Comparison of ultrasonography and magnetic resonance in the postoperative monitoring of complete subcutaneous rupture of the Achilles tendon]

The diagnostic accuracy of US and MRI in the subcutaneous rupture of the Achilles tendon has already been assessed. We used both techniques to study the Achilles tendon during the postoperative repair process after surgery according to Bosworth. The results were compared and discussed in relation to clinical recovery. Ten patients with complete subcutaneous rupture of the Achilles tendon were followed-up with physical examination and submitted to US and MR studies 40, 60 and 90 days postoperatively. Eighty patients recovered in the expected time, while 2 took longer. At 90 days, the US findings in 7 patients and the MR findings in 8 patients who recovered in the expected time could be considered normal. US poorly distinguished the tendon from the reinforcement flap because of gross tendon echostructure. The tendon and the reinforcement flap were not distinguishable at MRI because they were uniformly hypointense. Clinical recovery appeared as a hyperechoic structure and a gross fibrillar pattern at US and as a hypointense structure with some small hyperintense areas at MRI. US and MRI were in disagreement in one patient with a postoperative algodystrophic syndrome, where US showed some alterations which were considered false positives because of clinical recovery and negative MR findings. US and MR patterns were considered abnormal in the 2 patients with delayed recovery. US showed persistent hyperechoic areas within the tendon, while the MR signal was of intermediate intensity in the tendon and reinforcement flap. To conclude, we believe that US is an appropriate technique for the postoperative follow-up of complex subcutaneous ruptures of the Achilles tendon. Additional MRI should be performed in all the cases where US findings are in disagreement with clinics.     

Bilateral Achilles tendon rupture: a report on two cases

Two cases of traumatic bilateral Achilles tendon rupture are reported. One of the patients was a healthy middle-aged man, who had been an active national-level gymnast 20 years earlier. He had not suffered any complaints of Achilles tendons before. The ruptures occurred when, after a sauna, he showed his guests a vault forwards, which he had been able to perform easily. This time the landing took place on the toes, causing a high peak stretch to the calf muscles and Achilles tendons. The total rupture of both Achilles tendons was treated surgically, with an excellent result 2 days after the trauma. End-to-end suturation and a fascial flap plasty were made on both sides. No macroscopic degeneration could be detected on the rupture sites. He was allowed to walk freely 6 weeks after the surgery. The second case was a 54-year-old woman, who had suffered from Achilles tendinitis and peritendinitis for 2 years. Both tendons had been surgically treated, and severe adhesions and local degenerative changes had been found. The tendon rupture occurred when she injured her left ankle while getting out of the car. Two days later she fell at home, because of the weakness of the left side, and consequently the right Achilles tendon was injured. She was treated conservatively for 10 days, before the surgery was performed. Both tendons were ruptured and an extensive degeneration of the area was observed. The right side suffered from a rerupture, which was again treated surgically. After surgery the recovery was slow, but the final result 3 years later was moderate. Neither of the patients had any systemic diseases.     

Biochemistry and biomechanics of healing tendon: Part II. Effects of combined laser therapy and electrical stimulation

Twenty-two closed Achilles tendon ruptures caused by sports injuries in 22 patients (average age, 37.6 years) were repaired with Kirschmayer core suture and cross-stitch epitenon suture, and early active ankle motion with weightbearing was implemented after surgery. This study was undertaken to evaluate the effectiveness of the repair technique and rehabilitation protocol by assessing clinical results and magnetic resonance imaging findings. The follow-up period averaged 24.6 months. Twenty of the tendons (91%) healed without rerupture, and two tendons (9%) suffered a partial rerupture at 23 and 56 days, respectively. Active ankle extension reached from the minus range to 0 degree in an average of 9.7 days, and ankle motion recovered to normal in an average of 6.0 weeks. Full weightbearing without heel raising became possible in an average of 16.4 days, and heel raising with both legs became possible in an average of 7.3 weeks. The patients returned to full sports activity in 13.1 weeks. The interval until the area of high-intensity signal at the tendon repair site on T2-weighted magnetic resonance imaging scans became intermediate-intensity signal averaged 6.9 weeks, and the tendon repair site became low-intensity signal in an average of 12.6 weeks, demonstrating excellent tendon healing. Treatment employing Kirschmayer core suture and cross-stitch epitenon suture may help athletes return to sports activity in a shorter period than that allowed by previous methods of repair for Achilles tendon ruptures.     

