SLR - May 2016 - Michael Corpuz

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 Corpuz, DPM
Residency: Cedars-Sinai Medical Center, Los Angeles, CA

Podiatric Relevance: Though there has been somewhat of a shift towards nonoperative treatment methods for acute Achilles ruptures, surgical repair remains the most effective way to restore lost tendon length and tension in an aim to maximize functionality. What remains controversial in the literature is the practice of augmentation of the repair in hopes of accelerating healing of the degenerated tendon and reducing the chance of re-rupture. The authors of this publication aimed to further explore the role of tendon augmentation, comparing the long-term results of both augmented versus primary end-to-end repairs of Achilles tendon ruptures in patients with the same post-surgical rehabilitation course.

Methods: The study was a prospective, single-surgeon, randomized trial conducted in Finland from 1998-2001 involving an end total of 55 patients (minimum 13 year follow-up), comparing end-to-end repair (n = 28) with augmented repair (n = 27) of total Achilles tendon ruptures. End-to-end repair involved use of the Krackow locking loop alone, while the augmentation group also implemented a down-turned 10 mm wide central gastrocnemius aponeurosis flap. Regardless of treatment, patients were casted in neutral position and rehab protocol was identical. Primary outcome measure was the Leppilahti score at the 14-yr follow-up exam. Secondary outcome measures included calf muscle isokinetic strength, radiographic measurements of tendon elongation, and a RAND-36 quality of life survey.

Results: Average Leppilahti score after fourteen year follow-up for the end-to-end group was 87.1 while the augmented group recorded a mean of 91.5. This result was not statistically significant. In regards to measuring isokinetic strength, no significant difference was found (112.6 Nm vs 107.3 Nm). RAND-36 scores also showed no statistically significant difference between the two operative techniques.

Conclusions: The publication’s authors conclude that based on functional scoring, tendon strength, and a subjective quality of life survey, there is no statistically significant value in augmentation in the form of a gastroc flap versus solely primary end-to-end repair of acute Achilles tendon ruptures. The theoretical advantage of augmentation, which is increasing the amount of collagen in the vicinity of the healing tendon, thereby improving strength and decreasing incidence of re-rupture, was not necessarily confirmed with this study. One consideration in augmenting primary end-to-end repair is that the added bulk may hinder wound healing. Also, the amount of tendon gapping of each patient post-injury and/or post-debridement of the tendon intraoperatively was not addressed in the study, which can undoubtedly play a large role in whether or not augmenting the primary repair will be of added benefit. Further prospective studies will need to be carried out to strengthen the authors’ stance on how to surgically approach the acute Achilles tendon rupture.

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