Surgical treatment of partial Achilles tendon rupture TOR FINN DENSTAD, M.D., AND ASBJØRN ROAAS, M.D., Sandvika, Norway From the Martina Hansens Hospital, 1300 Sandvika, Norway
ABSTRACT
Although complete partial
ruptures of the Achilles tendon are well ruptures of this tendon formerly were regarded
known,
lesions. Since Ljunqvistl discussed 24 patients with tendon ruptures, this condition is well known Achilles partial in the Scandinavian countries. Isotopic and angiographic studies have shown that the vascularity of the Achilles tendon is reduced 2 to 6 cm above its insertion.2,prolonged and extreme loads placed upon the tendon can give microtraumas which cause localized tendinitis. This further reduces the vascularity of that part of the tendon, and structural degenerative changes may arise. The heavy training load seen in today’s top athletes, particularly among middle and long distance runners who cover more than 200 km per week, often on hard road surface, seems to lie close to the load that the tendon can tolerate. Although the complete ruptures are seen most often in middle-aged persons after a sudden jump or push-off, the partial ruptures occur in 20- to 30-year-old individuals who have reached their highest level of as rare
performance. The symptoms are first likely to appear when training is intensified, for instance, when shifting from cross-country
skiing ankle
to track as the season
joint
or
on symptoms. Local injections of steroid or anesthetics may reduce symptoms, but if the training load is not reduced simultaneously, complete tendon rupture may occur. It is doubtful that these methods of treatment give rise to partial ruptures. High dosage steroid therapy may be an underlying
bring
Fifty-four patients with a total of 58 partial ruptures of the Achilles tendon were treated surgically. The postoperative observation time ranged from 8 months to 7 years. Forty-six patients indicated that they were pleased with the results, 8 were satisfied, and 3 were unsatisfied (one died during the interim). Thirty-seven of the 44 patients who had been engaged in competitive sports preoperatively were able to return successfully to the activity. We recommend surgical treatment if conservative treatment for presumed tendinitis is not successful. The operative procedure may encourage revascularization to the Achilles tendon and innervation after surgical excision of the pathologic and degenerated tissue.
slip
begins.
of the foot when
Sudden
taking
push-offs a
stride
in the also
can
cause.
The purpose of this paper is to describe partial ruptures of the Achilles tendon and the results of the surgical treatment of a group of 54 patients, 44 of whom engaged in competitive
sports. MATERIALS AND METHODS At Martina Hansens Hospital, from 1970 to 1976, 58 partial Achilles tendon ruptures were operated upon in 54 patients (46 males and 8 females). The postoperative observation time ranged from 8 months to 7 years. All patients, except one who died during the interim, answered a questionnaire. Most of the patients were between 20 and 40 years old (Table 1). Fortyfour patients were engaged in competitive sports. All patients got pain in the tendon when approaching strenuous exercise. In 36 patients the pain came on gradually, in 16 patients it came on immediately as training was increased, and 6 patients had had a direct blow against the tendon. Pain had lasted from l U2 months to 8 years preoperatively (mean 2 years). Most of the patients had preoperatively used a heel inlay for a period of time. Different methods of treatment had been tried without
improvement (Table 2). At the preoperative examination, localized found in 56 tendons, localized swelling in 53,
tenderness was and a localized defect in the tendon in 2 of the 58 tendons operated on. Atrophy and diminished force in the calf muscles were common signs. Lateral view soft tissue roentgenograms showed localized swelling in 48 of 58 tendons that we examined. The operation was performed in a bloodless field. The tendon was examined and split, central parts inspected, and pathologic tissue excised. Usually the defect was closed side to side by fine sutures and exercises were started immediately, beginning with careful stretching and then increasing to active weight-loading exercises. In a few patients, the defect after 15
TABLE I
Age
distribution of 58
partial Achilles ruptures treated by surgery
DISCUSSION
TABLE2 Treatment
given to 58 partial Achilles ruptures
before admission
to
surgery
was considerable and a modified Lindholm4 repair performed by using one flap only to cover the defect. In these few cases, a plaster cast was applied for 6 weeks.
