Table of Contents  
REVIEW ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 2  |  Page : 34-39

Management of Achilles tendon injuries: Current trends


1 Department of Surgery, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
2 Department of Orthopaedics, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria

Date of Web Publication10-Mar-2016

Correspondence Address:
Oluwafemi O Awe
Department of Surgery, Irrua Specialist Teaching Hospital, Irrua Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.178455

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  Abstract 

Introduction: Achilles tendon injuries have been on the increase worldwide, especially in the last two decades. The classification of the injury has not been explicit and the management protocols are confusing, especially with respect to specific injuries. There is a need to have a look at the current trends in the management of this common injury in order to create awareness and stimulate the need for standardization of the treatment protocols, possibly reaching a consensus.
Materials and Methods: Information on the types of the injury, classification, and treatment modalities were obtained by searching the Pubmed, Medknow, Google Scholar, and other publications. These were collated and analyzed.
Results: In most of the information on Achilles tendon injuries, these were inappropriately equated with Achilles tendon ruptures, which are actually supposed to be a subset. In the same vein, the diverse treatment options available were mainly those extensively used in ruptures. These procedures range from open surgery and minimal access surgery to close or conservative management followed closely with physiotherapy.
Conclusion: There is a subtle misconception in the literature that we reviewed where Achilles tendon injuries were considered the same as Achilles tendon ruptures but this is not so. There are other injuries with different pathomechanisms and therefore, different managements. There is a need to include these other injuries and also broaden the management options. Minimal access surgery is preferred in ruptures.

Keywords: Achilles tendon, current trends, injuries, management, ruptures


How to cite this article:
Awe OO, Esezobor EE, Oniminya JE. Management of Achilles tendon injuries: Current trends. Nigerian J Plast Surg 2015;11:34-9

How to cite this URL:
Awe OO, Esezobor EE, Oniminya JE. Management of Achilles tendon injuries: Current trends. Nigerian J Plast Surg [serial online] 2015 [cited 2019 Jun 17];11:34-9. Available from: http://www.njps.org/text.asp?2015/11/2/34/178455


  Introduction Top


The Achilles tendon is the largest and strongest tendon in the body. It is formed as the tendinous part of both the gastrocnemius and soleus muscles. The tendons of the gastrocnemius and soleus fuse at the common musculotendinous junction to form the Achilles tendon (calcaneal tendon), which continues distally to attach to the calcaneal bone. The gastrocnemius muscle fibers extend 11–26 cm above the heel bone while the soleus muscle fibres extend 3-11 cm.[1]

It transmits the force of the body to the ground. There has been a sharp increase in its injuries because of increase in the incidence of trauma resulting from sport activities. Before 1950, there was no documentation about the incidence of Achilles rupture. The highest incidence in the age group of 40–50 years in Sweden (1950–1973) was 8.5/10.[2] In Scotland, the annual incidence increased from 4.7/10 in 1981 to 6/10 in 1994.[3]

The male sex predilection has a ratio ranging from 2:1[4] to11:1.[5] The peak incidence is reached at 30–40 years of age. Other causes of Achilles tendon injuries are traumatic transection or laceration, avulsion, and crush injury of the tendon. The Achilles tendon injuries are either closed or opened. The close injuries are treated operatively or nonoperatively and there is no consensus on the optimal method of treatment. The treatment of open injuries is basically operative.

The outcome of the management of the Achilles tendon depends on the type of patients involved. The incidence of rerupture is higher in athletes who return to active sport that was initially responsible for the first injury.

The complications of the management of Achilles tendon injuries are several and every method used in the repair is aimed at minimization or outright prevention of these. The most disturbing of these is infection, which is difficult to control followed by adhesions and sural nerve entrapment or injury.

The management of Achilles tendon injuries is a topical issue and a review of the current trends is hereby discussed.


  Materials and Methods Top


The articles on Achilles tendon injuries, tendon ruptures, and classification of Achilles tendon injuries and ruptures, and treatment modalities were searched. The most recent of these informations under each of the category were collated and analyzed. The search was done using the Pubmed, Medknow, Google Scholar, and other publications.


