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Abstract Background The Achilles tendon is the body’s strongest and largest tendon. It is commonly injured, particularly among athletes, accounting for a significant portion of serious tendon injuries. Several factors play a precipitating role in increasing the risk of these injuries. Objective Our objective is to derive and validate a risk calculator for the prediction of incidence of any complication following Achilles tendon repair. Methods We used de-identified data from the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2021. It comprises 7010 individuals who had undergone Achilles tendon rupture repair. Demographic and risk factors information was collected. To develop the calculator, the sample was divided into a derivation cohort (40%) and a validation cohort (60%). Multivariate logistic regression was used for statistical analysis, and a risk calculator for incidence of any complication was derived from the derivation cohort and validated on the remaining 60% of the sample. Patients with missing data were excluded, and the significance level was set at p

Background: The Achilles tendon is the body's strongest and largest tendon. It is commonly injured, particularly among athletes, accounting for a significant portion of serious tendon injuries. Several factors play a precipitating role in increasing the risk of these injuries. Objective: Our objective is to derive and validate a risk calculator for the prediction of incidence of any complication following Achilles tendon repair. Methods: We used de-identified data from the American College of Surgeons' National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2021. It comprises 7010 individuals who had undergone Achilles tendon rupture repair. Demographic and risk factors information was collected. To develop the calculator, the sample was divided into a derivation cohort (40%) and a validation cohort (60%). Multivariate logistic regression was used for statistical analysis, and a risk calculator for incidence of any complication was derived from the derivation cohort and validated on the remaining 60% of the sample. Patients with missing data were excluded, and the significance level was set at p < 0.05. Results: We analyzed the derivation cohort of 2245 individuals who underwent Achilles tendon repair surgery between 2005 and 2021, with a 5.5% overall complication. Multivariate logistic regression identified anesthesia type, ASA classification, certain co-morbidities (pre-operative dialysis and medication-requiring hypertension), and wound classification as significant predictors of complications. The developed risk calculator model had an area under the curve (AUC) of 0.685 in the derivation cohort and 0.655 in the validation cohort, surpassing the widely used and validated modified frailty index. A cut-off score threshold of 0.06 was established using Youden's index to dichotomize individuals into low and high risk for developing any postoperative complications. Conclusion: Our risk calculator includes factors that most significantly affect the incidence of any complication following Achilles tendon repair. [ABSTRACT FROM AUTHOR]

Background: In correlation with a growing body of evidence regarding nonoperative management for Achilles tendon rupture (ATR), studies from Europe and Canada have displayed a decreasing incidence in surgical management, which has not been noted in the United States. The primary objective of this study is to evaluate the US trend in ATR repair volume. Methods: The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination Case List Database was used. All cases using Current Procedural Terminology codes for primary ATR repair were requested from the years 2006-2020. Total submitted Achilles repair volume, the number of candidates submitting an Achilles repair case, and the overall submitted case volume per examination year was analyzed. Poisson and linear regressions were used to determine statistically significant trends. Results: The total number of Achilles repair cases submitted for the ABOS Part II Oral Examination significantly increased from 2006 to 2011 and then decreased until 2020. Taking Achilles repair cases as a proportion of total orthopaedic cases submitted, the same trend was seen. The number of candidates submitting an Achilles repair case increased from 2006 to 2009 and then decreased until 2020. Foot and Ankle fellowship-trained candidates submitted an increasing number of ATR repair cases per candidate during the time period studied. Conclusion: This is the first study to demonstrate a decline in the volume of ATR repair in the United States. The decline in ATR repair volume seen in the ABOS Part II Case Lists does not match previously published US surgeon practice patterns but is not necessarily generalizable to beyond this period. Although the overall ATR repair volume in the ABOS Part II Case Lists is decreasing, we found Foot and Ankle fellowship-trained surgeons are operating on an increasing number of ATRs during their board collection period. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Compositional changes in relation to musculoskeletal injuries are difficult to measure non-invasively. This study aims to use non-invasive label-free imaging with Multispectral Optoacoustic Tomography (MSOT) to evaluate compositional changes with injury. Five different patient groups were examined, covering diagnoses of Achilles or patellar tendinopathy, Achilles tendon rupture and gastrocnemius muscle strain injury. Injured and contralateral limbs were imaged using a commercial MSOT device. Hemoglobin, collagen, and lipid contents were estimated. Some patients were examined before and after exercise. Hemoglobin measures had high reproducibility and displayed systematic changes in response to exercise. The content and exercise response of hemoglobin was equal on both limbs. In contrast, collagen and lipid measures were inconsistent and did not display the expected distribution. In conclusion, MSOT is applicable to imaging of hemoglobin in musculoskeletal injuries, providing complimentary information to conventional ultrasound, but applicability to other components like collagen and lipids could not be shown.