excision was
RESULTS
During the operations, partial ruptures were found in 49 tendons, peritendinitis in 6 tendons, and 3 tendons were macroscopically normal. Tissue from 44 tendons was examined microscopically ; only 2 had no pathologic changes. In recent ruptures, the findings were devitalized tendon tissue, necrosis, hemorrhage, granulation tissue, and leukocytes. In older ruptures, scar tissue was found and staining methods for hemosiderin showed positive indications, i.e., consistent with old hemorrhage. Frequently, recent and older changes were seen in the same tendon. Only one patient got wound infection and needed antibiotic therapy; no other complications were recorded. The mean hospitalization time was 13 days, including postoperative physical therapy. Three patients required additional surgery. One had an additional procedure 2 months after the initial operation and again 2 years later. On both occasions, fibrous and fibrinous adhesions and abundant granulation tissue were found and excised. He has had no further indications of lesions. The second patient started regular heavy training too early, and not according to instructions. At reoperation, 4 months later, old hematoma, granulation tissue, and necrotic tissue were excised. Since then he has had complete recovery. The third patient was free of symptoms for 1 Yz years after the first operation but then developed symptoms at a new site in the tendon. He had a second operation at another hospital and a new partial rupture was found. After excision and physical therapy, he has done well and been in full training. On the follow-up questionnaire, 46 patients were pleased, 8 were satisfied, and 3 were unsatisfied. A 16-year-old girl was unsatisfied because of the appearance of the scar, otherwise she
symptom free. Another was unsatisfied because he was still not back in regular training, but he had had his operation only 8 months before the questionnaire was sent to him. (Our
was
16
experience is that up to 1 year can pass postoperatively until complete restitution is seen.) The third unsatisfied patient was the one who was re-operated upon at another hospital. All of the 44 patients who were engaged in competitive sports preoperatively started up again with their activities and 37 bettered or equaled their prior performance. Of those who did not succeed as well as before the repair of the tendon, only 2 patients blamed the operated tendon. load required of top athletes today, expect a rather high frequency of partial Achilles tendon ruptures. Our material shows a greater number of males than females, but the frequency will probably also increase in With the
heavy training
one must
females in the future because of their increasing participation in sports. Partial Achilles tendon ruptures are most frequently seen in young fully grown persons. A common symptom is sharp stabbing pain in the tendon on weight bearing, which may arise gradually or suddenly when the training is increased. Direct trauma against the tendon only seldom causes partial ruptures. The most common signs are localized swelling and tenderness. Roentgenographic examination may be valuable as a diagnostic aid, but the films must be taken so that the soft tissue shadows are clearly seen. Ljunqvist’ has stressed the importance of electrophysiologic studies, but we do not think such studies are necessary. The treatment of partial ruptures should be surgical, with excision of granulation tissue and devitalized tendon tissue. If indicated, the defect should be closed with a modified Lindholm repair. Careful progressive training postoperatively is important to obtain good results with surgical treatment. We have not seen many complications or serious ones.
Conservative treatment is recommended if there is doubt in
dealing with tendinitis or partial rupture of the Achilles tendon. When training is resumed after therapy, it must be begun gradually. Most of the recurrences after conservative therapy are a result of sportsmen returning to normal training too quickly. Training on hard road surface should be avoided because this predisposes recurrence. If conservative treatment of a presumed tendinitis is not successful, we recommend surgical treatment; frequently an exploration will reveal a partial rupture. During the last few years, we have given surgical treatment to a number of physically active patients suffering from partial Achilles tendon ruptures. The results after surgery seem satisfactory, even in those cases where the clinical, preoperative, and microscopic fmdings were only suggestive of a rupture. The explanation for this may be that surgical exploration when the tendon is split may change its vascular pattern and innervation.
REFERENCES 1.
Ljunqvist R: Subcutaneous partial rupture of the achilles tendon. Orthop Scand Suppl 113: 1-86, 1968 Lagergren C, Lindholm A: Vascular distribution in the achilles tendon, an angiographic and microangiographic study. Acta Chir
Acta 2.
Scand 116: 491-495, 1958/1959 3. Håstad K, Larsson L-G, Lindholm
Å:
Clearance of radiosodium
after local
deposit
in the achilles tendon. Acta Chir Scand 116:
251-255,1958/1959 4. Lindholm Å: A new method of operation in subcutaneous rupture of the achilles tendon. Acta Chir Scand 117: 261-270, 1959
EDITORIAL COMMENT Dr. Gian Carlo Puddu, Rome Italy: This paper deals with one of the most frequent problems we have in sports medicine. The authors are to be complimented for this presentation of a large series of partial Achilles rupture. Of our group’s experience the defect in the tendon tissue is due either to a peritendinitis with tendinosis, or to a pure tendinosis. Since the pure tendinosis is often asymptomatic, we
think that the cases presented by the authors are mostly peritendinitis with tendinosis. We agree with the surgical excision of the pathologic and degenerated tissue, but we also believe in the importance of multiple longitudinal incisions to encourage the revascularization of the tendon tissue. It is a pleasure to know that the authors with such a large series have brought a further demonstration of the importance of early surgery to stop the evolution of the Achilles tendon
disease.
