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Review
article
Acute
Achilles
tendon
rupture
treatment:
Where
are
we
now?
Randeep
Aujla*,
Sarang
Sapare,
Maneesh
Bhatia
Trauma
&
Orthopaedic
Surgery,
University
Hospitals
of
Leicester,
Leicester,
United
Kingdom
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
30
January
2017
Accepted
15
February
2018
Available
online
21
February
2018
Keywords:
Achilles
tendon
Rehabilitation
Non-surgical
Surgery
Minimally
invasive
A
B
S
T
R
A
C
T
Objective:
Our
objective
was
to
review
the
current
literature
regarding
acute
Achilles
tendon
ruptures
and
provide
a
succinct
summary
of
the
use
of
clinicians
treating
Achilles
tendon
ruptures.
We
aim
to
provide
guidance
for
treatment
based
upon
current
literature.
Methods:
We
reviewed
current
literature
and
subjectively
assessed
for
quality
and
influence
of
studies
in
current
practice.
Review:
The
Achilles
Tendon
Rupture
Score
(ATRS)
has
become
a
vital
tool
in
assessing
functional
outcome
following
interventions
as
re-rupture
rates
have
balanced
out
for
all
treatment
modalities.
There
remains
continued
debate
between
surgical
and
non-surgical
treatment
options.
Both
patterns
have
evolved
over
the
past
decade.
Percutaneous
fixation
techniques
are
superseding
traditional
open
surgery.
Functional
dynamic
non-surgical
regimes
are
also
being
developed
to
create
the
optimum
environment
for
the
Achilles
tendon
to
heal
and
provide
high
functional
outcomes.
There
even
remains
limited
evidence
that
platelet-rich
plasma
aids
healing,
the
significance
of
gap
between
tendon
ends
or
of
thromboprophylaxis
lowering
the
incidence
of
symptomatic
venous
thromboembolism.
Conclusions:
Acute
Achilles
tendon
ruptures
should
either
be
managed
in
a
functional
rehabilitation
regime
or
by
percutaneous
surgical
repair.
The
decision
depends
upon
both
patient
and
clinician
factors.
©
2018
Published
by
Elsevier,
a
division
of
RELX
India,
Pvt.
Ltd
on
behalf
of
International
Society
for
Knowledge
for
Surgeons
on
Arthroscopy
and
Arthroplasty.
Contents
1.
Background
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140
1.1.
Achilles
Tendon
Rupture
Score
(ATRS)
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140
2.
Currents
treatment
modalities
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2.1.
Plaster
cast
regime
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140
2.2.
Orthosis
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2.3.
Open
surgery
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2.4.
Percutaneous
surgery
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3.
Comparison
of
treatments
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3.1.
Any
surgery
vs.
any
non-surgical
regime
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3.2.
Open
surgery
vs
traditional
non-surgical
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3.3.
Plaster
cast
versus
walking
boot
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3.4.
Functional
regimes
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3.5.
Open
surgery
vs.
functional
non-surgical
regime
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3.6.
Open
surgery
vs.
minimally
invasive
surgery
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3.7.
Minimally
invasive
surgery
vs.
functional
non-surgical
regime
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4.
Adjuncts
to
treatment
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4.1.
Platelet
Rich
Plasma
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4.2.
Stem
cell
therapy
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5.
Controveries
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*
Corresponding
author
at:
44
Darwin
Crescent,
Loughborough,
Leicestershire,
LE115SB.
E-mail
address:
Randeep.aujla@hotmail.co.uk
(R.
Aujla).
http://dx.doi.org/10.1016/j.jajs.2018.02.003
2214-9635/©
2018
Published
by
Elsevier,
a
division
of
RELX
India,
Pvt.
Ltd
on
behalf
of
International
Society
for
Knowledge
for
Surgeons
on
Arthroscopy
and
Arthroplasty.
Journal
of
Arthroscopy
and
Joint
Surgery
5
(2018)
139–14 4
Contents
lists
available
at
ScienceDirect
Journal
of
Arthroscopy
and
Joint
Surgery
journal
homepa
ge:
www.elsev
ier.com/locate/jajs
5.1.
Does
Achilles
tendon
rupture
gap
matter?
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143
5.2.