Early motion after repair of Achilles tendon ruptures

The purpose of this study was to evaluate the clinical outcome of patients treated with limited immobilization and early motion after repair of acute Achilles tendon ruptures. Thirteen consecutive patients with complete ruptures of the Achilles tendon were identified, repaired, and rehabilitated with early motion starting an average of 10 days after surgery. Active range of motion was begun at an average of 23 days and weightbearing in a walking boot was started at an average of 3.5 weeks after surgery. The average length of follow-up was 27 months. Twelve of 13 patients returned to running activities in an average of 3 months. All 12 patients who participated in lateral motion activities before their injury returned to similar activities in an average of 7 months. The patients rated their overall status at an average of 93% of their preinjury level. Follow-up Cybex testing demonstrated plantarflexion strength averaging 92%, plantarflexion power averaging 88%, and plantarflexion endurance averaging 88% of the nonindexed extremity. Early range of motion after Achilles repair is safe and there is no increased risk of rerupture in compliant patients. The patients achieved good return of plantarflexion strength, power, and endurance.     

Methods and rationale for closed treatment of Achilles tendon ruptures

A method of closed treatment of Achilles tendon ruptures by casting, utilizing a long leg cast for 6 weeks and a short leg cast for 4 additional weeks, is presented. An experimental model using rabbits supports the clinical contention that closed approximation and immobilization of Achilles tendons allows tendon healing to progress, at least in the early stages. Observations made on the tendon sheath during early healing attribute a very positive role to it in providing needed blood supply to the tendon. The importance of maintaining a smooth gliding surface as well suggests that the tendon sheath should not be violated by surgical repair on the Achilles tendon.     

Tendon transfer for equinovarus deformed foot caused by cerebrovascular disease

Surgical correction was performed on 125 patients who had equinovarus deformity caused by a cerebrovascular accident and who needed an ankle foot orthosis for walking. The operative procedures involved anterior transfer of the long toe flexors (flexor hallux longus and flexor digitorum longus; long toe flexor group) or lateral transfer of the anterior tibial tendon (anterior tibial tendon group), combined with lengthening of the Achilles tendon. On evaluation more than 2 years after surgery, 83 of 110 patients of the long toe flexor group and eight of 15 patients of the anterior tibial tendon group were able to walk without a brace. Five patients of the anterior tibial tendon group who had shown strong contraction of the anterior tibial muscle during the swing phase before surgery, needed a brace because of a drop foot after surgery. Thus, lateral transfer of the anterior tibial tendon was abandoned in 1984. Recurrence of varus deformity was seen in approximately 15% of the patients in both groups. Anterior transfer of the long toe flexors, using them as dorsiflexor tendons or for tenodesis, seemed to produce better results.     

Conservative functional therapy of closed rupture of the Achilles tendon. Treatment approach and analysis of results

In a prospective study in the period from May 1989 to April 1994, 161 patients at the Unfallchirurgische Klinik in Braunschweig were treated for rupture of the Achilles tendon using a conservative functional method. A follow-up examination was carried out on 132 patients (81%) after an average of 12.6 months. Conservative therapy was indicated if dynamic ultrasonography showed sufficient adaptation of the rupture. Continuous retention of the adapted tendon fragments was guaranteed by means of special footwear that raises the back of the foot (Variostabil). The average age of the patients was 39.5 years. In 97 cases (73.5%) the injury was caused by sports. In 68 ruptures the dehiscence was compensated in plantar flexion. In 48 cases the dehiscence was 1-5 mm, and in 16 cases it was between 6 and 10 mm. The average period of hospitalization was 4.8 days (1/19). The period of inability to work was an average of 4 weeks (27.4 days (0/98)). The rupture healed on an average of 9.5 weeks (5.9/23). Complications included seven cases of re-rupture (5.3%), and, in the course of treatment, four patients (3%) suffered profound leg vein thrombosis that in one case developed into postthrombotic syndrome. In two cases there was tendovaginitis of the Achilles tendon. Early functional conservative therapy using the VARIO-STABIL shoe is a suitable method for treating a newly ruptured Achilles tendon. When there is a precise indication, the method is equally as good as operative therapy and because of the low complication rate, it is even preferable.     

