December issue.indd

*Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, North Staffordshire Hospital, Thornburrow Drive, Hartshill, Stoke on Trent, Staffordshire, ST4 7QB, UK and Gilbert Bain Hospital, Lerwick, Shetland

Introduction

Patients and methods

We followed up 25 patients (average age 47.9 years, range 22 to 77) after open repair of their Achilles tendon rupture. All had been operated on by a single general surgeon using an end-to-end reabsorbable suture, and immobilised in a plaster of Paris cast for six weeks. All patients had been discharged from follow up by 18 weeks from the operation. At an average of 3.4 years (range six months to 9.25 years), 18 had “excellent”, six (24%) “good” and one (4%) “satisfactory” results. All but one patient were able to walk on tiptoes, and 20 of the 22 patients examined directly walked without a limp. Ultrasonography showed the injured tendons to be on average 2.3 times thicker in the antero-posterior diameter and 1.7 times thicker in the transverse diameter. In the hands of a single non-specialist but fully trained general surgeon, this management regimen produced full return to pre-operative activities in the majority of patients, and a low rate of local complications. The macroscopic and ultrasonographic appearance of the operated tendon remained abnormal, but this was not associated with any overt clinical disturbance

INTRODUCTION

Achilles tendon ruptures (ATRs) have become more common over the past decade, especially in the Nordic countries.¹ Patients typically present with a history of sudden pain in the posterior aspect of the affected leg, often reporting that, at the time of injury, they thought that they had been struck by an object or kicked. They are often unable to weight bear and experience weakness or stiffness of the affected ankle.² Examination may reveal diffuse oedema and bruising and, unless the swelling is severe, a palpable gap may be felt along the course of the tendon.3 Generally, ATRs do not pose diagnostic problems.³ However, it is not uncommon to find that the first examining doctor misses more than 20% of such injuries.⁴

Controversy still rages regarding its optimal management, and conservative management, open and percutaneous repair are all advocated.⁵ Opponents of operative repair cite a high rate of complication as the main disadvantage.^5-10 Forty years ago, Arner and Lindholm reported a 24.4% complication rate, including two cases of deep vein thrombosis, one of fatal pulmonary embolism, three wound infections, 11 instances of wound necrosis and four repeat ruptures in a series of 86 operative repairs of ATRs.¹¹ Recent evidence suggests that operative repair is safe, with a low rate of complications and a high proportion of patients who returned to their pre-injury activities.¹²

Typically, reports on the management of ruptured Achilles tendons focus on the experience from teaching centres, with excellent outcomes when the operation is performed by surgeons with a special interest.⁵

The primary author of this report (AC) is a fully trained Consultant General Surgeon in a remote and rural hospital where no orthopaedic service is available. His impression was that his patients achieved good clinical, functional and cosmetic results using ‘classical’ operative and rehabilitation techniques, and this study documents the results obtained in 10 years of practice during which all patients with an ATR in his setting were operated on by him, and followed the same post-operative regimen.

PATIENTS AND METHODS

All the procedures described in this article were performed after local Ethical Committee approval had been granted. All patients gave their written informed consent to be operated and to undergo the procedures described hereinafter.

In the period between 1 January 1990 to 31 December 1999, 25 patients (13 males, 13 left ruptures) were admitted to Gilbert Bain Hospital, Lerwick, Shetland with the clinical diagnosis of a subcutaneous ATR. The hospital has 68 beds, serves an isolated island population of 23,000, and has a non-specialist Surgical Unit. The main author is one of two Consultant General Surgeons, and the only one operating on musculoskeletal injuries. There are no other hospitals in the whole of the Shetland Islands, and the decision on whether to transfer musculo-skeletal patients to the teaching centre (Aberdeen) on the mainland is made according to the judgement of the Consultant General Surgeon. The diagnosis of ATR was based on the history and clinical findings [tenderness with swelling in the Achilles area, presence of a palpable gap in the tendon, and presence of a positive calf squeeze test (absence of plantar flexion of the injured ankle with the knee flexed during passive calf squeeze)].¹³ Imaging techniques were not used for diagnostic purposes. Following diagnosis, patients were counselled on the advantages and disadvantages of operative versus conservative management, and all opted to be treated operatively.

Three patients reported pain in the Achilles tendon region before they noted deterioration in their mobility while walking, but could not remember a single traumatic episode. One of these patients had received two corticosteroid injections around the Achilles tendon.

