The secondary outcomes were quality of life, complications and resource use at 8 weeks and at 3, 6 and 9 months. Results: Participants had a mean age of There was no statistically significant difference in Achilles Tendon Rupture Score at 9 months post injury There was a statistically significant difference in Achilles Tendon Rupture Score at 8 weeks post injury in favour of the functional brace group 5. Quality of life showed the same pattern, with a statistically significant difference at 8 weeks post injury but not at later time points.
Complication profiles were similar in both groups. Re-rupture of the tendon occurred 17 times in the plaster cast group and 13 times in the functional brace group. There was no difference in resource use. Conclusions: This trial provides strong evidence that early weight-bearing in a functional brace provides similar outcomes to traditional plaster casting and is safe for patients receiving non-operative treatment of Achilles tendon rupture.
Limitations: Some patients declined to participate in the trial, but only a small proportion of these declined because they had a preference for one treatment or another.
The sural nerve is identified and protected throughout the procedure. The deep fascia is then incised and the PB muscle belly with the tendon is visualized.
The interposing scar tissue is resected from the ruptured ends of the Achilles tendon. In order the harvest the PB tendon distally a separate incision is made 1 cm to 1. The tendon is transected at this point and pulled through the original posterolateral incision.
The foot is then plantarflexed 20 degrees and end-to-end anastomosis is attempted when feasible. Some use the plantaris tendon to augment the primary anastomosis. If the distal stump of the Achilles tendon appears to be in good condition the PB tendon is pulled through the distal stump lateral to medial and sutured to the proximal and the distal tendon stumps.
It can also be secured to the calcaneus with an interference screw or suture anchors Miskulin, The use of FDL tendon has been advocated as it mimics the course of the Achilles tendon without comprising the lesser digit function postoperatively. There use of this tendon also avoids the loss of eversion and ankle balance seen with transfer of the PB. Mann et al first described the technique in 7 patients with duration of symptoms ranging from 3 to 36 months with an average follow up of 39 months.
They achieved excellent result in 4 patients, good in 2, and fair in 1. The 6 patients who achieved good to excellent result were all able to return to pre-injury activities without pain. Two patients with good result had wound complications requiring a secondary procedure. No re-ruptures were reported in their series and active plantarflexion of the digits were preserved and no hammer-toe deformities were seen postoperatively Mann et al.
The exposure involves a hockey stick shaped incision beginning medial to the Achilles tendon and continues distally to the insertion. The incision is curved laterally to expose the entire Achilles tendon unit. A second linear incision is made just distal and inferior to the navicular tuberosity but superior to the abductor hallucis muscle.
The master knot of Henry can be released in order to improve the visualization of the tendons. The FDL tendon is identified proximal to the division to digital branches and resected. The proximal aspect of the distal FDL tendon segment is then sutured to the FHL tendon while the digits are held with the interphalangeal joints in neutral position. If the patient had pre-existing hammer-toe deformities, the distal portion can be left free.
The FDL tendon is then freed and pulled through the original posterior incision. The tendon sheath is incised and the transferred tendon is placed next to the Achilles tendon. A drill hole is made in the posterior aspect of the calcaneus and the tendon is passed through from medial to lateral and sutured onto itself while the foot is held in 10 to 15 degrees of plantarflexion.
If fortification of the tendon interface is deemed necessary, a central slip from the proximal Achilles stump is mobilized and flipped distally and cross-sutured to the FDL tendon and the distal stump Mann et al.
Recently FHL tendon transfer in conjunction with fascia advancement has been advocated for neglected ruptures with defects greater than 5 cm Elias, ; Den Hartog, The argument for the combined procedures is that fascia advancement, whether in forms of turn-down flap, V-Y plasty, etc. Elias et al. Subjectively all patients were satisfied with the outcome. No re-ruptures were reported in their series.
The authors concluded that their result is at least comparable to previous studies in which fascial advancement or a FHL tendon transfer was performed alone. Tendon allograft has become popular especially for the reconstructive knee and shoulder surgery.
Achilles tendon allografts have shown to be effective in anterior cruciate ligament ACL reconstruction with similar functional outcomes compared to autografts. Poehling et al. The use of Achilles tendon allograft for reconstruction of the neglected Achilles ruptures have been reported but mostly limited to case reports Nellas et al. All authors reported favorable outcome after the operation. The use of allograft has been recommended when significant segmental defect is encountered, such as, greater than 10 cm when fascia advancement or tendon transfer is not able to provide sufficient bridging between the tendon ends Den Hartog, ; Lepow, The use of an allograft allows bridging of a large tendon defect with an adequate graft, avoidance of donor site morbidity, and relative ease of surgical technique.
However, any allograft carries the small risk of transmission of disease and graft rejection by the host. The risk of viral disease transmission has been shown to be low, however, with the most recent report by the American Association of Tissue Banks showing no incidence of viral disease transmission in more than 2 million musculoskeletal allografts distributed within 5 years at the time of the report Mahirogullari et al.