Venous-thromboembolism
in
Achilles
tendon
rupture
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5.3.
Predictors
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outcome
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6.
Conclusion
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143
Conflicts
of
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143
Funding
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143
Ethical
approval
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143
References
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143
1.
Background
The
Achilles
tendon
is
the
most
frequently
ruptured
tendon
in
the
body.
1
The
incidence
of
Achilles
tendon
ruptures
(ATR)
is
rising.
1–4
Table
1
highlights
the
demographics
of
ATR
across
multiple
communities,
the
majority
of
these
studies
taking
place
in
Scandinavia.
3,5–7
Incidences
ranging
from
6
to
37.3
per
100,000
have
been
quoted.
1,3
Five
studies
demonstrate
an
increased
incidence
over
their
studied
periods.
Most
of
these
studies
attribute
the
increased
incidence
with
a
higher
population
participation
in
sporting
activities.
However,
there
is
a
trend
away
from
surgical
treatment.
7–9
Males
are
far
greater
affected
than
females
with
a
male-to-female
ratio
ranging
between
0.9–7.7:1,
with
only
one
study
finding
a
female
predominance.
10
1.1.
Achilles
Tendon
Rupture
Score
(ATRS)
Outcome
measures
for
patients
with
AT
ruptures
are
based
on
a
mixture
of
subjective
parameters.
The
Achilles
Tendon
Rupture
Score
(ATRS)
was
first
developed
in
2007
after
a
need
for
a
validated
patient-relevant
evaluation
tool
was
identified.
17
The
ATRS
has
been
proved
to
have
a
high
level
of
reliability,
validity,
sensitivity
and
internal
consistency.
18,19
The
ATRS
gives
surgeons
the
best
tool
to
assess
the
functional
outcomes
post-Achilles
tendon
ruptures.
Ability
to
single-heel
raise
does
correlate
with
PROMs
however
this
outcome
is
not
widely
reported.
20
2.
Currents
treatment
modalities
2.1.
Plaster
cast
regime
Plaster
cast
regimes
have
been
the
traditional
method
to
non-
operatively
treat
acute
ATR.
Equinus
casts
are
still
utilised
acute
from
Accident
and
Emergency
Departments
but
regimes
progress-
ing
to
sequential
plantigrade
positions
were
common.
21
Plaster
cast
allows
the
treating
surgeon
control
over
the
amount
of
plantaflexion
to
apply
at
the
ankle
and
assurances
about
patient
compliance.
There
is
however
the
risk
of
plaster
sores,
poor
skin
management/hygiene
and
stiffness.
2.2.
Orthosis
Management
of
acute
ATR
within
an
orthosis
is
commonplace
now.
The
benefits
include
flexibility
of
ankle
position,
ability
to
take
care
of
any
skin
problems,
improved
weight
bearing
ability,
earlier
return
of
function
and
improved
patient
satisfaction.
22,23
Disadvantages
of
the
orthosis
is
that
they
do
not
full
immobilise
all
patients
due
their
off-the-shelf
design
although
air
filled
liners
improve
the
fit
(Fig.
1).
There
is
also
the
issue
to
possible
patient
removal
of
the
orthosis.
This
lack
of
compliance
could
potentially
impair
tendon
healing.
2.3.
Open
surgery
Open
surgery
involves
exposure
and
debridement
of
the
ends
of
the
ruptured
tendon.
Following
this
suture
repair
is
conducted
and
repair
of
the
dissected
paratenon.
Usually
equinus
plaster
cast
is
applied
before
the
initiation
of
the
surgeons
chosen
rehabilitation
regime.
2.4.
Percutaneous
surgery
More
recently
percutaneous
repair
systems
have
been
launched
to
reduce
the
morbidity
associated
with
Achilles
tendon
repairs.
These
systems
allow
reduced
impact
upon
soft
tissues
and
obviate
the
need
for
breaching
the
paratenon.
However
there
is
an
association
with
nerve
injury.
Strength
is
comparable
to
open
Kessler
formation
repairs
(Fig.
2).
24
3.
Comparison
of
treatments
3.1.
Any
surgery
vs.
any
non-surgical
regime
A
recent
meta-analysis
looked
to
compare
all
surgical
versus
all
non-surgically
managed
acute
ATR.