The following variables were studied: age, sex, side and mode of injury, time from injury to presentation to their family doctor or to hospital, significant co-morbidities, time from presentation to operation. We recorded details of the anaesthetic procedure, tourniquet times, findings at operation and operative technique. We also studied operative complications and length of hospital stay and recorded details of follow-up visits at 2, 4, 6, 10 and 12 weeks, with particular reference to wound healing, mobilisation and return to full painless function for “normal” activities. Other outpatient visits were made as necessary, for up to 18 weeks from the operation.

All patients were assessed by a consultant anaesthetist pre-operatively, and were operated from 24 hours to 10 days (average three days), with nine (36%) patients being operated within 24 hours of admission. Any delays were due to patients electing to receive their operation at a later date for personal reasons. All patients were given a compression stocking to wear on the non-injured leg. Seventeen (68%) patients received subcutaneous Heparin 5000 iu one hour before the operation and three times a day until discharge. Prophylactic antibiotics were not given. General anaesthesia was employed in 21 patients, with the remaining four patients receiving spinal anaesthesia. All operations were performed by the main author (AC). With the patient prone such that the feet are unsupported and dependant, a mid-thigh tourniquet was applied and inflated to 250 mmHg (mean tourniquet time 43 minutes, range 34-58 minutes), a lateral curvilinear (“lazy C”) incision was made, with the dome of the C centred over the palpable gap, and extended proximally and distally for 3-4cm. The repair was performed in a standard fashion using the technique described in a previous publication by our group.14 With the ankle plantarflexed as necessary, the tendon ends were approximated and repaired end-to-end using a Bunnell type suture, taking four or five bites both proximally and distally, extending just proximal to the Achilles tendon insertion distally and just distal to the musculotendinous junction proximally. The suture material of choice was No 1 PDS (Ethicon W9234T) this was used in 23 (92%) patients patients, with No 1 Prolene (Ethicon W8450) used in the remaining two patients. Care was taken to ensure that the resultant large knot would have been well buried within the two repaired ends.

The number of outpatient visits varied from four to five (average 4.4). At the time of discharge from hospital after the operation, 23 patients were given an appointment for review 10-14 days postoperatively (OPD1). In the remaining two patients (inpatient stays of 10 and 25 days), OPD1 was carried out as inpatients. At OPD1, a window was cut in the plaster cast overlying the wound, the wound inspected, and skin sutures removed. Patients were then asked to remain non-weight bearing with the use of crutches. At OPD2 (four weeks postoperatively), the plaster of Paris cast was removed, the wound again inspected, and a synthetic belowknee cast was applied, with the ankle 15° short of neutral. The heel area of the new cast was built-up to allow the patient to progress to partial and then full weight-bearing.

At OPD3 (six weeks postoperatively), the cast was removed, and the patient referred to physiotherapy for active mobilisation, using a 1.5cm heel raise within a shoe. At OPD4 (10 or 12 weeks postoperatively), patients were assessed as to whether function had recovered sufficiently to return to activities of normal daily living, without walking aids. If this was the case, patients were discharged to the care of their own general practitioners. If not, further follow-ups at 14 weeks (OPD5) and 18 weeks (OPD6) were arranged, respectively.

The repair was then “smoothed off” using circumferential interrupted 4/0 PDS (Ethicon W1932T) sutures with buried knots, the bites taking on the in situ Bunnell suture.

The soundness of the repair was then assessed by gently dorsiflexing the ankle; if any “give” was noted, this area was buttressed with more 4/0 PDS sutures. With the ankle in a neutral position, the paratenon was left open, subcutaneous tissue repaired with interrupted fine catgut and skin repaired using interrupted vertical mattress sutures of 3/0 Prolene (Ethicon W8021T).

The skin wound was dressed with gauze, sterile plaster wool (Velband) was applied, followed by a below-knee plaster of Paris cast with the ankle in natural plantar-flexion. The tourniquet was then released.

Postoperatively, the injured leg was elevated on a Braun frame until discharge. No cast had to be removed, split or bivalved. When the cast had dried, patients were encouraged to mobilise non-weight bearing with the use of crutches, under the direction of a physiotherapist. Once patients were comfortable and proficient with crutches, they were discharged, social factors permitting.

Patients rated the outcome of treatment as excellent if there was no pain, they were satisfied with a full return to their pre-injury status without any significant symptoms. A good result consisted of a full return to their activities, with only intermittent or mild discomfort. Patients with a satisfactory result had discomfort that did not allow return to pre-injury level. Patients were able to undertake their pre-injury work and leisure activities, but train at a reduced intensity than before the injury. Patients with a poor result had given up their pre-injury work and leisure activities, and had discomfort in activities of daily living.

In March 2000, a letter was written to all 25 patients inviting them to attend the hospital to complete a patient satisfaction questionnaire, undergo assessment of function by a physiotherapist, undergo an ultrasound scan of both the repaired and the contralateral Achilles tendon and have the scar photographed.

A fully trained physiotherapist (JS) assessed the 22 patients who attended the hospital for the long-term follow-up. The following variables were measured: range of ankle dorsiflexion, calf girth, functional plantarflexion strength, including the ability to walk on tiptoes, bilateral and unilateral heel raise, two footed spring, ability to land on toes from a six inch step, ability to hop on toes and time balancing on one leg. The patients’ gait was also visually assessed.

This was performed bilaterally on 21 patients by a single examiner (A MacG) using a Hitachi EUB 555 ultrasound machine equipped with a 7.5 Megahertz linear array footprint transducer. All subjects were scanned in the prone position with their feet hanging over the edge of the examination couch.¹⁵ The ankles were held in the relaxed neutral position. No stand off medium was required. The Achilles tendons were examined in the longitudinal and transverse planes, special care being taken in placing the transducer to ensure that the ultrasound beam was perpendicular to the tendon to avoid anisotropy.

We assessed the following variables: widest tendon diameters [transverse and antero-posterior (AP)], gliding, the presence of attenuation, gap or suture material at repair site, and intratendinous ultrasonographic appearance.

RESULTS

Co-morbidity: Nineteen patients (76%) had no significant comorbidity. Of the remaining six, two had mild hypertension, one chronic obstructive pulmonary disease, one ischaemic heart disease, one rheumatoid arthritis, one was obese, one was on long-term oral corticosteroids, one was hypothyroid and one had a lymphoma.

Postoperative complications: Twenty-three patients made an uncomplicated recovery. Two patients were slow to mobilise owing to pre-morbid conditions such as arthritis. No patient had a postoperative deep vein thrombosis.

All patients were discharged within 18 weeks of the operation, and none were referred back to hospital care by their family practitioner. At no time did any patient show evidence of sural nerve dysfunction. Of the 25 patients operated, 22 attended the hospital, and three (two of whom had emigrated) returned the information by post.

In the seven patients reporting pain or discomfort, the symptoms were mild and occurred in cold weather in three and after vigorous activity in the remaining four patients: no patient reported constant pain/discomfort. Fourteen patients did not report any reduction in muscle strength, localised swelling, stiffness/reduction in movement or cramps. Four individuals reported reduced muscle strength, six some peritendinous swelling, and seven some stiffness and reduction in range of motion of the ankle. Only four (16%) patients expressed concern about re-rupturing the repaired tendon, but nine (36%) were worried about rupturing the uninjured tendon, although none reported any pain or discomfort in the non-ruptured tendon.

Fifteen (60%) patients returned to manual work, six (24%) patients had sedentary occupations, and the remaining four (16%) were retired or unemployed. Manual workers’ average return to work time was 11.1 weeks (range 8 to 24 weeks) after surgery, but sedentary workers returned to work 2.5 weeks (range one to six weeks) after the operation. No patients changed their occupation as a result of their injury.

Although none of the patients was a competitive athlete, most (88%) enjoyed sports and physical activities, with 52% of all patients reporting more than three sports interests at recreational levels. Of the 22 patients with a sporting interest, 20 reported that their level of sporting participation had returned to pre-injury levels.

All but one were satisfied with the appearance of the scar. Three patients reported that the scar was irritated by tight footwear, and two that the scar itched occasionally. Two patients reported some numbness and one some paraesthesiae in the area of the sural nerve distribution.

Only three of 22 patients had regained the same calf girth bilaterally, regardless of the length of time since injury and “footedness” of the patient. Circumference losses ranged from 1% to 8% (average 4%), compared with the non-injured side. Where the circumference of the ankle was measured just above the malleoli, 14 of 22 (63%) injured limbs had increased in circumference (range 1% - 5%, average 4%), probably owing to the contribution made by increased (repaired) tendon diameter.

