appropriate functional management. The orthoses used within functional management however, remains variable. Functional treatment works on the premise that the ankle/hindfoot is positioned in sufficient equinus to allow for early weight-bearing on a ‘shortened’ Achilles tendon. Our aim in this study was to test if 2 common walking orthoses achieved a satisfactory equinus position of the hindfoot. Methods. 10 sequentially treated patients with 11 Achilles tendon injuries were assigned either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus corrected vacuum brace system (EEB). Weight bearing lateral radiographs were obtained in plaster and the orthosis, which were subsequently analysed using a Carestream PACS system. The Mann-Whitney test was used to compare means. Results. Initial radiographs of all patients in cast immobilization showed a mean tibio-talar angle (TTA) of 55.67° (SD1.21) and a mean 1. st. metatarsal-tibia angle (1MTA) of 73.83° (SD9.45). There were 6 Achilles tendons treated in the FAWW. Their measurements showed a mean TTA of 27.67°(SD7.71) and 1MTA 37.00 (5.22). 5 tendons were treated using an EEB; there was a statistically significant (p< .05) increase in both the TTA 47.6° (SD5.90) and 1MTA 53.67 (SD5.77) compared to the FAWW group. Discussion. Plantar-flexion at the ankle was significantly greater in the EEB comparative to the FAWW, and very similar to the initial equinus cast. The use of wedges produced an equinus appearance through the midfoot, without producing equinus in the hindfoot as the heel pad rests on the top wedge. We express caution in the use of wedges for Achilles treatment as they do not shorten the Achilles tendon and may result in a lengthened tendon and reduced plantar-flexion power in the long-term

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

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

To determine whether the findings from a landmark Canadian trial assessing the optimal management of acute rupture of the Achilles tendon influenced the practice patterns of orthopaedic surgeons in Ontario, Canada.

Aims

The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada.