Chou: OKU: Foot and Ankle 7

Section 7: Tendon Disorders and Sports-Related Foot and Ankle Injuries

thickening in the patients who received a percutaneous repair. A retrospective study of 270 patients compared open repair with percutaneous repair and found no statis tically significant difference between the two approaches with regard to complications. 18 Early motion was evaluated after open repair in a retro spective study of 107 patients, 96 of whom (90%) received no immobilization and started exercise 3 to 5 days after surgical repair. 19 Patients were able to resume heavy labor and sports activity 13 weeks after surgery on average. No rerupture, gap formation, or tendon elongation was noted. The study concluded that early motion may facilitate the proliferation, transportation, and alignment of tendon cells, thereby leading to an improvement in the overall reconstruction of the tendon. However, those results are somewhat contradictory to the results found in a separate 2022 prospective study of 60 patients who underwent percutaneous Achilles tendon repair that compared the outcomes of a traditional accelerated rehabilitation pro gram to a slower rehabilitation protocol. In this study, both groups were allowed immediate weight bearing; however, the patients with the slower rehabilitation protocol were immobilized for a longer period and started eccentric exercises at a later time (approximately 12 weeks after surgery). The slower rehabilitation group was found to have improved patient-reported functional outcomes, calf circumference, isometric strength, and Achilles tendon ten sion as measured by resting angle at a 12-month follow-up. These results suggest that the added benefits of earlier mobilization may potentially be offset by an increased risk of tendon elongation during the healing process. 20 In addition to tendon elongation, another marker that has been identified as a potential correlate to functional outcomes is the Achilles tendon cross-sectional area. A 2020 prospective study of 22 patients evaluated tendon structure using ultrasonography and patient functional outcomes at multiple time points up to 1 year after Achilles tendon rupture. In this study, which did not control for treatment provided, tendon cross-sectional area at 12 weeks was found to be the strongest predictor of improved performance on heel-rise testing at 1 year. 21 The effect of various rehabilitation protocols on Achilles tendon cross-sectional area after rupture continues to be explored. CHRONIC ACHILLES TENDON RUPTURES An estimated 10% to 25% of Achilles tendon ruptures are neglected or not immediately identified. 22 The patient risk factors for delayed diagnosis include age older than 55 years, a high body mass index, and injury unrelated to sports activity. 1 Although there is no clear demarcation between acute and chronic rupture, a rupture estimated to have been present for 4 to 6 weeks is likely to have

characteristics consistent with chronic rupture. Chronic rupture is more challenging to treat than acute rupture because of the presence of a gap between the tendon ends, retraction and scarring of the calf muscle, and loss of muscle contractility. The patient may have vague symptoms that are not specific to the Achilles tendon region. There may be a sense of weakness or unsteadiness in gait, rather than pain. Difficulty in stair climbing and walking uphill is common. Loss of tendon contour is seen on examination. Some patients have sufficient reparative tissue to make palpation of a gap difficult. The Thompson test usually is positive but is less reliable than with acute rupture. The Matles test also usually is positive. Most patients are unable to perform a single-leg heel rise. Retraction and scarring of the tendon ends means that nonsurgical restoration of the physiologic tension of the gastrocnemius-soleus complex is difficult. The use of an ankle-foot orthosis should be considered for a patient who is a poor surgical candidate because of significant comorbidities. A patient with minimal functional deficits also may benefit from nonsurgical treatment. The benefit of physical therapy is in recruiting other muscle groups to compensate for the loss of Achilles tendon function. There is limited evidence regarding the outcomes of non surgical management of chronic Achilles tendon ruptures in the literature. 23

Surgical treatment of a chronic rupture involves the restoration of continuity to tendon ends that have retracted and created irreducible gaps. The available surgical techniques include tendon mobilization, turn down flaps, tendon advancement, tendon transfer, free tissue transfer, and synthetic graft. 22 A 2- to 3-cm gap can be effectively treated using tendon mobilization and stretching of the proximal musculature, followed by end-­ to-end repair. The use of turndown flaps involves freeing a strip of tendon from the proximal residual tendon and weaving it through the distal and proximal tendon ends. A study reported on the treatment of chronic ruptures with removal of a section of scar tissue and direct pri mary repair of the remaining scar tissue without the use of any graft in 30 patients. 24 At 33 months average follow-up, there were no reruptures and all patients were able to use stairs. Fourteen patients who were involved in sports were able to return to their sport. Histologic evaluation of the interposed scar tissue showed the bio logic potential for healing. A V-Y tendon advancement can be used for gaps smaller than 5 cm and patients have reported satisfactory outcomes; however, the cosmetic results may be unsatisfactory and persistent plantar flex ion weakness is seen. 25 Tendon transfers are an option for the treatment of chronic ruptures. Tendon transfer provides not only material to fill gaps between rupture ends but also additional strength with its associated Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

Section 7: Tendon Disorders and Sports Related Foot and Ankle Injuries

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Orthopaedic Knowledge Update ® : Foot and Ankle 7