Oxford grading: Eighteen of 22 patients had normal and equal scores for strength of the gastrocnemius/soleus unit on both sides. In four patients, a score of 4+ was recorded for the injured side, 5 for the uninjured side. These latter patients all reported some weakness on their questionnaire and all showed reductions in mid-calf girths. None, however, showed increased ranges of dorsiflexion, suggesting that the small reductions in weakness recorded was not due to laxity at the site of repair.

Ability to walk on tiptoes: With one exception, all patients were able to do this.

Unilateral heel raise: Eighteen of 22 patients were able to perform this test successfully on the operated side, and 21 of the 22 on uninjured sides.

Two footed spring: All of the 20 patients tested in this fashion were able to perform this test successfully. Two elderly patients were not administered this test.

Land on toes from a 6 inch step: This was achieved by 19 of 20 patients. One patient felt too apprehensive to try, and the test was not attempted on two elderly subjects.

Hop on toes (one side at time): Nineteen of 20 patients were able to complete this test successfully on the injured sides, and 20 of 20 patients on the uninjured sides. Again, we did not administer the test on two elderly subjects.

Balance time on one leg (up to 20 sec.): This was found to be equal on both sides in 14 of 22 patients. Three patients had a better result on the injured side, and three patients had decreased times; in either case only a matter of a few seconds.

Twenty of 22 patients walked without a limp. One patient had a limp because he was recovering from a recent two stage revision bilateral hip replacement. One patient’s gait was slow, unsteady and wide-based. No patient used a heel raise.

High resolution real time ultrasound assessment (HRRTUS) (Table 2 and Table 5)

Widest tendon diameters: The transverse/AP ratio in the uninjured tendons was 1.6, suggesting an oval crosssectional shape. As the transverse/AP ratio was 1.22, the repaired tendons showed a more “circular” cross sectional shape than uninjured tendons. We did not find evidence of any statistically significant association between tendon diameter and length of time between repair examination.

Gliding: All tendons (repaired or contralateral) showed good movement of the tendon alone, with no combined movement of tendon with surrounding soft tissue.16

Attenuation, gap or suture material at repair site: No tendon was attenuated or exhibited a discernible gap at the repair site. There was no ultrasonographic evidence of suture material.17

Intratendinous ultrasonographic appearance: Hypoechogenic areas were detected in 17 of 21 (81%) repaired tendons and in two uninjured tendons (Figure 2). Hyperechogenic areas were nearly as common, occurring in 16 of 21 (76%) repaired tendons, often in association with hypoechogenic changes. Hyperechogenic areas were detected in two uninjured tendons, both in males aged 71 and 80, respectively, who sustained their ruptures whilst “walking along” (Figure 3).

Figure 1: Transverse ultrasound scan showing the increased size of the repaired tendon (left side of the figure: antero-posterior diameter: 7.1mm; transverse diameter: 13.5mm), when compared with the uninjured tendon (right side of the figure: antero-posterior diameter: 4.6 mm; transverse diameter: 8.8mm)

Figure 2: Transverse ultrasound scan showing hypoechogenic area (triangle) in a tendon repaired 4.5 years previously. The scan shows the same tendon at 2cm (left side of the figure) and at 4cm (right side of the figure) from the calcaneal insertion. The patient was asymptomatic and the hypoechogenic area was confined to the medial one sixth to one fifth of the tendon for two thirds of its length

Figure 3: Longitudinal (left side of the figure) and transverse (right side of the figure) ultrasound scan showing a well defined hyperechogenic area (arrow) in the transverse scan in a tendon repaired seven years previously

DISCUSSION

The many techniques and procedures described for the management of an acutely ruptured Achilles tendon can be grouped under three headings: open operative, percutaneous operative, and non-operative. There is no agreed protocol, and the choice of management regimen still lies largely with the preference of the surgeon and the patient. Surgery has been the method of choice in the last two decades in athletes and young people and in cases of delayed ruptures.³ However, conservative management has its advocates and, in the right patients, conservative management with functional treatment has produced excellent results.¹⁸