  Results Top


The Achilles tendon is the largest and strongest tendon in the body. It is formed as the tendinous part of both the gastrocnemius and soleus muscles. The tendons of the gastrocnemius and soleus fuse at the common musculotendinous junction to form the Achilles tendon (calcaneal tendon), which continue distally to attach to the calcaneal bone. The gastrocnemius muscle fibers extend 11–26 cm above the heel bone and the soleus muscle fibers extend 3–11 cm.[1] It receives its blood supply from the muscles, the heel bone insertions, the endotenon and peritenon. At its midpoint, 4–7 cm from the heel bone insertion, arterial nutrition is precarious and supplied only by anterior vessels through the fatty tissue into the peritenon. The midtendon vessels are very few, and the relative cross-section area is small.[6]

The Achilles tendon is covered by a thin paratenon and epitenon, which glide in relation to each other. There is no true sheath.

The sural nerve, posterior tibial artery, and the beginning of the small saphenous vein are the important lateral relations. The sural nerve is the closest to the tendon, which makes the incidence of the sural nerve entrapment or injury, especially in the percutaneous and minimally invasive repairs very high. The tendon is a cellular and extracellular structure, consisting of 30% water. Its strength and stiffness are determined by collagen cross-linkages.[7],[8],[9],[10],[11],[12],[13],[14]

The incidence of Achilles tendon injury has increased in the last three decades.

Male predilection has been reported in studies with peak incidence in 4th decade of life.[4],[5] Most Achilles tendon injuries are unilateral with slight left leg predominance.[15],[16]

Sports-related events are responsible for about 75% of Achilles tendon ruptures. Approximately 10% of the cases involve professional athletes, 80% recreational athletes, and 10% no-athletes.[17],[18],[19] Most Achilles tendon ruptures occur spontaneously without direct trauma to the tendon, especially in sudden unexpected dorsiflexion of the ankle, violent dorsiflexion of a plantar-flexed foot, and pushing off with a weight-bearing forefoot while extending the knee joint.[20] These are hinged on degenerative and mechanical theories. Direct trauma includes accidental forceful contact on activated tendon and open tendon lacerations with broken glass, knife, axe cut, cutlass, motorbike spoke, and rarely bone fracture laceration from within.[21],[22],[23],[24],[25]

The diagnosis of Achilles tendon injury is mainly clinical. It is based on clinical symptoms and findings and the mechanism of injuries,[26] which include calf pain, a snapping sound just above the heel, laceration along the tendon followed by loss of push-off strength. There is a palpable gap of 2–6 cm above the heel bone;[27] in 20% of the missed diagnoses of Achilles tendon rupture, there is associated edema and swelling and plantar flexion due to long toe flexor muscles.[4],[28] The most common clinical diagnostic test is Thompson test––plantar flexion when the calf muscles are squeezed.[29] Diagnosis can be confirmed by ultrasound or magnetic resonance imaging (MRI) in rupture.[30],[31] There are also different degrees of severity of Achilles tendon rupture.

Classification/type

Achilles tendon injuries have several classifications, leading to different terminologies being used for the same entity. Achilles tendon injuries include all problems associated with the tendon except that of infection and degenerative changes; this is based on the generally accepted definition of wound (injury) as a disruption in tissue physiology and/or anatomy.

Achilles tendon injuries could be either open or closed injuries. Open injuries can be either laceration/transection, avulsion, or crush injury of the tendon. The open injuries are usually obvious and easy to diagnose.

Closed injuries, otherwise called ruptures, can be classified clinically [Table 1] or sonographically [Table 2]:[32]{Table 1}{Table 2}

Treatment

The aims of treatment include the following:

  • Reestablishment of continuity of the tendon
  • Maintenance of the gliding properties of the tendon
  • Restoring strength to perform the anticipated functions.


Treatment options

There are two major groups of treatment options. These are operative and nonoperative options.

Operative

Operative options can be mainly subdivided into two major subdivisions, i.e.,open (conventional) and percutaneous/minimally invasive surgeries.