Background: The proposed advantages of hamstring autograft reconstruction when compared to alternative procedures, such as flexor hallucis longus (FHL) transfer, V-Y lengthening, and allograft reconstruction, are improved healing and reproduction of normal tendon biomechanics and reduced morbidity within the foot and ankle. In this study, we examined the effect of Achilles tendon reconstruction using hamstring autografts on strength and functional outcomes. Methods: Patients who underwent Achilles repair with a hamstring autograft for insertional or midsubstance tendinopathy, delayed diagnosis of rupture, or infection after primary repair were evaluated for inclusion. Forty-six patients were identified; 12 further augmented with an FHL transfer are included in the analysis. Isokinetic testing was completed with a Biodex dynamometer under supervision of a physical therapist masked to surgical side. Pre- and postoperative Foot and Ankle Outcome Scores (FAOS, before March 2016) or Patient-Reported Outcomes Measurement Information System (PROMIS, after March 2016) surveys were collected. Results: For knee flexion, peak torque was not significantly different when comparing operative and nonoperative sides at 180 degrees/second (45.38 Nm vs 45.96 Nm; P =.69) nor at 300 degrees/second (44.2 Nm vs 47.02 Nm; P =.069). Knee extension absolute peak torque was only found to be significantly weaker on the operative side at the faster testing (75.5 Nm vs 79.56 Nm; P <.05). Peak ankle plantarflexion torque was significantly weaker on the operative side at both the slower speed (60 degrees/second: 39.9 Nm vs 48.76 Nm; P <.005) and the faster speed (120 degrees/second: 31.3 Nm vs 40.7 Nm; P <.001). Average power for ankle plantarflexion did not differ significantly from the operative side to the nonoperative side in the slower test (26.46 W vs 27.48 W; P =.60) but did significantly differ on the faster test (32.13 W vs 37.63 W; P =.041). At an average of 19.9 months postoperation, all physical function and pain-related patient-reported outcome scores showed clinically and statistically significant improvement. Conclusion: Achilles reconstruction with a hamstring autograft ± FHL transfer allowed patients with severe Achilles pathology to return to good subjective function, with modest deficits in calf strength compared with the uninjured side. Overall knee flexion strength did not appear impaired. These results suggest that hamstring autograft reconstruction is a viable method to treat these complex cases involving a lack of healthy tissue, allowing patients to return to symptom-free physical function and athletic activity. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

The Achilles tendon is frequently injured in the young to middle aged population. Previous studies have shown that there is an increased risk of delay in postsurgical wound healing amongst tobacco smoking patients with Achilles tendon injury. This study utilized the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. We included patients between the ages of 18 and 35 years who underwent primary Achilles tendon repair between years 2011 and 2020. The procedure type (with or without graft, CPT 27650 and 27652), patient demographics, and comorbidities were included. Primary outcomes of interest were 30-day readmission, minor complications, outcomes related to wound healing (wound disruption, superficial surgical site infection, deep incisional surgical site infection, organ-space site infections) and reoperations within 30 days of index surgery. A total of 1944 patients met the inclusion criteria for this study. One thousand six hundred and fifty-nine patients were nonsmokers, while 285 were smokers. Logistic regression showed no differences between smokers and nonsmokers (reference group) for 30-day readmission, reoperation, and minor complications. However, Black non-Hispanic patients were found to be 0.3 times (95% confidence interval: 0.1, 0.98) as likely to develop minor complications as compared to the White non-Hispanic patients. Wound-related complications after Achilles tendon repair remain low in younger (18-35 years) patients. When comparing clinical outcomes between nonsmokers and smokers, we found no statistically significant difference in this retrospective study. [ABSTRACT FROM AUTHOR]