In addition, functional outcomes over a long follow-up period have not been established. In an animal study the mechanical strength of an allograft tendon is similar to that of an autograft Mahirogullari et al, This process has been shown to vary from 26 weeks to 18 months in animal studies Shino et al.
The allograft serves as a scaffold for remodeling and once the maturation process is complete, histological studies have shown similar cellular composition to a native tendon Drez et al. However, the correlation of this process with the return to normal function has yet to be established. The surgical approach is made through the standard posteromedial incision with the patient in the prone position.
A surgical plane is created between the subcutaneous tissue and the paratenon which is then incised. All fibrotic tissue interposed between the ruptured ends is resected until normal appearing tendon is visualized on both ends of the native tendon [ Figure 9 ].
The Achilles allograft is thawed and rehydrated in sterile normal saline solution for 30 minutes prior to insertion. The graft is cut to the appropriate size to fill defect with the.
All fibrotic tissue has been debrided in this neglected rupture, creating a large defect. Common tendon suture such as a running Krackow, Kessler or modified Bunnel stitch are used at either end to secure the allograft.
Proximally the allograft gastrocnemius aponeurosis is placed over the native aponeurosis prior to suturing. Distally, the allograft comes with attached portion of a calcaneus and in cases where the distal tendon end is insufficient for repair, the calcaneal portion can be fixed to the recipient calcaneus with either some drill holes from dorsal to plantar at the insertion site [ Figure 12 ] or with an inset technique using the allograft bone portion and internal fixation at the insertion site [ Figures 13 - 14 ].
The Achilles tendon allograft with attached bone is being prepared for insertion. The allograft Achilles tendon is sewn into place with the appropriate amount of tension. The dorsal aspect of the calcaneus has been prepared with drill holes to accept sutures for anchoring of the allograft to the bone. MRI with insufficient Achilles tendon at the calcaneus. Technique showing utilization of bone block with the Achilles tendon allograft. Several synthetic materials have been used with success in some early studies.
The use of synthetic materials avoids the sacrifice of functional tendon structures and extensive incision and dissection. Foreign body reaction has been observed with the use of carbon or polyester fiber Amis et al.
However, the introduction of a foreign material into an area notorious for tenuous healing makes the use of a synthetic graft unfavorable. Unlike synthetic grafts, an acellular dermal matrix graft has been shown in animal studies to be able to b incorporate into the native tissue and resemble autologous tendon histologically Mandelbaum et al. Lee in reported on 9 patients who underwent primary repair of a neglected Achilles rupture with augmentation by an acellular dermal matrix graft.
The follow-up ranged from 20 to 30 months with no incidence of re-rupture. All patients were able to perform single heel raise on the reconstructed side Lee, Although most operations result in reasonably successful and functional outcomes, significant complications can occur.
One of the variables during surgical reconstruction is determining the optimal tension of the repaired tendon. If the tendon complex is too tight, then the patient will have some difficulty in attaining a plantigrade foot.
Extensive physical therapy in the postoperative period may diminish some of the equinus position but generally the resultant deformity is not easily treated because the resultant scar tissue that forms in the gap has a more limited capacity to stretch than native tissue. The collagen structure is more loosely organized with irregular cross-linking, resulting in a less resilient tendon.
On the other hand, the reconstructed tendon may have healed in a lengthened position which causes some functional weakness. The ultimate determinant of a good result is the capability to do a single limb heel-rise. In most cases, this is attainable around 6 months postoperatively but will not be possible if the tendon reconstruction has too much laxity and not enough tension.
The patient may complain of weakness particularly on hills, but on physical exam there is a distinct asymmetry with the affected leg assuming a more dorsiflexed posture in the prone position [ Figure 15 ]. One way to avoid this complication during the repair is to match the position of the unaffected leg intraoperatively.
Often this requires that the unaffected leg be draped free as well for comparison. Modulation of the position is actually easier in the neglected rupture because the tendon is not frayed and more accurate purchase of the tissues by the suture allows for better control of the length. If however, the patient has unacceptable weakness, a shortening of the reconstructed tendon can be performed [ Figures 16 - 17 ].
Although the incidence of rerupture is far less after repair of a neglected rupture compared to repair of the acute rupture, the incidence is not zero. Given the high tensile strength sutures available today, the failure point is almost always at the suture tissue junction rather than a failure of the suture material. From a speculative standpoint, the quality of tissue after a negelected rupture is not as robust and may handle the tension from sutures poorly.
Introduction: Spasticity is an important early complication of stroke, which may lead to shortening of gastrocnemius and soleus muscles and contracture in the Achilles tendon and soft tissues of the ankle. Serial casting is another alternative method for reducing contractures due to spasticity. The present study aimed to determine if serial casting after BTX-A injection could help to limit the development of calf contracture in chronic hemiplegic patients.
Method: The records of patients with stroke that were treated in the brain injury rehabilitation clinic between January and December were screened.
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