SLR - May 2016 - Michael A. Howell

Title: Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up

Reference: Heikkinen J, Lantto I, Flinkkila T, Ohtonen P, Pajala A, Siira P, Leppilahti J. Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up. J Bone Joint Surg Am. 2016 Jan 20; 98 (2):85-92.

Scientific Literature Review

Reviewed By: Michael A. Howell, DPM
Residency Program: West Penn Hospital, Pittsburgh, PA

Podiatric Relevance: Achilles tendon ruptures are a common pathology treated by podiatrists across the country. Although Achilles tendon repairs have been augmented using different kinds of flaps and grafts, the implantation of a single surgical model and whether or not to augment has not been universally accepted. Therefore, the authors of this article were interested in expanding on a previous short-term study and comparing the long-term results of augmented and nonaugmented surgical repairs of total Achilles tendon ruptures.

Methods: This study was a prospective randomized trial with a mean fourteen-year follow up comparing augmented with nonaugmented repair for acute Achilles tendon ruptures. Between the years 1998-2001, sixty patients with acute Achilles tendon rupture were randomized. The sixty patients were randomized preoperatively to receive end-to-end repair with use of the Krackow locking loop surgical technique alone (nonaugmented repair group; thirty-two patients) or the same repair augmented with a down-turned gastrocnemius fascial flap (augmented repair group; twenty-eight patients). Both groups received the same postoperative treatment with an early immobilization brace. Outcome measures included the Leppilahti Achilles tendon score, isokinetic plantarflexion strength, tendon elongation, and the RAND 36-item health survey.

Results: After a mean of fourteen years of follow-up, the mean Leppilahti score, which includes subjective (pain, stiffness, muscle weakness, footwear restriction) and objective (active range of ankle motion and isokinetic calf muscle strength) factors, was 87.1 points for the nonaugmented repairs and 91.5 points for the augmented repairs. The surgical technique did not have an impact on strength parameters, with a mean peak torque of 112.6 Nm after the nonaugmented repairs and 107.3 Nm after the augmented repairs. The mean tendon elongation was 12.7 mm after the nonaugmented repairs and 14.5 mm after the augmented repairs. RAND-36 scores indicated no between-group difference in health domains.

Conclusions: The authors of this study feel that, overall, augmented repair of total Achilles tendon ruptures provided no advantage over simple end-to-end repair. Achilles tendon ruptures result in a permanent calf muscle strength deficit, but its clinical relevance remains unclear. The present fourteen-year follow up study showed that augmented and nonaugmented surgical repair of Achilles tendon rupture produced similar clinical results, isokinetic strength, tendon elongation, complications, and re-rupture rates.

Strengths of the present study include its prospective randomized design and homogeneous group of patients. The clinical observers were blinded to the treatment groups. The study was a long-term follow-up of a previously published, prospective, randomized, controlled trial with a difference of 13 years.

Although there was no advantage between the two groups, I do believe an augmented repair can be a good surgical reconstruction method when reconstruction with one’s own tissue is impossible because the rupture gap is too large. Therefore, surgical treatment with an augmented repair is recommended for patients with neglected chronic Achilles tendon ruptures who have discomfort in activities of daily living. Knowing these outcomes might help guide procedure selection for physicians and will provide information to patients to help them understand what to expect.

Educational Opportunities