SLR - November 2018 - Julio D. Perez-Mustelier

Ultrasonographic Evaluation of the Early Healing Process After Achilles Tendon Repair

Reference: Hiramatsu K, Tsujii A, Nakamura N, Mitsuoka T. Ultrasonographic Evaluation of the Early Healing Process After Achilles Tendon Repair. Orthopaedic Journal of Sports Medicine, 6(8), 232596711878988. doi:10.1177/2325967118789883

Scientific Literature Review

Reviewed By: Julio D. Perez-Mustelier, DPM
Residency Program: Bethesda Hospital East, Boynton Beach, FL

Podiatric Relevance: Achilles tendon ruptures are a commonly encountered pathology in a podiatric practice. Ruptures of the Achilles tendon are often encountered in middle-aged patients who overexert themselves in physical activity or sports, otherwise known as “weekend warriors.” Achilles tendon ruptures are also frequently seen in professional athletes, such as football and basketball players. Studies have found that approximately 20 percent of these patients are unable to return to their previous level of activity. The challenge of a surgical repair of the Achilles tendon is visually determining when the Achilles tendon is healthy enough for patients to return to full activity, after additional clinical evaluations.  

Methods: A small-sized level IV prospective study performed at a single institution included 26 patients who underwent primary Achilles tendon repair between 2012 and 2016. Postoperatively, patients were evaluated with ultrasound at months one, two, three, four, five, six and 12. Diagnosis of Achilles tendon rupture was made either clinically, with a palpable gap or positive calf-squeeze test, or by ultrasound. Exclusion criteria included patients with previous Achilles tendon ruptures, functional impairments of the contralateral side or diabetes. Subjective outcomes were analyzed at months 6 and 12 using the Achilles tendon Total Rupture Score, as well as the Tegner activity scale. Ultrasound findings were based on the cross-sectional area and intratendinous morphology of the repaired tendon, using the author’s own grading system with reference to the modified Moller grading system.

Results: By comparing the cross-sectional area ratio of the affected tendon with the contralateral limb that the CSA of the reconstructed tendon gradually increased postoperatively, reaching a maximum at six months and decreased at 12 months. These findings suggest that repaired tendon sufficient mechanical strength at six months. Ultrasound findings show a plateauing of intratendinous hyperechoic area at four months and a continued increase in the fibrillar appearance of the tendon until 12 months. Achilles tendon repair scores did not differ significantly between months six and 12, and all patients achieved maximal scores at 12 months. The small sample size limits this study, and a larger multicenter prospective study would be beneficial to further this research. This study also proposes the idea that, in addition to clinical parameters, visualization of the tendon morphology can aid in providing objective criteria for return to activity or sports.

Conclusions: The cross-sectional area of the surgically repaired Achilles tendon showed much larger CSA of the affected side, reaching a maximum at six months and decreased at 12 months postoperatively. The authors conclude that ultrasound evaluation of a repaired Achilles tendons provides a convenient and inexpensive modality for postoperative assessment. The quality of the visualized tendon, along with clinical parameters, including muscle strength and functional performance, can assist in determining return to activity or sport. 

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