Magnetic resonance imaging scanning in the diagnosis of zone II flexor tendon rupture

This study was undertaken to determine the usefulness of magnetic resonance imaging (MRI) in the diagnosis of flexor tendon rupture in patients who had prior surgery. Magnetic resonance imaging scans were performed on 11 digits (16 tendons) with the clinical diagnosis of flexor tendon rupture. Clinical suspicion correlated with MRI and surgical findings. Clinical examination yielded a 60% accuracy in diagnosis. MRI differentiated rupture from adhesions with a 100% accuracy rate. The MRI scan is a valuable tool in diagnosing tendon ruptures and may help reduce the incidence of unnecessary tendon explorations.     

Outcome and prognostic factors of achilles rupture repair using a new scoring method

A new clinical scoring system, including subjective assessment of symptoms and evaluation of ankle range of motion and isokinetic measurement of ankle plantar flexion and dorsiflexion strengths, is presented in 101 patients (86 men, 15 women) who had repair of a closed Achilles tendon rupture. Twenty-one patients were competitive athletes and 70 were recreational athletes. Eighty-one percent of the ruptures were related to sports, and 32% occurred while playing volleyball. Twenty-six patients had previous Achilles tendon symptoms. At followup, an average of 3.1 years after repair, the overall result scores were excellent in 34 cases, good in 46, fair in 17, and poor in four. Only age was a predictor of overall results. The isokinetic strength scores were excellent or good in 72 cases, fair in 18, and poor in 11. Presence of systemic diseases, activity level, previous Achilles tendon symptoms, and later return to physical exercise were predictors of strength results. Gender, body weight, height, period between rupture and operation, surgeon, rupture site, operative method, complications, and thickness, width, and area of the Achilles tendon at followup were not related significantly to the outcome.     

Can sonography predict the outcome in patients with achillodynia?

PURPOSE: We evaluated whether the grade assigned to the Achilles tendon's appearance on sonograms can be used to predict the outcome of achillodynia. METHODS: A retrospective evaluation was done of a case series of patients with Achilles tendon pain seen at a sports medicine clinic. The study consisted of chart reviews, telephone follow-up interviews, and grading of ultrasound images of the tendon obtained during the initial visit. The grading scheme was as follows: grade 1, normal tendon; grade 2, enlarged tendon; and grade 3, tendon containing a hypoechoic area, regardless of size. The time needed to recover from symptoms was compared between grades using survival analysis. RESULTS: The group consisted of 33 patients, with a mean age of 35.8 years and a mean follow-up time of 24.3 months. There was a statistically significant difference in the time to full recovery between grades (p = 0.02). Patients with grade 1 tendons had a prompter resolution of symptoms than did patients with grade 2 or 3 tendons. CONCLUSIONS: This retrospective study of the outcome of achillodynia demonstrates the possible use of tendon sonography as a prognostic tool to supplement physical examination.     