25
The
primary
outcome
measure
was
re-rupture.
A
small
benefit
was
found
in
the
surgical
group,
but
with
so
many
variables
involved
in
each
management
regime,
this
is
an
inaccurate
representation
to
counsel
patients.
Also,
functional
outcomes
must
become
of
higher
importance
following
ATR
as
this
is
what
we
must
provide
for
patients.
We
shall
attempt
to
break
down
comparisons
of
treatment
regimes
to
Table
1
A
table
to
show
critical
demographics
from
multiple
studies
assessing
acute
Achilles
tendon
ruptures.
Study
Community
Population
Size
Study
Period
Incidence
per
100,000
Mean
Age
M:F
ratio
Trend
Erickson
et
al.
10
USA
25.6
million
2005–2011
10.8
0.9
Increasing
(6.7–10.8)
Huttunen
et
al.
7
Sweden
9.5
million
2001–2012
55.3
(male)/14.7
(female)
3.8
Maffulli
et
al.
1
Scotland
5.1
million
1980–1995
6.0
30
1.7
Increasing
(4.7–6)
Suchak
et
al.
2
Alberta,
Canada
950,000
1998–2002
9.9
41.4
4.0
Increasing
(5.5–9.9)
Moller
et
al.
11
Malmo,
Sweden
230,000
1987–1991
30
37
6.3
Houshian
et
al.
3
Multiple
cities,
Denmark
220,000
1984–1996
37.3
42.1
3.1
Increasing
(18.2–37.3)
Lantto
et
al.
6
Oulu,
Finland
140,000
1979 –2011
21.5
43
(SD
13)
7.7
Increasing
(2.1–21.5)
Levi
et
al.
5
Copenhagen,
Denmark
89,000
1978 –1995
13.4
41
2.9
Risk
factors
for
ATR
include
the
use
of
steroids
12,13
and
fluoroquinolone
antibiotic
therapy.
14–16
140
R.
Aujla
et
al.
/
Journal
of
Arthroscopy
and
Joint
Surgery
5
(2018)
139 –144
include
similar
studies
to
gain
stronger
conclusions
when
comparing
surgical
and
non-surgical
regimes.
3.2.
Open
surgery
vs
traditional
non-surgical
Trends
in
treating
AT
ruptures
have
been
traditionally
based
on
re-rupture
rate
as
the
primary
outcome
measure.
The
re-rupture
rate
has
been
notoriously
quoted
as
being
lower
in
surgical
treatment
based
on
an
early
meta-analysis.
26
However,
this
result
was
based
on
four
studies
all
pre-dating
2001,
with
one
from
1981,
which
compared
open
surgery
and
traditional
non-surgical
regimes
using
plaster
cast
with
non-weight
bearing
immobilisation.
21,27–29
A
defining
study
was
performed
by
Keating
et
al.
in
2011.
Their
RCT
compared
standard
open
surgery
against
a
traditional
casting
immobilisation
regime.
30
Re-rupture
rates
were
5%
and
10%
respectively,
both
which
would
be
considered
high
rates
for
the
latest
treatment
methods.
Limited
functional
outcome
scores
were
included,
and
both
treatment
methods
are
relatively
historical
despite
being
published
in
2011.
Based
on
this
evidence
there
was
an
era
of
functional
dynamic
regimes
and
modern
surgical
methods.
3.3.
Plaster
cast
versus
walking
boot
As
orthopaedics
moves
forward,
there
is
a
constant
drive
away
from
the
use
of
plaster
of
Paris
to
more
patient-friendly
methods
including
synthetic
casts,
orthosis
and
splints.
This
pressure
has
made
its
way
into
acute
ATR
management
also.
Many
centres
initially
treated
with
a
plaster
cast
immobilisation
from
the
Accident
and
Emergency
department.
This
allows
easy,
cheap
and
immediate
immobilisation
of
the
injured
limb.
A
group
from
Sheffield
in
the
UK
compared
cast
immobilisation
versus
controlled
early
mobilisation
in
an
orthosis.
22
The
splint
led
to
early
regain
mobility
and
increased
satisfaction.
A
systematic
review
reviewed
plaster
cast
immobilisation
versus
dynamic
functional
rehabilitation
following
surgical
repair
of
the
ATR.