Finally, the authors showed us satisfying results, thus allowing a certain optimism in treating this frequent pathology.
17
ABSTRACT
Although complete partial
ruptures of the Achilles tendon are well ruptures of this tendon formerly were regarded
known,
lesions. Since Ljunqvistl discussed 24 patients with tendon ruptures, this condition is well known Achilles partial in the Scandinavian countries. Isotopic and angiographic studies have shown that the vascularity of the Achilles tendon is reduced 2 to 6 cm above its insertion.2,prolonged and extreme loads placed upon the tendon can give microtraumas which cause localized tendinitis. This further reduces the vascularity of that part of the tendon, and structural degenerative changes may arise. The heavy training load seen in today’s top athletes, particularly among middle and long distance runners who cover more than 200 km per week, often on hard road surface, seems to lie close to the load that the tendon can tolerate. Although the complete ruptures are seen most often in middle-aged persons after a sudden jump or push-off, the partial ruptures occur in 20- to 30-year-old individuals who have reached their highest level of as rare
performance. The symptoms are first likely to appear when training is intensified, for instance, when shifting from cross-country
skiing ankle
to track as the season
joint
or
on symptoms. Local injections of steroid or anesthetics may reduce symptoms, but if the training load is not reduced simultaneously, complete tendon rupture may occur. It is doubtful that these methods of treatment give rise to partial ruptures. High dosage steroid therapy may be an underlying
bring
Fifty-four patients with a total of 58 partial ruptures of the Achilles tendon were treated surgically. The postoperative observation time ranged from 8 months to 7 years. Forty-six patients indicated that they were pleased with the results, 8 were satisfied, and 3 were unsatisfied (one died during the interim). Thirty-seven of the 44 patients who had been engaged in competitive sports preoperatively were able to return successfully to the activity. We recommend surgical treatment if conservative treatment for presumed tendinitis is not successful. The operative procedure may encourage revascularization to the Achilles tendon and innervation after surgical excision of the pathologic and degenerated tissue.
slip
begins.
of the foot when
Sudden
taking
push-offs a
stride
in the also
can
cause.
The purpose of this paper is to describe partial ruptures of the Achilles tendon and the results of the surgical treatment of a group of 54 patients, 44 of whom engaged in competitive
sports. MATERIALS AND METHODS At Martina Hansens Hospital, from 1970 to 1976, 58 partial Achilles tendon ruptures were operated upon in 54 patients (46 males and 8 females). The postoperative observation time ranged from 8 months to 7 years. All patients, except one who died during the interim, answered a questionnaire. Most of the patients were between 20 and 40 years old (Table 1). Fortyfour patients were engaged in competitive sports. All patients got pain in the tendon when approaching strenuous exercise. In 36 patients the pain came on gradually, in 16 patients it came on immediately as training was increased, and 6 patients had had a direct blow against the tendon. Pain had lasted from l U2 months to 8 years preoperatively (mean 2 years). Most of the patients had preoperatively used a heel inlay for a period of time. Different methods of treatment had been tried without
improvement (Table 2). At the preoperative examination, localized found in 56 tendons, localized swelling in 53,
tenderness was and a localized defect in the tendon in 2 of the 58 tendons operated on. Atrophy and diminished force in the calf muscles were common signs. Lateral view soft tissue roentgenograms showed localized swelling in 48 of 58 tendons that we examined. The operation was performed in a bloodless field. The tendon was examined and split, central parts inspected, and pathologic tissue excised. Usually the defect was closed side to side by fine sutures and exercises were started immediately, beginning with careful stretching and then increasing to active weight-loading exercises. In a few patients, the defect after 15
TABLE I
Age
distribution of 58
partial Achilles ruptures treated by surgery
DISCUSSION
TABLE2 Treatment
given to 58 partial Achilles ruptures
before admission
to
surgery
was considerable and a modified Lindholm4 repair performed by using one flap only to cover the defect. In these few cases, a plaster cast was applied for 6 weeks.