Our patients elected to be treated operatively, although we were careful in explaining the benefits of conservative management. The modalities of the treatment reported in this study are fairly typical and apply basic surgical principles. Also, the main author does not rely on the strength of the suture or on early mobilisation for postoperative rehabilitation. Nevertheless, the long-term outcomes of surgery reported in the present article are comparable with those from much bigger centres where specialist surgeons undertake the operative repair of a ruptured Achilles tendon. Many operative techniques have been employed to repair ruptured Achilles tendons, ranging from simple end-to-end suturing by Bunnell or Kessler-type of sutures, to more complex repairs using fascial reinforcement or tendon grafts.¹⁹ Arner and Lindholm reported a 24.4% complication rate in a series of 86 operative repairs of Achilles tendon ruptures.¹¹ More recently, Soldatis et al reported only two complications, both delayed wound healing, in 23 operatively treated patients.²⁰ The explanation for this low complication rate may be greater operative experience combined with improved technique. However, wound problems should not be unexpected when open repair is used, as the most commonly used longitudinal incision passes through poorly vascularised skin.²¹ To prevent these, Aldham advocated a transverse incision just distal to the gap in the tendon.²²

Several authors propose primary augmentation of the repair with the plantaris tendon, the peroneus tendon or gastrocnemius fascial turndown flaps.^23-25 However, there is no evidence that in acute Achilles tendon rupture augmentations fare any better than a non-augmented endtoend repair.²⁶ Our results bear witness to the fact that endtoend repair is perfectly acceptable, at least in patients in whom the tendon ends can be juxtaposed. There has been a recent tendency towards using stronger suture material.²⁷ However, the majority of surgeons still use simple endtoend sutures and the present study confirms that, following appropriate immobilisation, this technique is adequate.⁵ Also, although one of the authors (NM) advocates two weeks of immobilisation in a synthetic cast with the ankle in gravity equinus, followed by four weeks in a front slab allowing free plantarflexion of the ankle but limiting dorsiflexion to neutral (with weight bearing as able as soon as possible after the operation) the long-term results of the more traditional postoperative regimen adopted by the main author in this study justify its continued use.

Given the isolation of the setting where the main author practices, and the population living there, it is not practical either to have an orthopaedic surgeon to undertake routine musculo-skeletal procedures or to transfer ATR patients to the teaching centre. The incidence of ATR in Scotland is 6 per 100,000 people per year.¹ The population of the Shetland Islands has been stable at 23,000 over the course of the 10 years of this study, and all diagnosed ATRs are treated by the main author. The incidence of such injuries, therefore, has remained constant at just above 10 per 100,000 people per year.

Given the relatively small number of patients, we did not analyse the data collected according to the time at presentation after the injury. It appears that both the early and the delayed repairs fared well, and that the long-term outcome following operative repair of ATRs is favourable, although it should be acknowledged that we did not deal with very long standing neglected ruptures. Also, these patients had a greater rate of complications than patients treated early with simple end-to-end suture, probably reflecting the technically more complicated surgery necessary in these cases. The lateral approach to the Achilles tendon has been associated with iatrogenic sural nerve lesions.²⁸ Although paraesthesiae were reported by some of our patients, this happened only when the patients were specifically questioned. The parasthesiae did not interfere with the activities of daily living, and were not perceived by the patients as limiting the success of the operation.

We have shown that, after surgical repair, the operated tendon remains significantly thicker than the contralateral. This seems to be a constant feature following ATR treatment and should not cause concern to the patient and the surgeon.¹⁷ Some authors have identified, using HRRTUS, significant intratendinous alterations, considered to be microtears, in a high proportion of athletes with Achilles tendinopathy and partial tendon rupture.²⁹ Of the tendons with chronic tendinopathy, 13% had more than three microtears, with an increase to 87% in partial ruptures. The authors proposed an association between microtear formation and ATR. Similar areas of intratendinous altered echogenicity have been identified in the normal tendon in ATR patients and in the asymptomatic side in patellar tendinopathy patients.^30,31 In the present study, we identified areas of abnormal ultrasonographic appearance in most of the operated tendons and in two of the normal asymptomatic contralateral ones. Karjalainen et al (1996,1997) reported intratendinous areas of altered MRI signal in a variable proportion of their patients.^32,33 They found that this signal was correlated, in the short-term, with a poor outcome. In our patients, we do not know how long these areas of altered signal had been present. However, all patients had a good clinical result even in the early postoperative period. In the absence of clinical symptoms, these areas should be regarded as non-pathological and should be ignored.³⁴ It would be interesting to know the histological appearance of these foci but, as no patient required re-operation, it was not ethically justifiable to biopsy these areas.