A. Open surgery: The conventional surgery can be augmented or nonaugmented.

  1. Nonaugmentation open surgery: This is the end-to-end suturing using the Kessler procedure or the modified Kessler procedure to provide strength and prevent failure and gapping after repair. In Turkey, a simple end-to-end suturing has been compared to suturing with plantaris longus tendon augmentation in 30 patients and no difference was found between the groups.
  2. Augmentation open surgery: There are several types of augmentation (one central gastrocnemius fascia flap, two gastrocnemius flaps, plantaris longus tendon augmentation, flexor hallucis longus tendon, flexor digitorum longus, and peroneous brevis tendon). At least 41 open surgery options have been described.[33]


The flexor hallucis longus has been used to repair chronic Achilles tendon rupture. The procedure was initially described by Hansen et al. and modified by Wagner et al. The surgery performed under general anesthesia with tourniquet applied at the thigh show excellent outcome at 6 years follow-up.[34] Gastrocnemius aponeurosis has also been used by making a rectangular 1–2-cm wide by 8-cm long flap from the proximal tendon and gastrocnemius aponeurosis, which is raised down to 3 cm above the rupture site. The proximal flap is flipped downward across the repair site and sutured down. The fascial defect is closed with interrupted sutures. Plantaris tendon augmentation has been described by weaving across the repair site. It can be left attached either proximally or distally. Alternatively, it can be fanned out to make a 2–5 cm membrane that is then sutured around the repair site. An attempt should always be made to close the paratenon over the tendon repair site to improve the healing and prevent adhesion. Complications of the open surgery include deep infection, rerupture, hypertrophic scar, and skin adhesion. These are used mainly in open injuries.[35],[36],[37]

B. Minimally invasive surgery: This includes the following methods–using suture guide (Achillon device) and double-ended needle.

  1. The Achillon technique: A 2-cm longitudinal incision made over the palpable gap of the ruptured Achilles tendon and transverse incision is not done because it is associated with sural nerve injury though it has a better cosmetic outcome. The Achillon technique involves using a U-shaped device with four limbs for tendon approximation. Placing the two inner limbs within the paratenon enclosing the ruptured tendon ends and the outer limbs outside the skin and long needle with Ethibond sutures can be passed through the holes of the four limbs while the Achilles tendon is still secure between the inner limbs. When the device is withdrawn, the sutures passing through the tendon can be retrieved for approximation of the rupture ends of the Achilles tendon. The method reduces the risk of sural nerve entrapment as the suture knots are within the paratenon. The paratenon is repaired with vicryl sutures.[38]
  2. The double-ended needle technique:[39] The patient is placed under general anesthesia in a prone position. There is no tourniquet. A 2-cm transverse incision is made proximal to the palpable gap in the substance of the ruptured Achilles tendon. The paratenon is identified and incised if intact. A 2-cm diameter Steinmann's pin is sharpened at both ends and a hole is placed at the center to accommodate no.1 polydioxanone suture (PDS). The needle is passed through the rupture end of the tendon and exited through skin on the opposite side about 2 cm from the ruptured end. The other end of the needle still inside the paratenon is maneuvered to pass the distal dissection so that it exits the skin on the opposite side of the tendon. This is repeated two to three times in a zigzag manner. The distance between the each entry through which the tendon is approximated is 1.5 cm to avoid strangulation. Another needle and a new no.1 PDS is passed through and exited from the proximal end of the corresponding ruptured tendon as previously described. Both ends of the Achilles tendon are then tied together by pulling the sutures together assisted by the plantar flexion of the foot. The paratenon is closed over the repaired site and the skin is closed.


3. Percutaneous surgery: This was first described by Ma and Griffith,[40] then by Maffulli and Sutherland 1991, and then by McClelland and Maffulli.[41]

a. Sutherland and Maffulli technique described six stab incisions with four of them over the proximal ends of the ruptured tendon and the remaining two just proximal to the calcaneal insertion. In the technique described by McClelland and Maffulli, three transverse incision, the middle over the palpable defect. The other two are 4-cm proximal and 4-cm distal to the middle one. A no.2 PDS double stranded suture on a long curved needle is passed transverse through the distal incision through the substance of the tendon and out through the same incision. The needle is then reintroduced medially into the distal incision through a different entry point and passed longitudinally to lock the tendon, and is directed toward the middle incision and out through the rupture tendon end. The suture still protruding from the distal incision is retracted onto the needle and reintroduced laterally through the distal incision and into the tendon. It passes proximally through the tendon to exit from the middle incision. The same procedure is carried out for the proximal half of the ruptured tendon to produce an eight-strand repair. The sutures are tied in with the ankle in plantar flexion.