The
concluded
that
functional
regimes
were
safe
with
high
satisfaction
rates.
31
There
has
been
no
study
directly
comparing
plaster
cast
and
orthosis
in
similar
cohorts.
The
UK
STAR
study
is
aiming
to
assess
the
effect
on
functional
outcomes
following
treatment
in
either
functional
bracing
or
plaster
cast
immobilisation.
This
multi-
centre
randomised
controlled
trial
(RCT)
will
aim
to
recruit
330
patients
over
the
future
three
years.
This
study
is
likely
to
lay
to
rest
the
argument
between
plaster
cast
and
functional
bracing.
3.4.
Functional
regimes
Recent
studies
had
supported
non-surgical
treatment
using
functional/dynamic
rehabilitation
for
acute
ATR
with
comparable
re-ruptures
rates
between
surgical
and
non-surgical
regimes
when
these
methods
were
utilised.
23
Early
weight-bearing
with
a
dynamic
range
of
motion
has
been
shown
to
achieve
favourable
outcomes
regarding
the
range
of
motion,
strength,
and
return
to
activities
while
minimising
the
possibility
of
healing
in
a
lengthened
position,
or
re-rupture.
32
These
results
were
summar-
ised
by
McCormack
et
al.
Meta-analysis
of
RCTs
comparing
post-
surgical
dynamic
regimes
versus
immobilisation
in
a
cast.
31
They
pooled
data
from
10
studies
(570
patients)
to
show
that
there
was
no
increase
in
complication
rates
and
a
higher
patient
satisfaction
after
using
dynamic
regimes.
An
RCT
performed
by
Valkering
et
al.
compared
early
full-
weight
bearing
and
non-weight
bearing
following
open
surgical
repair.
Interestingly
they
found
raised
levels
of
biological
markers
of
tendon
repair
(procollagen
type
1,
glutamate,
lactate
and
pyruvate)
in
the
full-weight
bearing
cohort
with
an
improved
early
ankle
range
of
motion.
33
In
a
similar
study,
Barfod
et
al.
demonstrated
an
increased
stiffness
in
the
plantar
flexor
muscle-tendon
complex
in
the
non-weight
bearing
group.
34
These
results
add
some
clinical
evidence
that
early
stressing
of
the
healing
tendon
tissue
can
lead
to
an
improved
outcome,
likely
due
to
collagen
fibre
orientation.
However,
these
regimes
were
all
instituted
after
surgical
repair.
Fig.
1.
An
example
of
an
orthosis
that
can
be
used
(VACOPed
1
).
Fig.
2.
The
Achillon
1
system
used
for
percutaneous
repair.
R.
Aujla
et
al.
/
Journal
of
Arthroscopy
and
Joint
Surgery
5
(2018)
139–14 4
141
Hutchison
et
al.
implemented
a
hospital-wide
(Swansea
Morriston
Achilles
Rupture
Treatment;
SMART)
programme
between
2008
and
2014,
reporting
on
211
non-operatively
managed
ATR.
35
The
regime
involved
two
weeks
in
an
equinus
cast
followed
by
eight
weeks
in
a
VACOped
boot.
They
allowed
immediate
full-weight
bearing.
Mean
ATRS
at
nine
months
was
72.4
(SD
14)
with
a
re-rupture
rate
of
1.1%.
However,
this
final
functional
level
was
only
available
for
20%
of
patients
included
in
the
study.
A
similar
study
from
Northern
Ireland
presented
949
ATR
seen
between
1996
and
2008.
36
This
study
used
different
methods
to
immobilise
the
limb
but
included
all
patients.
Initially,
they
used
a
custom-made
rigid
polypropylene
double
shell
patellar
tendon
bearing
orthosis
before
an
aircast
pneumatic
walking
boot
was
introduced
in
1999.
A
re-rupture
rate
of
2.8%
with
good
to
excellent
subjective
assessments
in
99.4%
was
found.
Currently,
there
is
no
consensus
as
to
the
most
superior
functional
regime.
37
Immediate
full-weight
bearing
regimes
have
been
implemented,
in
both
non-surgical
and
post-surgical
regimes,
without
compromise
to
outcomes
or
re-rupture
rates.
