SLR - March 2021 - Amar R. Gulati

Midterm Functional Performance Following Open Surgical Repair of Acute Achilles Tendon Rupture

Reference: Wenning M, Mauch M, Heitner A, Streicher P, Ritzmann R, Paul J. Midterm Functional Performance Following Open Surgical Repair of Acute Achilles Tendon Rupture. Archives of Orthopaedic and Trauma Surgery. 2021 Jan 23. doi: 10.1007/s00402-020-03746-3.

Level of Evidence: Level III

Scientific Literature Review
Reviewed By: Amar R. Gulati, DPM
Residency Program: Medstar Health Podiatric Surgery Residency – Washington, DC

Podiatric Relevance: The treatment of Achilles tendon ruptures is a heavily debated topic. It is an injury that is not unfamiliar to the podiatric surgeon. This study aims to evaluate mid-term functional performance in younger males with acute ruptures who underwent anatomic vs. conventional open repair. The authors postulated that despite surgical repair, patients would continue to have a deficit in plantarflexory strength. Furthermore, they compared the results between both surgical approaches. 

Methods: After filtering through inclusion and exclusion criteria, 52 patients were included in this study. The patients either underwent anatomic reconstruction (AR) of their Achilles (respecting the twisting of the fibers and pre-tensioning the tendon appropriately) or conventional (CR) treatment (end-to-end repair). The following outcomes were measured at approximately 3.5 +/- 1.4 years; patient-reported outcomes via Achilles Tendon Rupture Score (ATRS), isokinetic strength testing, heel raise test via a novel three-dimension videography system, and gait analysis with pressure recording.

Results: Outcomes measured using ATRS had statistically significant higher results in the AR group compared to the CR group. When comparing isokinetic strength, the AR group had higher peak torques than the CR group throughout plantar-flexion range of motion. However, during gait analysis, no significant difference were found except for a longer ground time of the hind foot on the operated side. Overall, patient satisfaction remained high through outcomes despite an average of 10.2 percent in plantarflexion strength deficit compared to the non-operative side. Isokinetic strength testing showed a progressively larger deficit in strength with greater end-range plantarflexion compared to the non-operative side. Heel raise testing showed that the non-operative side had a higher heel-raise height in all scenarios. Additionally, the AR group exhibited a higher heel-raise compared to the CR group. 

Conclusions: Recent literature has resulted in frequent debate on the treatment modality for Achilles tendon ruptures. Postoperative complications such as soleus atrophy and decreased plantarflexion strength have been documented. Additionally, more recent literature lends itself in favor of non-operative treatment with more aggressive rehabilitation. The authors present a quantitative evaluation of mid-term results from patients who underwent two types of surgical treatment. The sample size consisted of younger, male patients without associated co-morbidities and a focus on return to sport. Their results reflect that deficits are still noted in operative treatment, however, anatomic reconstruction proves more effective in reducing deficits than conventional treatment. Further studies with comparisons to non-operative treatment would help our understanding with how to approach these debilitating injuries.

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