The major strengths of this study are that all patients were operated on by a single surgeon using the same technique, postoperative management was uniform throughout the study and the operating surgeon was not involved in the final assessment of the patients. Between direct examination and postal communication, we achieved a 100% follow-up rate. There are, however, limitations of the present study. Although the patients were initially followed-up prospectively, this is not a longitudinal study. We acknowledge that the evidence given for assessing post-surgical outcomes would not be as strong as that produced by a randomised controlled trial. However, despite these limitations, the findings can be valuable for the formulation of hypotheses for future prospective randomised trials.

In conclusion, we have shown that, following a subcutaneous Achilles tendon rupture presenting up to 18 weeks from the injury, simple end-to-end suture through a lateral approach with postoperative below knee cast immobilisation for six weeks is a safe technique. In the hands of a single nonspecialist but fully trained general surgeon, this management regimen produces acceptable long-term results, with full return to pre-operative activities in the majority of patients, and a low rate of local complications. The macroscopic and ultrasonographic appearance of the operated tendon remains abnormal, but this is not associated with clinically relevant disturbances.

ACKNOWLEDGEMENTS

Many thanks are given to Sister Jennifer Johnson, Miss Amanda Sinclair, and Miss Linda Lothian for their help in the preparation of this article.

REFERENCES

1. Maffulli N, Waterston SW et al. Changing incidence of Achilles tendon rupture in Scotland: a 15-year study. Clin J Sport Med 1999; 9: 157-60
2. Maffulli N. Clinical tests in sports medicine: more on Achilles tendon. Br J Sports Med 1996; 30: 250
3. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999; 81-A: 1019-36
4. Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med 1998; 26: 266-70
5. Lo IK, Kirkley A et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review. Clin J Sport Med 1997; 7: 207-11
6. Stein SR, Luekens CA Jnr. Closed treatment of Achilles tendon ruptures. Orthop Clin N Am 1976; 7: 241-46
7. Carden DG, Noble J et al. Rupture of the calcaneal tendon. The early and late management. J Bone Joint Surg Br 1987; 69-B: 416-20
8. Gillies H, Chalmers J. The management of fresh ruptures of the tendo Achilles. J Bone Joint Surg Am 1970; 52-A: 337-43
9. Lea RB, Smith L. Non-surgical treatment of tendo Achilles rupture. J Bone Joint Surg Am 1972; 54-A: 1398-407
10. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. A prospective randomised study. J Bone Joint Surg Am 1981; 63-A: 394-99
11. Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon. A study of 92 cases. Acta Chir Scand, Supplementum 239, 1959
12. Wong J, Barrass V, Maffulli N, Quantitative review of operative and nonoperative management of achilles tendon ruptures. Am J Sports Med 2002; 30: 565-75
13. Simmonds FA. The diagnosis of the ruptured Achilles tendon. The Practitioner 1957; 179: 56-58
14. Pintore E, Barra V, Pintore R, Maffulli N. Peroneus brevis tendon transfer in neglected tears of the Achilles tendon. J Trauma 2001; 50: 71-78
15. Maffulli N, Regine R et al. Ultrasound diagnosis of Achilles tendon pathology in runners. Br J Sports Med 1987; 21: 158-62
16. Rupp S, Tempelhof S, Fritsch E. Ultrasound of the Achilles tendon after surgical repair: morphology and function. Br J Radiol 1995; 68: 454-58
17. Maffulli N, Dymond NP et al. Surgical repair of ruptured Achilles tendon in sportsmen and sedentary patients: a longitudinal ultrasound assessment. Int J Sports Med 1990; 11: 78-84
18. Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon. A prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br 1992; 74: 206-9
19. DiStefano VJ, Nixon JE. Achilles tendon rupture: pathogenesis, diagnosis and treatment by a modified pullout wire technique. J Trauma 1972; 12: 671-77
20. Soldatis JJ, Goodfellow DB et al. End-to-end operative repair of Achilles tendon rupture. Am J Sports Med 1997; 25: 90-95
21. Haertsch PA. The blood supply to the skin of the leg: a post-mortem investigation. Br J Plastic Surg 1981; 34: 470-77
22. Aldham CH. Repair of calcaneal tendon ruptures. A safe technique. J Bone Joint Surg Br 1989; 71: 486-88
23. Lynn TA. Repair of the torn Achilles tendon, using the plantaris tendon as a reinforcing membrane. J Bone Joint Surg Am 1966; 48-A: 268-72
24. Perez-Teuffer A. Traumatic rupture of the Achilles tendon. Reconstruction by transplant and graft using the lateral peroneus brevis. Orthop Clin North Am 1974; 5: 89-93
25. Lindholm AB. A new method of operation in subcutaneous rupture of the Achilles tendon. Acta Chir Scand 1959; 117: 261-64
26. Jessing P, Hansen E. Surgical treatment of 102 tendo achillis ruptures: suture or tenontoplasty? Acta Chir Scand 1975; 141: 370-77
27. Mandelbaum BR, Myerson MS et al. Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med 1995; 23: 392-95
28. Lawrence SJ, Botte MJ. The sural nerve in the foot and ankle: an anatomic study with clinical and surgical implications. Foot Ankle Int 1994; 15: 490-92
29. Gibbon WW, Cooper JR et al. Sonographic incidence of tendon microtears in athletes with chronic Achilles tendinosis. Br J Sports Med 1999; 33: 129-30
30. Gibson W. Are ‘spontaneous’ Achilles tendon rupture truly spontaneous? Br J Sports Med 1998; 32: 266
31. Cook JL, Khan KM, et al. Patellar tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Victorian Institute of Sport Tendon Study Group. Clin J Sport Med 1988; 8: 73-77
32. Karjalainen PT, Ahovuo J et al. Postoperative MR imaging and ultrasonography of surgically repaired Achilles tendon ruptures. Acta Radiol 1996; 37: 639-46
33. Karjalainen PT, Aronen HJ et al. Magnetic resonance imaging during healing of surgically repaired Achilles tendon ruptures. Am J Sports Med 1997; 25: 164-71
34. Khan KM, Tress BW et al. Treat the patient, not the Xray: advances in diagnostic imaging do not replace the need for clinical interpretation. Clin J Sport Med 1998; 8: 1-4