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Achilles tendon ruptures in collegiate gymnastics have significantly increased in the past few years, with 20 ruptures in the first three weeks of competition alone in 2020 according to Bonanno et al., 2022. Female gymnasts are ten times more likely to tear their Achilles than any other college athletes, with an incidence of 16.73/100,000. Men’s basketball has the next highest incidence at 4.26/100,000 (Bonanno et al., 2022). Contributing factors for the increase in ruptures are not well researched or understood. This paper will explore the relevant literature on the risk factors of tears and return to sport protocols. It will touch on early rehab but mainly focus on return to sport testing and progression for gymnastics from a physical therapy perspective. It will explore topics discussed in interviews with numerous sports physical therapists with extensive gymnastics or collegiate athletics experience. Gymnastics is a very technical sport where each athlete has individual skills with different biomechanical requirements; therefore, needs vary between athletes. This paper aims to address the transition phase between the time when surgical protocols allow a return to sport and the actual return to performance during recovery. In this specific domain, there is an ongoing need for prospective, longitudinal studies to investigate testing and outcome measures tailored to gymnastics. These studies can play a crucial role in guiding athletes, trainers, coaches, and therapists in facilitating a safe and effective return to performance after surgery.

Acute Achilles tendon rupture is a common injury and when missed leads to the development of a chronic Achilles tendon rupture. Studies suggest surgical treatment (either repair or reconstruction) for most patients with a chronic Achilles rupture due to the functional deficit caused by the lack of an intact Achilles tendon. Numerous autograft options such as the flexor hallucis longus, hamstrings, peroneal and quadriceps tendon have been used to reconstruct the Achilles tendon, either as a tendon transfer or as an interposition graft. The choice of autograft used usually depends on the size of the defect left after debridement of the Achilles tendon edges, but is often dictated by surgeon preference and tissue availability. Currently, there is no consensus as to the best autograft option. The aim of this study was to evaluate the various autograft options used to reconstruct the Achilles tendon, and the advantages and disadvantages of using each tendon, focussing specifically on the harvesting technique, anatomical and biomechanical properties. This was done by reviewing the current published literature, supplemented by carrying out anatomical dissection in the cadaveric lab. The flexor hallucis longus is synergistically related to the Achilles tendon and biomechanically strong, however harvesting can result in weakness in big toe flexion. The peroneus brevis whilst being biomechanically strong is a much shorter tendon compared to the other autograft options. Similarly, the quadriceps tendon is also a strong tendon option, but may not be appropriate for larger chronic Achilles tendon rupture gaps. The semitendinosus tendon can be tripled/quadrupled to resemble the Achilles tendon, but is associated with higher risks of patient morbidity when harvesting the tendon. Treatment of chronic Achilles tendon ruptures remains a challenge. Each autograft option has its own unique advantages and disadvantages which should be considered on a case-specific basis. Further work is required to analyse the biomechanical properties of the autograft options to determine if one option is superior. [ABSTRACT FROM AUTHOR]

Many if not most of us watched in utter disbelief and horror last September 11th as Aaron Rogers, the newly acquired $75 million dollar quarterback with the New York Jets just 4 snaps into the new season, suffered an Achilles Tendon ruptures (ATR) in his inaugural game on nationally televised Monday Night Football with his new and excited team and demanding fanbase. With cell phones in hand, we watched as our X apps lit up with claims of an excess of ATRs in the NFL in recent years and much of the blame placed on the new rubberized turf surfaces in place in most of the NFL stadiums. That first week of the NFL season the NFL Players Association, the NFLPA, put out a statement to this effect that demanded removal of rubberized turf surfaces throughout the NFL! With Kirk Cousins devastating ATR a few weeks later, amongst 21 others this season, and Aaron Rogers return to practice after a mere seven to eight weeks post-injury, this conundrum remains foremost in our hyper-questioning minds! [ABSTRACT FROM AUTHOR]