Propofol bolus facilitates reduction of luxed temporomandibular joints

All patients with badminton-related acute Achilles tendon ruptures registered during 1990 to 1994 at the University Hospital of Ume? were retrospectively followed up using a questionnaire. Thirty-one patients (mean age, 36.0 years), 27 men and 4 women, were included. Thirty patients (97%) described themselves as recreational players or beginners. The majority of the injuries (29 of 31, 94%) happened at the middle or end of the planned game. Previous local symptoms had been noticed by five patients (16%). Long-term results showed that patients treated with surgery had a significantly shorter sick leave absence than patients treated without surgery (50 versus 75 days). There was no obvious selection favoring any treatment modality. None of the surgically treated patients had reruptures, but two reruptures occurred in the nonsurgically treated group. There seemed to be fewer remaining symptoms and a higher sports activity level after the injury in the surgically treated group. Our results indicate that local muscle fatigue may interfere with strength and coordination. Preventive measures such as specific treatment of minor injuries and adequate training of strength, endurance, and coordination are important. Our findings also indicate that surgical treatment and careful postoperative rehabilitation is of great importance among badminton players of any age or sports level with Achilles tendon rupture.     

Partial rupture in chronic achilles tendinopathy. A retrospective analysis of 342 cases

342 achilles tendons in 298 patients were operated on for painful chronic achilles tendinopathy (81% men; mean age 35 (18-82) years; 79% athletes). A partial rupture was found in 23%, tendinosis (degeneration) in 49% and no macroscopic pathology in 28% of the tendons. In partial ruptures, as compared with non-ruptured tendons, the lesion was commoner in the distal part of the tendon and more frequent in physically active men slightly below middle age who had received local steroid injections before surgery. In a logistic regression analyzing age, gender, physical activity and preoperative steroid injections, only preoperative steroid injections and male gender predicted a partial rupture.     

Locations of crossover breakpoints within the CMT 1 A-REP repeat in patients with hereditary neuropathy with liability to pressure palsy--detection by recombinant chromosome-specific polymerase chain reaction

The "short Achilles tendon" syndrome, characterised by limited dorsiflexion of the tibiotarsal joint, is not well-known but could be a disposing factor for trophic disorders and plantar ulcer related to hypersupport in the diabetic subject. We report two cases of multicomplicated diabetic patients treated during several months for plantar ulcer superinfected with underlying osteoarthrits, whose course became rapidly favourable after tenotomy of the Achilles tendon. This simple surgical act can be performed in ambulatory conditions under local anaesthesia. Functional disability is negligible. The benefit of this treatment as part of the curative or preventive therapeutic arsenal for care of the diabetic foot remains to be evaluated.     

Balloon extraction of esophageal foreign bodies in children

A study to determine the sensitivity, specificity, and positive and negative predictive values of several clinical diagnostic tests of subcutaneous Achilles tendon rupture was performed during a 13-year period. There were 174 patients with clinical diagnosis of unilateral complete subcutaneous Achilles tendon tear and 28 patients with unilateral suspected but no actual Achilles tendon tear. The following tests were used: palpation, calf squeeze, Matles, Copeland, and O'Brien. Palpation of the gap was the least sensitive clinical test with the patient awake (0.73), increasing to 0.81 when the test was performed under anesthesia; the Copeland and O'Brien tests showed a sensitivity of 0.8. Both the calf squeeze and Matles tests were significantly more sensitive than the other tests (0.96 and 0.88, respectively; 0.022 < P < 0.05). All tests showed a high positive predictive value, with no statistically significant difference between the various tests. In the 28 patients with no evidence of a subcutaneous Achilles tendon tear on imaging, the tests showed a high capability to detect that the Achilles tendon was intact (gap palpation specificity, 0.89; calf squeeze test specificity, 0.93; Matles test specificity, 0.85). Whichever tests were performed, at least two of them were positive for a subcutaneous tear of the Achilles tendon in all patients in this study.     

Enthesopathy and tendinopathy in gout: computed tomographic assessment

OBJECTIVE: To establish if computed tomography (CT) imaging, which has proved helpful in detecting intra-articular tophi in gout, can also be used to document gouty enthesopathy and tendinopathy. METHODS: Three patients with tophaceous gout and clinical involvement of the Achilles tendon (two cases) or patellar tendon (one case) were assessed with CT examination and plain radiographs. RESULTS: In the first two cases, CT images revealed linear or nodular high attenuation opacities within the substance of the Achilles tendons and their calcaneal insertion. In case 3, dense linear opacities were seen within the patellar tendon and within its tibial insertion. No such opacities of the tendons and entheses were seen on standard radiographs of these patients. CONCLUSIONS: CT appears to be the imaging method of choice for demonstrating monosodium urate deposits in entheses and tendons in tophaceous gout.     