Correspondence: Professor N. Maffulli, Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, North Staffordshire Hospital, Thornburrow Drive, Hartshill, Stoke on Trent, Staffordshire, ST4 7QB

Age at Injury	47.9 (22-77)
Mechanism of injury	Badminton (8) Soccer (4) Scottish dancing (2) Netball (1) Pushing a car (1) Fall (5) Walking (4)
Duration of follow-up	3.4 years (6 months - 9.25 years)
Inpatient stay (days)	3.6 (1-25)
Timing between injury and presentation (average age)	Within 24 hours: 13 (38.3 years) Between 1 and 14 days: 7 (57 years) Between 4 and 18 weeks: 5 (60.4 years)

Age	Sex	Mechanism of Injury	Time from injury to diagnosis (days)	Time from diagnosis to operation (days)	Time from injury to operation (days)	Length of inpatient stay (days)	Short-term complications	Years from repair to assessment	Patient satisfaction	Long-term complications
67	M	Walking*	42	8	50	2	Nil	9.25	Excellent	Nil
34	M	Badminton	Immediate	1	1	1	Nil	8.75	Excellent	Nil
49	F	Fall down stairs	14	1	15	3	Nil	8.1	Excellent	Nil
40	M	Walking	42	10	52	2	Nil	6.25	Good	Scar irritation with shoes
38	M	Football	1	2	3	2	Nil	6.1	Excellent	Nil
32	F	Fall	7	5	12	3	Nil	4.75	Excellent	Nil
54	M	Fall from height	126	3	129	2	Nil	4.7	Excellent	Nil
48	F	Dancing	Immediate	1	1	1	Nil	3.5	Good	Nil
41	F	Pushing car	1	4	5	3	Nil	3.5	Good	Nil
29	M	Badminton	Immediate	3	3	1	Nil	3.2	Excellent	Nil
50	F	Dancing	9	3	12	2	Nil	3.2	Satisfactory	Paraesthesia in the sural nerve territory
22	F	Badminton	Immediate	1	1	2	Nil	3.1	Excellent	Nil
35	M	Badminton	Immediate	1	1	2	Nil	2.9	Excellent	Nil
46	F	Netball	Immediate	1	1	2	Nil	2.6	Excellent	Nil
42	F	Badminton	14	1	15	2	Nil	2.5	Excellent	Nil
41	M	Football	12	1	2	1	Nil	2.0	Good	Paraesthesia in the sural nerve territory; scar irritation with shoes
68	F	Fall/stumble**	28	4	32	10	Slow to mobilise	1.8	Excellent	Nil
51	F	Badminton	Immediate	6	6	2	Nil	1.6	Excellent	Nil
77	M	Fall/stumble	2	2	4	6	Nil	1.6	Excellent	Nil
44	M	Football	Immediate	1	1	2	Nil	1.3	Excellent	Nil
77	F	Walking	5	2	7	25	Slow to mobilise	1.2	Good	Scar irritation
42	F	Badminton	Immediate	2	2	3	Nil	1.1	Good	Nil
70	M	Badminton	2	2	4	4	Nil	1.1	Excellent	Nil
28	M	Football	Immediate	2	2	2	Nil	1.1	Excellent	Nil
73	M	Walking**	21	7	28	5	Nil	0.05	Excellent	Nil