Background: Soft tissue complications after Achilles tendon repair has led to increased interest in less invasive techniques. Various limited open techniques have gained popularity as an alternative to open operative repair. The purpose of this study was to biomechanically compare an open Krackow and limited open repair for Achilles tendon rupture. We hypothesized that there would be no statistical difference in load to failure, work to failure, and initial linear stiffness. Methods: A simulated Achilles tendon rupture was created 4 cm proximal to its insertion in 18 fresh-frozen cadaveric below-knee lower limbs. Specimens were randomized to open or limited open PARS Achilles Jig System repair. Repairs were loaded to failure at a rate of 25.4 mm/s to reflect loading during normal ankle range of motion. Load to failure, work to failure, and initial linear stiffness were compared between the 2 repair types. Results: The average load to failure (353.8 ± 88.8 N vs 313.3 ± 99.9 N; P = .38) and work to failure (6.4 ± 2.3 J vs 6.3 ± 3.5 J; P = .904) were not statistically different for Krackow and PARS repair, respectively. Mean initial linear stiffness of the Krackow repair (17.8 ± 5.4 N/mm) was significantly greater than PARS repair (11.8 ± 2.5 N/mm) (P = .011). Conclusion: No significant difference in repair strength was seen, but higher initial linear stiffness for Krackow repair suggests superior resistance to gap formation, which may occur during postoperative rehabilitation. With equal repair strength, but less soft tissue devitalization, the PARS may be a favorable option for patients with risk factors for soft tissue complications. [ABSTRACT FROM AUTHOR]

Background: The development of Achilles tendon treatment modalities has been rapid, and it is increasingly difficult for clinicians to stay up to date with the most influential studies in this field. In order to fully understand the current state of the literature regarding Achilles tendon injury, it is invaluable to be familiar with the foundational articles and studies upon which the field is built. Purpose: To objectively determine the 50 most frequently cited studies in Achilles tendon pathology and to conduct a bibliometric analysis. Study Design: Cross-sectional study. Methods: The Clarivate Analytics Web of Knowledge database was used to gather data and metrics of Achilles tendon research. The 50 most cited articles were selected for analysis from an initial 17,244 identified articles. The information extracted for each article included author name, publication year, country of origin, journal name, study type, and level of evidence. Results: For these 50 studies, the total number of citations was calculated to be 13,159, with a mean of 263.2 citations per paper. The most cited article collected 657 citations. The publication dates of the 50 studies included in this analysis spanned 41 years (1972-2013). The largest number of articles were published by Swedish authors (n = 14); however, many other countries were represented, including Canada and Finland (n = 6 articles each). The most prevalent study designs were cohort studies (n = 13) with level 4 evidence studies being the most common (n = 14). Conclusion: Among the 50 most influential articles in Achilles tendon pathology, the study designs most commonly used were cohort studies and review articles. Sweden was the country of origin for the most studies included on this list, which reflects this country's interest and commitment to researching Achilles tendon injuries and treatments. [ABSTRACT FROM AUTHOR]

Recent literature suggests that functional treatment of acute non-insertional Achilles tendon ruptures yields outcomes (re-rupture and function) similar to those of surgery, but does not address the unique issues in treating high performance athletes or other high demand patients. Decision analysis was used to develop an estimate of outcome utility for both types of treatment using published Costs and Quality-Adjusted Life Years (QALYs) values. The expected value for either treatment was then calculated for high, intermediate, and normal demand patients, using the specific functional needs of the patients. Nonoperative treatment is the preferred management for normal demand patients, while high and intermediate demand patients are more likely to experience better expected functional outcomes from surgery. The combination of a decision analysis and expected value analysis provides evidence-based support for the existing intuitive recommendations that favor surgical treatment in elite athletes and other high demand patients. III [ABSTRACT FROM AUTHOR]