38-
–41
Aujla
et
al
has
demonstrated
that
a
functional
regime
of
8
weeks
duration,
compared
to
10
weeks,
lead
to
no
detriment
in
functional
outcome
scores
following
ATR.
42
3.5.
Open
surgery
vs.
functional
non-surgical
regime
Three
RCTs
have
compared
traditional
open
surgery
and
non-
surgical
functional
rehabilitation.
19,43,32
Willits
et
al.
showed
no
difference
in
re-rupture
rate,
calf
strength,
the
range
of
motion,
calf
circumference
or
Leppilahti
score.
32
They
advised
non-surgical
treatment
to
avoid
surgical
complications.
Nilsson-Helander
et
al.
found
no
difference
in
re-rupture
rates,
Achilles
Tendon
Rupture
Score
(ATRS)
at
6
and
12
months.
The
only
statistically
significant
difference
in
outcome
was
noted
in
the
12-month
heel-rise
work
test
in
favour
of
surgical
treatment.
19
Olsson
et
al.
demonstrated
no
difference
in
symptoms,
physical
activity
level
or
quality
of
life.
Statistical
superiority
was
only
shown
in
drop
counter-drop
jump
and
hopping
in
favour
of
surgery.
43
These
results
suggest
that
open
surgical
repair
may
lead
to
superior
functional
in
loading
activities
over
functional
non-surgical
regimes
with
no
discernable
differ-
ence
in
functional
scores
or
re-rupture
rate.
This
would
support
the
use
of
dynamic
functional
non-operative
regimes
for
the
majority
of
patients.
It
provides
fewer
risks
with
equivocal
re-rupture
rates.
3.6.
Open
surgery
vs.
minimally
invasive
surgery
As
surgical
techniques
improved
the
desire
for
minimally
invasive
surgery
(MIS)
has
to
lead
to
multiple
systems
being
developed.
Laboratory
studies
have
demonstrated
no
difference
in
ultimate
tensile
strength
of
repair
between
percutaneous
MIS
and
open
techniques.
44
A
meta-analysis
of
six
RCTs
compared
traditional
open
surgery
versus
MIS
techniques.
45
This
showed
no
difference
in
re-rupture
rate,
nerve
injury,
deep
infection,
tissue
adhesions
or
deep
vein
thrombosis.
However,
MIS
was
shown
to
provide
three
times
greater
good
to
excellent
subjective
outcomes
and
a
significantly
lower
superficial
infection
rate.
45
Hsu
et
al.
showed
in
their
retrospective
series
that
their
percutaneous
technique
had
a
significantly
improved
rate
of
return
to
baseline
physical
activities
over
open
repair
with
no
difference
in
complication
rates.
46
3.7.
Minimally
invasive
surgery
vs.
functional
non-surgical
regime
No
RCT
has
yet
been
conducted
directly
comparing
modern
MIS
versus
a
non-surgical
functional
dynamic
regime
with
the
primary
outcome
measure
being
a
patient
function.
Metz
et
al.
did
conduct
an
MIS
versus
functional
non-surgical
regime
in
a
VACOped
boot,
but
they
did
not
include
the
ATRS
as
part
of
their
outcomes.
40
They
did
include
Leppilahti
scores
as
functional
outcome
assessment,
which
showed
no
statistical
difference,
but
this
was
not
the
primary
outcome
being
assessed.
4.
Adjuncts
to
treatment
4.1.
Platelet
Rich
Plasma
(PRP)
There
have
been
multiple
studies
assessing
the
use
of
biological
augmentation
following
surgical
repair
of
ATR.
47–49
These
cohort
studies
suggest
an
earlier
return
to
work
with
no
adverse
outcomes.
De
Carli
et
al.
went
on
step
further
and
evaluated
all
patients
with
MRI
imaging.
They
found
no
clinical
difference
between
the
PRP
and
non-PRP
cohorts
but
did
find
increased
signal
enhancement,
to
gadolinium,
in
the
PRP
cohort
suggesting
better
tendon
remodelling.
50
Kaniki
et
al.
injected
PRP
twice
within
the
first
two
weeks
following
acute
ATR
treated
in
a
non-surgical
regime.