Time to return to sport (20 patients) (weeks)	16 (6-36)
Dorisflexion: equal	11 of 22 patients
Dorisflexion: increased on the injured side	7 patients (mean 6°, range 2-10°)
Dorisflexion: decreased on the injured side	4 patients (mean 3.5°, range 2-5°)
Antero-posterior diameter at ultrasound uninjured tendon (mm)	6 (3.6 -13.3)
Antero-posterior diameter at ultrasound repaired tendon (mm)	13.8 (7.1-18)
Transverse diameter at ultrasound uninjured tendon (mm)	10 (6.8-20.2)
Transverse diameter at ultrasound repaired tendon (mm)	16.9 (13.5-21.6)
Satisfaction rating	Excellent: 18; Good: 6; Satisfactory: 1

Ruptured	Unruptured	% Increase	Ruptured	Unruptured	% Increase	Free Glide	Attenuation	Ends together?	Suture material	Hypo-echogenic	Hyper-echogenic
10.5mm	9.6mm	9%	14.6mm	14.4mm	^+1.4%	Yes	No	Yes	No	Yes	Yes**
Could	not	attend	for	assessment
9.3mm	7.4mm	25%	17.7mm	11.8mm	50%	Yes	No	Yes	No	Yes	Yes
7.6mm	5.7mm	33%	16.4mm	6.6mm	141%	Yes	No	Yes	No	Yes	Yes
9.1mm	7.0mm	30%	19.2mm	12.0mm	60%	Yes	No	Yes	No	Yes	Yes
7.6mm	5.9mm	28%	13.5mm	8.6mm	57%	Yes	No	Yes	No	Yes	Yes
7.1mm	5.1mm	39%	14.6mm	8.2mm	78%	Yes	No	Yes	No	Yes	Yes
7.1mm	4.6mm	54%	13.5mm	8.8mm	53%	Yes	No	Yes	No	Yes	Yes
7.4mm	4.8mm	54%	21.6mm	10.5mm	105%	Yes	No	Yes	No	No	No
8.2mm	4.4mm	86%	15.5mm	7.7mm	101%	Yes	No	Yes	No	Yes	Yes
9.7mm	3.6mm	170%	18.1mm	7.4mm	144%	Yes	No	Yes	No	Yes	Yes
11.8mm	4.3mm	174%	19.5mm	10.8mm	80%	Yes	No	Yes	No	Yes	Yes
10.3mm	6.0mm	16%	21.2mm	9.6mm	120%	Yes	No	Yes	No	Yes	Yes
9.4mm	4.2mm	123%	16.3mm	7.2mm	126%	Yes	No	Yes	No	Yes	Yes
12.8mm	4.5mm	184%	15.3mm	8.7mm	75%	Yes	No	Yes	No	No	No
7.0mm	6.0mm	16%	17.0mm	7.5mm	126%	Yes	No	Yes	No	Yes	Yes
7.2mm	5.1mm	41%	17.8mm	9.1mm	95%	Yes	No	Yes	No	Yes	Yes
11.0mm	5.8mm	90%	15.6mm	10.8mm	44%	Yes	No	Yes	No	Yes	Yes
9.6mm	6.0mm	60%	15.9mm	9.2mm	73%	Yes	No	Yes	No	No	No
Could	not	attend	for	assessment
8.9mm	5.4mm	64%	18.2mm	9.3mm	95%	Yes	No	Yes	No	No	No
14.7mm	8.1mm	82%	13.9mm	12.0mm	15%	Yes	No	Yes	No	Yes	Yes
17.9mm	13.3mm	35%	22.3mm	12.2mm	10%	Yes	No	Yes	No	Yes	Yes
Could	not	attend	for	assessment

ORIGINAL ARTICLE

Clinical and functional results of open operative repair for Achilles tendon rupture in a non-specialist surgical unit

INTRODUCTION

PATIENTS AND METHODS

RESULTS

DISCUSSION

ACKNOWLEDGEMENTS

REFERENCES