b. Ma and Griffith technique requires the execution of six to eight incisions at the sides of proximal and distal stumps of the tendon, in order to be able to direct and cross the wire suture. This does not shorten the immobilization period. A below-knee plaster of Paris (POP) cast is applied at ankle plantar flexed for 30 days, and then in the neutral position for the next 20 days. Returning to sports activities is permitted after about 12 weeks.

c. Tenolig device[42] consists of a thread with a diameter of 0.85 mm and length of 36 cm onto which a 7-mm wide metal harpoon is mounted, crimped at its distal end by a 15-cm long flexible triangular-tipped needle and an anchoring system. Two small incisions are made on the either side of the proximal portion of the tendon approximately 6 cm above the rupture. The sural aponeurosis displayed, the needle is then inserted, taking care to penetrate into the proximal and distal stumps of the tendon and is then pushed out at the sides of the calcaneal tuberosity 4 cm or 5 cm below the rupture. These two techniques were compared by Taglialavoro et al.[43]

The complications of minimal access surgery are mainly sural nerve entrapment and rerupture. The incidence of deep infection, deep venous thrombosis, and skin adhesion is less than in open surgery.

Nonoperative

Various braces and cast options have also been used to treat Achilles tendon ruptures. The nonsurgical option is preferred for elderly patients with skin problems and chronic diseases affecting wound healing[3] though there is a favorable outcome of percutaneous repair in these patients.[44]

Physiotherapy

All patients who have operative or nonoperative treatment have traditional below-knee plaster boot with the ankle held in plantar flexion for 8 weeks and thereafter a heel rise for 4 weeks, allowing walking and calf muscle exercises.[45],[46] Some authors have even advocated 12 weeks of casting with simultaneous reduction of plantar flexed ankle to the neutral position.[47] As knowledge on tendon healing has accumulated, the use of more active nonsurgical options have been advocated.[48],[49],[50] Cast immobilization for 2–3 weeks followed by controlled early mobilization in a splint was introduced in the 1990s and the authors reported more rapid recovery of ankle motion and return to normal activities than with the traditional 8 weeks of cast treatment.[51] The main complications are rerupturing with an incidence of 8–21%[18],[19] and venous thrombosis and pathological tendon elongation, with associated increase in morbidity.

The current trend is moving toward minimal access surgery with less complication and early mobilization so that there is early return to work or to sports unless in patients in which this is contraindicated or not applicable as stated above.


  Discussion Top


The management of the open Achilles tendon injury is open surgery. It could be a nonaugmented procedure in transection but augmented, especially with plantaris or peroneus brevis tendon in cases with loss of part of the tendon or in crush injuries. The management of open Achilles tendon has been subsumed under that of tendon rupture. In most of the literature, Achilles tendon injuries have been equated with Achilles ruptures. This is inappropriate and has tailored the management of open Achilles tendon in the same way, not considering the different pathophysiologies and pathogeneses. The pathogenesis of open Achilles tendon injury is that of disruption in the continuity of the tendon in otherwise healthy fibers with intact elastic properties. Due to this, it is expected that the duration of immobilization in these patients should be shorter than those of ruptures. Close Achilles tendon rupture in the elderly is treated with nonoperative option or percutaneous surgery because wound complications are notorious in them. Minimally invasive procedures are very important in young and active adults (sportsmen) who want to return sport very early, and these also have the added advantage of a low incidence of rerupture.


  Conclusion Top


It is an established fact that Achilles tendon injuries are not limited to close injuries or ruptures. The open injuries with a different pathogenesis are an integral part and their treatment should be tailored accordingly. There is still a serious controversy in the choice of treatment option for close injuries of the Achilles tendon. There are several treatment options, which have been tried but there is no consensus on the optimal method of treatment. Achilles tendon injuries vary in severity, and there has been no objective method of comparing the results of the various methods of treatment. There may be a need for MRI evaluation to select identical injuries for comparing the treatment groups though the outcome of a treatment option dependsalso on other factors such as the age, the occupation, the recreation/hobby, and the expectation of the patients. What a younger professional athlete considered unsatisfactory may be satisfactory to another patient who is office worker. A sedentary elderly patient will be more easily satisfied and this is one of the reasons why the percutaneous surgery or nonoperative technique have favorable outcome in them. There might be need to search for newer treatment options as part of the goals for achieving optimal method of treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors declare that there is no conflict of interest regarding the publication of this article.

 
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