Martin Granath,1 Pär Hedlund,1 Christoph Spang,2 Håkan Alfredson3,4 1Orthopaedic Department, Hässleholm Hospital, Hässleholm, Sweden; 2Private Orthopaedic Spine Center, Würzburg, Germany; 3Institute of Sports Exercise and Health, University College Hospital London, London, UK; 4Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umeå, 90187, SwedenCorrespondence: Håkan Alfredson, Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umeå, 90187, Sweden, Tel +46 702288441, Email hakan.alfredson@umu.seBackground: Delayed Achilles tendon ruptures leaving large defects are difficult to treat, and the potential for tendon regeneration is thought to be limited. Furthermore, post-operative wound healing problems, sometimes including infections, can be challenging to treat and negatively affect rehabilitation.Case Presentation: This 74-year-old lady suffered from insertional Achilles tendinopathy. After treatment with a local cortisone injection, she sustained a total insertional Achilles tendon rupture. This rupture was treated conservatively, and after treatment the Achilles re-ruptured in the insertional area. The rupture was then treated with re-insertion into the calcaneal insertion. Early in the post-operative period the patient sustained a deep surgical wound infection and sepsis. Because of poor effect of treatment with antibiotics, and total tendon destruction, the whole Achilles was extirpated. After extirpation there was immobilization in a cast followed by mobilization and gradually increased loading. At a one-year follow-up, the patient was walking without a limp, could do heel-raise halfway up standing on one leg, there was a palpable Achilles tendon and ultrasound scanning showed a structure very similar to a slightly thickened and tendinopathic Achilles tendon. There was an obvious regeneration of the whole Achilles tendon, and the tendon function was surprisingly good.Conclusion: This case study clearly shows the regeneration potential in the Achilles tendon and provides significant knowledge of importance for clinicians dealing with Achilles tendon injuries.Keywords: Achilles tendon, tendinopathy, Achilles rupture, infection, regeneration

Fluoroquinolone antibiotics can increase the risk of tendon rupture. Treatment of these Achilles ruptures can be difficult due to comorbidities. A case series of 13 consecutive patients with Achilles ruptures following fluoroquinolone use were identified over a 2 year period through the Achilles Tendon rupture clinic and managed conservatively using functional rehabilitation. Follow-up with the Achilles tendon rupture score (ATRS) was completed at 3 months, 6 months and 12 months. Improvements were seen in ATRS scores over 12 months. This case series is the largest published. Improvements were seen in ATRS scores indicating that this cohort can be managed successfully using functional rehabilitation after fluoroquinolone-induced Achilles rupture. • Largest case series of Fluoroquinolone-related Achilles tendon ruptures. • All patients managed through functional rehabilitation. • Improvements seen in ATRS score but this may not be appropriate for this cohort of patients. [ABSTRACT FROM AUTHOR]

Abstract Background Following conservative management for acute Achilles tendon (AT) ruptures, the tendon may heal in continuity, and some patients may present with an elongated Achilles tendon–gastrosoleus complex. This study investigated the efficacy and feasibility of a novel minimally invasive technique, which we named “check-rein procedure”, in patients with intact and elongated AT following conservative management for AT ruptures. Methods All patients who underwent the check-rein procedure for elongation of the gastrosoleus–AT complex by one experienced surgeon were prospectively enrolled. The AT resting angle (ATRA) and AT rupture score (ATRS) were assessed at baseline and repeated at 2-year follow-up, as were calf circumference and isometric plantarflexion strength of both ankles. Results Forty-three patients (43 procedures) were analysed. The mean time elapsed from injury to surgery was 28.7 ± 7.9 weeks. The mean age at surgery was 38.5 ± 5.7 years. At the last follow-up, ATRS, ATRA, isometric strength difference, and calf circumference of the affected side were increased (P

Abstract Background Despite the literature on acute Achilles tendon ruptures, there remains a lack of consensus regarding the optimal treatment. The purpose of this survey study was to investigate treatment preferences among Army orthopaedic surgeons when presented with a standardized case of an acute Achilles rupture and determine if surgeon factors correlated with treatment preference. Methods A hypothetical case of a 37-year-old male with history, physical exam, and imaging consistent with an Achilles rupture was sent to board-certified Army orthopaedic surgeons to determine their preferred management. Demographic data was collected to include: practice setting, years from residency graduation, and completion of fellowship. Correlations analyzed between demographics and treatment preferences. Results Sixty-two surgeons responded. 62% of respondents selected surgical intervention. Of these, 59% chose a traditional open technique. 50% of respondents were general orthopaedic. There was a correlation between fellowship training and operative management (P = 0.042). Within the operative management group there was no statistical difference (P > 0.05) in need for further imaging, technique used, post-operative immobilization, length of immobilization, weight-bearing protocol, and time to release to running. The majority of non-operative responders would splint/cast in plantarflexion or CAM boot with heel lift for