excision was
RESULTS
During the operations, partial ruptures were found in 49 tendons, peritendinitis in 6 tendons, and 3 tendons were macroscopically normal. Tissue from 44 tendons was examined microscopically ; only 2 had no pathologic changes. In recent ruptures, the findings were devitalized tendon tissue, necrosis, hemorrhage, granulation tissue, and leukocytes. In older ruptures, scar tissue was found and staining methods for hemosiderin showed positive indications, i.e., consistent with old hemorrhage. Frequently, recent and older changes were seen in the same tendon. Only one patient got wound infection and needed antibiotic therapy; no other complications were recorded. The mean hospitalization time was 13 days, including postoperative physical therapy. Three patients required additional surgery. One had an additional procedure 2 months after the initial operation and again 2 years later. On both occasions, fibrous and fibrinous adhesions and abundant granulation tissue were found and excised. He has had no further indications of lesions. The second patient started regular heavy training too early, and not according to instructions. At reoperation, 4 months later, old hematoma, granulation tissue, and necrotic tissue were excised. Since then he has had complete recovery. The third patient was free of symptoms for 1 Yz years after the first operation but then developed symptoms at a new site in the tendon. He had a second operation at another hospital and a new partial rupture was found. After excision and physical therapy, he has done well and been in full training. On the follow-up questionnaire, 46 patients were pleased, 8 were satisfied, and 3 were unsatisfied. A 16-year-old girl was unsatisfied because of the appearance of the scar, otherwise she
symptom free. Another was unsatisfied because he was still not back in regular training, but he had had his operation only 8 months before the questionnaire was sent to him. (Our
was
16
experience is that up to 1 year can pass postoperatively until complete restitution is seen.) The third unsatisfied patient was the one who was re-operated upon at another hospital. All of the 44 patients who were engaged in competitive sports preoperatively started up again with their activities and 37 bettered or equaled their prior performance. Of those who did not succeed as well as before the repair of the tendon, only 2 patients blamed the operated tendon. load required of top athletes today, expect a rather high frequency of partial Achilles tendon ruptures. Our material shows a greater number of males than females, but the frequency will probably also increase in With the
heavy training
one must
females in the future because of their increasing participation in sports. Partial Achilles tendon ruptures are most frequently seen in young fully grown persons. A common symptom is sharp stabbing pain in the tendon on weight bearing, which may arise gradually or suddenly when the training is increased. Direct trauma against the tendon only seldom causes partial ruptures. The most common signs are localized swelling and tenderness. Roentgenographic examination may be valuable as a diagnostic aid, but the films must be taken so that the soft tissue shadows are clearly seen. Ljunqvist’ has stressed the importance of electrophysiologic studies, but we do not think such studies are necessary. The treatment of partial ruptures should be surgical, with excision of granulation tissue and devitalized tendon tissue. If indicated, the defect should be closed with a modified Lindholm repair. Careful progressive training postoperatively is important to obtain good results with surgical treatment. We have not seen many complications or serious ones.
Conservative treatment is recommended if there is doubt in
dealing with tendinitis or partial rupture of the Achilles tendon. When training is resumed after therapy, it must be begun gradually. Most of the recurrences after conservative therapy are a result of sportsmen returning to normal training too quickly. Training on hard road surface should be avoided because this predisposes recurrence. If conservative treatment of a presumed tendinitis is not successful, we recommend surgical treatment; frequently an exploration will reveal a partial rupture. During the last few years, we have given surgical treatment to a number of physically active patients suffering from partial Achilles tendon ruptures. The results after surgery seem satisfactory, even in those cases where the clinical, preoperative, and microscopic fmdings were only suggestive of a rupture. The explanation for this may be that surgical exploration when the tendon is split may change its vascular pattern and innervation.
REFERENCES 1.
Ljunqvist R: Subcutaneous partial rupture of the achilles tendon. Orthop Scand Suppl 113: 1-86, 1968 Lagergren C, Lindholm A: Vascular distribution in the achilles tendon, an angiographic and microangiographic study. Acta Chir
Acta 2.
Scand 116: 491-495, 1958/1959 3. Håstad K, Larsson L-G, Lindholm
Å:
Clearance of radiosodium
after local
deposit
in the achilles tendon. Acta Chir Scand 116:
251-255,1958/1959 4. Lindholm Å: A new method of operation in subcutaneous rupture of the achilles tendon. Acta Chir Scand 117: 261-270, 1959
EDITORIAL COMMENT Dr. Gian Carlo Puddu, Rome Italy: This paper deals with one of the most frequent problems we have in sports medicine. The authors are to be complimented for this presentation of a large series of partial Achilles rupture. Of our group’s experience the defect in the tendon tissue is due either to a peritendinitis with tendinosis, or to a pure tendinosis. Since the pure tendinosis is often asymptomatic, we
think that the cases presented by the authors are mostly peritendinitis with tendinosis. We agree with the surgical excision of the pathologic and degenerated tissue, but we also believe in the importance of multiple longitudinal incisions to encourage the revascularization of the tendon tissue. It is a pleasure to know that the authors with such a large series have brought a further demonstration of the importance of early surgery to stop the evolution of the Achilles tendon
disease.
Finally, the authors showed us satisfying results, thus allowing a certain optimism in treating this frequent pathology.
17
