tendon rupture treatment in athletes

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ABSTRACT

Treatment for Achilles tendon ruptures in athletes iscontroversial. Surgical xation has lower rates of re-rupture and confers increased strength and function,whereas conservative treatment has lower risks ofwound complications. We review the literature onthe optimal treatment for Achilles tendon rupture inathletes.

Key words:Ach il les tendon; athletes

introduction

Achilles tendon rupture was rst reported in 1575.1 Itsincidence has increased since then.2 75% of Achillestendon ruptures occur during sporting activities,particularly those involving jumping or twistingmotions.36 The ruptures used to occur in men in their40s,7 and the male-to-female ratio was about 6:1.8,9

In a more recent study in athletes,10 age and sex no

Review article: Treatment for Achilles tendonruptures in athletes

Maria Stavrou, Andreas Seraphim, Nawfal Al-Hadithy, Simon C MordecaiListerGeneralHospital,Stevenage,UnitedKingdom

Addresscorrespondenceandreprintrequeststo:MariaStavrou,6NevernSquare,Flat3,SW59NN,London,UnitedKingdom.

Email:[email protected]

Journal of Orthopaedic Surgery 2013;21(2):232-5

longer had as strong inuence on the rupture rate.This could be due to increased participation in sports

by females and older people.11The optimal treatment for Achilles tendon

rupture remains controversial. Conservativetreatment involves early application of an equinuscast for 6 to 8 weeks to approximate the edges of theruptured tendon together to promote healing. It hasa higher rate of re-rupture and is reserved for lessactive patients. Operative (open and percutaneous)treatment is usually for younger, more activepatients, and has more favourable functionaloutcomes, with lower re-rupture rates but highercomplication rates.

Before the 20th century, treatment for Achillestendon ruptures was primarily conservative. In the

60s, open surgery achieved better outcome but withhigher complication rates.12 In the 70s, this trendshifted toward conservative treatment, owing toincreasing complications and wound infections withoperative techniques.13 Poor wound healing remainsthe most common complication of open repair, andis likely to be due to incision on poorly vascularisedtissue.14 Athletes have higher expectations and


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234 MStavrouetal. Journal of Orthopaedic Surgery

rate was 9.8% in the conservative group and 2.2%in the operative group. The overall postoperativecomplication rate was as high as 20%. This was dueto poor surgical techniques in early papers. Patientsin the operative group were more likely to return to

sports and work. Older studies tended to recommendnon-operative treatment and score lower. In highdemand patients, operative intervention was thetreatment of choice. In addition, percutaneousxation resulted in high rates of sural nerve injury andwound complications.25 The percutaneous techniquewas inferior to open end-to-end Bunnel suturing, andhad higher rates of complication (sural nerve injuries

being the most common) and re-rupture (33%).26

In a prospective randomised study of 40recreational sportsmen (mean age, 40.7 years)undergoing open (end-to-end Bunnel suturing) or

percutaneous repair,27

outcome was similar in termsof subjective satisfaction and isokinetics. There were2 (10%) cases of delayed healing in the open group,and one re-rupture (5%) in the percutaneous group.All diagnoses were made using ultrasonography.

In a meta-analysis of 800 patients in 12 trialscomparing operative (open or percutaneous) withnon-operative (casting or functional brace) treatmentsfor Achilles tendon rupture,28 operative treatmentconferred lower risks of re-rupture (relative risk[RR]=0.27; 95% condence interval [CI], 0.110.64) buthigher rates of other complications (RR=10.60; 95%

CI, 4.8223.28). These included infection, adhesions,and disturbed skin sensibility. Percutaneous repairconferred a lower complication rate than open repair(RR=2.84; 95% CI, 1.067.62).

In another meta-analysis of 777 patients in 8

randomised controlled trials,29 the non-operativegroup had signicantly higher re-rupture rates(Z=3.33, RR=0.4, p


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Vol. 21 No. 2, August 2013 Achillestendonrupturesinathletes 235

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rupturedtendoAchilles.Injury1997;28:28992.16. McComisGP,NawoczenskiDA,DeHavenKE.FunctionalbracingforruptureoftheAchillestendon.Clinicalresultsand

analysisofground-reactionforcesandtemporaldata.JBoneSurgAm1997;79:1799808.17. Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand Suppl1959:116(Suppl239);151.

18.GilliesH,ChalmersJ.Themanagementoffreshrupturesofthetendoachillis.JBoneJointSurgAm1970;52:33743.19.InglisAE,ScottWN,SculcoTP,PattersonAH.Rupturesofthetendoachillis.Anobjectiveassessmentofsurgicalandnon-

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JointSurgBr1987;69:41620.21. CettiR,ChristensenSE,EjstedR,JensenNM,JorgensenU.OperativeversusnonoperativetreatmentofAchillestendon

rupture.Aprospectiverandomizedstudyandreviewoftheliterature.AmJSportsMed1993;21:7919.22. IngvarJ,TgilM,EnerothM.NonoperativetreatmentofAchillestendonrupture:196consecutivepatientswitha7%re-

rupturerate.ActaOrthop2005;76:597601.23. MaesR,CopinG,AverousC.IspercutaneousrepairoftheAchillestendonasafetechnique?Astudyof124cases.Acta

OrthopBelg2006:72:17983.24. WongJ,BarrassV,MaffulliN.Quantitativereviewofoperativeandnonoperativemanagementofachillestendonruptures

2002;30:56575.25. MaG,GrifthTG.Percutaneousrepairofacuteclosedrupturedachillestendon:anewtechnique.ClinOrthopRelatRes

1979;(128):24755.26. AracilJ,PinaA,LozanoJ,TorroV,EscribaI.PercutaneoussutureofAchillestendonruptures.FootAnkle2002;13:3501.27. GiganteA,MoschiniA,VerdenelliA,DelTortoM,UlisseS,dePalmaL.Openversuspercutaneousrepairinthetreatment

ofacuteAchillestendonrupture:arandomisedprospectivestudy.KneeSurgSportsTraumatolArthosc2008;16:2049.28. KhanRJ,FickD,KeoghA,CrawfordJ,BrammarT,ParkerM.Treatmentofacuteachillestendonruptures.Ameta-analysis

ofrandomized,controlledtrials.JBoneJointSurgAm2005;87:220210.29. ZhaoHM,YuGR,YangYF,ZhouJQ,AubeeluckA.Outcomesandcomplicationsofoperativeversusnon-operativetreatment

ofacuteAchillestendonrupture:ameta-analysis.ChinMedJ(Engl)2011;124:40505.

tendon rupture treatment in athletes

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