They
compared
this
to
a
previous
historical
cohort
that
underwent
the
same
non-surgical
regime
but
with
no
PRP.
No
measurable
difference
was
found
in
strength
at
1
or
2
years
following
injury.
51
No
RCT
using
biological
augmentation
has
been
performed
as
of
yet,
but
the
Platelet
Rich
Plasma
in
Achilles
Tendon
Healing
(PATH-
2)
trial
is
on-going
at
the
moment
in
the
United
Kingdom.
This
pragmatic
multi-centre
RCT
is
comparing
the
use
of
PRP
in
non-
surgically
managed
ATR.
The
primary
outcome
measure
is
heel-
rise
endurance
test
at
24
weeks.
4.2.
Stem
cell
therapy
A
small
cohort,
level
4
study
in
patients
with
sport-related
Achilles
tendon
ruptures
showed
excellent
results
with
no
re-
ruptures
when
open
Achilles
tendon
repair
was
augmented
with
bone
marrow
aspirate
concentrate
(BMAC).
49
Kadakia
et
al.
showed
promising
results
of
use
of
bone
marrow-
derived
stem
cells
in
animal
models.
52
In
another
animal
model,
Yuksel
et
al
showed
the
efficacy
of
local
bone
marrow
mesenchymal
stem
cell
therapy,
and
platelet-
rich
plasma
positively
affected
the
recovery
of
the
tendon
histopathologically,
immunohistochemically,
and
biomechanically
and
increase
the
structural
strength.
53
Mesenchymal
stem
cells
were
used
to
treat
rabbits
with
surgically
Achilles
tendon
rupture
and
were
divided
into
three
groups
looking
at
tendon
healing
at
14
and
28
days.
The
three
groups
were,
cross-section
of
the
Achilles
tendon
(CSAT);
CSAT
+
Suture;
and
CSAT
+
MSC
(mesenchymal
stem
cell).
A
comparison
showed
a
statistically
significant
decrease
in
the
inflammatory
process
and
an
increase
in
the
structural
organisation
of
collagen
in
the
CSAT
and
CSAT
+
MSC
groups.
54
In
an
animal
study,
rats
were
divided
into
three
groups:
the
BMC
group
(bone
marrow
cells
injected
around
the
tendon),
the
MSC
group
(mesenchymal
stem
cells
injected
around
the
tendon),
and
the
non-treated
control
group
(incision
only).
The
researchers
looked
at
outcome
measures
which
included
mechanical
testing,
collagen
immunohistochemistry,
histological
analysis,
and
reverse
transcription-polymerase
chain
reaction
to
detect
expression
of
transforming
growth
factor-b
(TGF-b)
and
vascular
endothelial
growth
factor
(VEGF).
They
reported
the
ultimate
failure
load
in
the
BMC
group
was
significantly
higher
than
that
in
the
non-treated
or
the
MSC
group
at
seven
days
after
incision
(3.8
N
vs.
0.9
N
or
2.1
N,
p
<
0.016)
and
at
fourteen
days
after
incision
(10.2
N
vs.
6.1
N
or
8.2
N,
p
<
0.016).
Hence
they
concluded
transplantation
of
whole
bone
marrow
cells
might
be
a
better
option
than
cultured
mesenchymal
stem
cells.
55
142
R.
Aujla
et
al.
/
Journal
of
Arthroscopy
and
Joint
Surgery
5
(2018)
139 –144
5.
Controveries
5.1.
Does
Achilles
tendon
rupture
gap
matter?
It
was
Kotnis
et
al.
in
2006
that
highlighted
the
need
to
assess
ATR
gap
to
aid
decision
making
for
surgical
treatment.
56
They
assessed
125
ATR
patients
and
surgically
managed
those
with
a
residual
gap
of
>5
mm
in
full
equinus.
As
a
result
of
this
protocol,
they
treat
54%
of
ATR
surgically
with
either
open
or
percutaneous
repair,
but
they
did
not
employ
a
dynamic
functional
rehabilitation
regime
in
either
arm.
There
was
no
significant
difference
in
complications,
but
no
functional
results
were
recorded.
Two
earlier
studies
employed
a
similar
5
mm
gap
protocol.
57,58
Other
studies
have
utilised
a
10
mm
gap
to
drive
surgical
treatment.