Surgical repair of Achilles tendon rupture. Comparison of surgical with conservative treatment

Achilles tendon suture combined with a triceps surae tendon tip-over graft was performed in 314 patients with acute rupture of the Achilles tendon between 1980 and 1991. Analysis of these cases showed a low tissue complication rate compared with that reported in the literature. An average of 8.1 years after repair, 223 patients were examined using Holz's scale of clinical assessment after Achilles tendon repair. The results were 'good' in 87.4%, 'fair' in 11.2% and 'poor' in 1.4%. The re-rupture rate was very low (0.4%). These results are better than the re-rupture rate after surgical repair with solely end-to-end suture or after conservative immobilizing or conservative functional treatment. In conclusion, these data show that the fascial reinforcement is a valuable complement to the tendon suture.     

Complete rupture of the distal semimembranosus complex in a professional athlete

Complete ruptures of the distal hamstring tendons rarely cause functional disability significant enough to warrant surgical intervention. Isolated ruptures of the distal semimembranosus tendon complex have not been reported previously in the literature. A case of a complete rupture of the distal semimembranosus tendon complex occurring in a professional football player with resultant functional disability is reported here. The magnetic resonance imaging scan was essential for an accurate diagnosis. Subsequent surgical repair and postoperative rehabilitation is described. Strict attention to recreating the multiple attachments of the semimembranosus tendon complex is recommended.     

Hand flexor tenosynovitis in rheumatoid arthritis. Prevalence, distribution, and associated rheumatic features

Tenosynovitis of one or more flexor tendons of the hand (mean 3.1 tendons per patient) was noted in 55% of 100 patients with rheumatoid arthritis (RA) examined periodically during a mean period of 5 years. The third flexor tendon was involved most frequently (71% of patients), followed by the second (62%), fourth (53%), fifth (27%), and first (13%). Patients with flexor tendonitis (FT) had a significantly higher prevalence of rheumatoid nodules (56% vs 33%), carpal tunnel syndrome (47% vs 13%), wrist extensor tenosynovitis (47% vs 9%), and elbow epicondylitis (22% vs 7%) than patients without FT. Dupuytren's contracture, DeQuervain's tenovaginitis, flexor carpi radialis and ulnaris tendonitis, and Achilles tendonitis were found exclusively in patients with FT. A control group of 50 non-RA patients with FT had statistically fewer diseased tendons per patient (mean 1.5) and a different digital distribution, the thumb being affected more frequently (P less than 0.05) than in RA patients.     

Imaging of tendons--adaptation, degeneration, rupture

Tendon imaging is mainly performed with ultrasonography (US) and magnetic resonance imaging (MRI) and has been improved within the last years because of technical advancements and a better understanding of tendon pathology. Several concepts concerning the etiology and the course of tendon diseases have influenced image interpretation and vice versa. Adaptive mechanisms within the tendon tissue against stress can be observed mainly on histologic specimens and not macroscopically or with in-vivo imaging. Degeneration may occur in the form of tendinitis, peritendinitis, enthesitis, or myotendinal junction abnormality. Distinct imaging findings exist for most of these forms. Many concepts that have been developed to explain tendon degeneration have been applied on virtually all tendons in the human body. They can be grouped into those which focus on hypovascularization, on biomechanical overload, and on degeneration secondary to other underlying disease. Tendon rupture seems, in many cases, to be the final stage of tendinitis. From this point of view, imaging may be used to predict the risk of tendon rupture together with other intrinsic and with extrinsic parameters. These considerations result in the concept of the "vulnerable zone" and of the "critical phase" in which tendon ruptures may predominantly occur.