35
However,
this
was
based
on
tendon
lengthening
showing
poor
function
in
a
cadaveric
study.
59
A
more
recent
study
found
no
difference
in
function
when
comparing
acute
ATR
with
gaps
less
than
or
greater
than
10
mm
using
a
functional
dynamic
regime.
60
Roberts
et
al.
assessed
69
ATR
using
MRI
and
found
no
significant
correlation
between
gap
size
and
one-year
functional
outcome
in
non-
surgically
managed
ATR.
61
Westin
et
al.
demonstrated
that
a
gap
of
>10
mm
led
to
an
increased
re-rupture
rate
and
lowered
functional
outcome,
but
this
was
based
on
a
cohort
of
just
45
patients.
62
Ultrasound
is
a
dynamic
assessment
but
is
inherently
user-
dependent.
Those
that
criticise
this
protocol
would
discuss
how
ATR
rarely
occurs
as
a
clean-ended
rupture
and
often
depicts
a
horses-tail
appearance.
This
makes
precise
identification
of
rupture
ends
confusing
and
inaccurate.
Overall
there
is
no
clear
evidence
that
gap
size
affects
functional
outcome.
5.2.
Venous-thromboembolism
in
Achilles
tendon
rupture
There
remains
an
unexplained
high
rate
of
VTE
in
patients
after
acute
ATR
when
compared
to
other
lower
limb
injuries
requiring
immobilisation.
63
The
incidence
is
said
to
vary
between
0.8%
and
23.5%.
64,65
The
true
incidence,
of
symptomatic
VTE,
likely
to
be
between
3
and
7%
depending
on
an
individual
institutes
treatment
algorithm
and
thresholds
to
investigate.
Lapidus
et
al.
showed
an
asymptomatic
deep
vein
thrombosis
rate
of
34–36%
after
ATR
with
or
without
chemical
thromboprophylaxis.
66
Studies
have
failed
to
show
any
benefit
of
using
low-molecular-weight
heparin
(LMWH)
or
aspirin
in
patients
after
ATR
to
reduce
symptomatic
VTE
rate.
66–
68
Nevertheless,
the
majority
of
hospital
recognise
ATR
as
a
high-
risk
patient
and
treat
with
thromboprophylaxis
after
risk
assess-
ment.
5.3.
Predictors
of
outcome
Domeij-Arverud
et
al.
used
data
from
a
prospective
RCT
comparing
post-operative
regimes
in
surgically
treated
ATR.
69
They
found
improved
outcomes
in
patients
aged
under
40,
females
and
in
patients
that
did
not
suffer
from
a
VTE
during
treatment.
Conversely,
two
studies
have
shown
superior
results
in
males.
70,71
In
our
unpublished
data
across
236
ATR
treated
in
a
functional
regime
found
that
age
had
an
inverse
correlation
with
outcome
and
that
males
had
superior
functional
outcomes
at
final
follow-
up.
6.
Conclusion
We
propose
that
a
two-tier
treatment
protocol
is
required
for
the
acute
ACT.
The
vast
majority
of
patients
will
achieve
good
functional
outcomes
using
a
dynamic
functional
regime
of
8–10
weeks
duration.
Three
randomised
controlled
trials
have
shown
no
differences
in
functional
outcomes
between
dynamic
functional
regimes
and
open
surgery.
There
are
minimal
risks
to
the
patients
along
with
Achilles
Tendon
Rupture
Scores
of
75–85
out
of
100 .
For
patients
with
higher
demands,
a
minimally
invasive
technique
can
be
used
to
repair
the
Achilles
tendon
surgically.
This
provides
superior,
yet
not
statistically
proven,
higher
Achilles
Tendon
Rupture
Scores
of
85–90
out
of
100
that
may
provide
this
cohort
with
improved
results.
A
randomised
controlled
trial
comparing
these
two
methods,
utilising
functional
outcomes,
could
be
undertaken
to
quantify
the
functional
difference
between
the
two.
Conflicts
of
interest
No
benefits
in
any
form
have
been
received
or
will
be
received
from
a
commercial
party
related
directly
or
indirectly
to
the
subject
of
this
article.
Funding
None.
Ethical
approval
N/A.
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