Background: The percutaneous knotless repair technique for Achilles tendon ruptures utilizes a Percutaneous Achilles Repair System (PARS) device for suturing the proximal tendon and 2 suture anchors for fixing the sutures into the calcaneus. Determining the best position of the suture anchors may optimize the strength of this repair. Methods: Twelve pairs of human ankle cadaveric specimens were randomly assigned to receive suture anchors placed at 45°, 90°, or 135° from the sagittal plane. The anchors were tensioned according to a protocol representing progressive, postoperative rehabilitation. Load, number of loading cycles, displacement, and mode of failure were recorded. Results: With the anchors placed at 45°, 90°, and 135°, the ultimate failure loads were mean 265 ± 64 N, 264 ± 75 N, and 279 ± 40 N, and the total number of loading cycles were mean 459 ± 166, 466 ± 158, and 469 ± 110, respectively. The effect of anchor angle on failure load, number of loading cycles, and displacement was not statistically significant. Visually, the anchors at 45° and 90° demonstrated sutures cutting through the bone. Conclusion: We found no statistically significant difference in pullout strength between the 3 different anchor angles. Sutures cutting through the bone may be a concern with acute anchor angles. This suggests that a 135° anchor angle may result in a lower risk of tendon elongation with the percutaneous knotless repair technique. Levels of Evidence: Cadaveric laboratory study [ABSTRACT FROM AUTHOR]

Objective: Professional Basketball players are at high risk of Achilles tendon rupture. Despite this, there remains limited research into the factors affecting rehabilitation and the long term outcomes of these players. Our aim is to quantify the effect of a player’s Achilles tendon rupture on their post-injury performance, and also to explore for correlations between their recovery timeline and pre-injury characteristics. Creation of an injury timeline of past incidents will allow injured players to better track their progress and also inform them about the probable impact on their careers. Hypothesis: Players with Achilles tendon rupture injury will exhibit decreased performance compared to their pre-injury self and their non-injured peers after recovery. Methods: Professional basketball players who sustained a unilateral Achilles tendon rupture from 1992 to 2016 were collected. 12 players met our inclusion criteria and their Player Efficiency Ratings (PER) were obtained as primary outcome measures; matched controls were chosen based on the PER, Age and playing position. The players’ index season PER was compared against the PER during the 10 games immediately following the players’ return and the PER of their post-injury peak performing season. The same data analysis was performed against their control group. To investigate the factors affecting the recovery and long-term consequences of their injury, we correlated the variables of Age, BMI, Time of Injury and pre-injury PER with the player’s time to return to play and their post-injury PER. Results: 2 out of 12 players failed to return to playing in the elite professional league following an Achilles Tendon Rupture, others returned after a mean recovery time of 10 months. When compared to players’ index PER, the mean PER reduction during the 10 games immediately following the players’ return was 7.15 (P

Background: The sudden and debilitating nature of lower extremity injuries can trigger mood disturbances, including major depressive disorder. Methods: This prospective study enrolled patients undergoing operative repair of ankle fractures and Achilles ruptures and followed them for 1 year postoperatively. The validated Patient Health Questionnaire (PHQ-9) for depressive symptoms was administered at the preoperative visit and at postoperative weeks 1, 2, 4, 8, 16, 24, 32, 40, and 52. PHQ-9 is scored 0 to 27, with higher values indicating greater depression symptoms. Results: Fifty-eight patients completed 1 year of follow-up. The mean PHQ-9 score was 2.7 (range, 0-20) at the preoperative visit, peaked at postoperative week 1 (4.9; range, 0-16), and reached its low at postoperative week 52 (0.8; range, 0-7). Cumulative incidences of depressive symptoms during the first year following surgery were 51.7% for at least mild depression, 22.4% for at least moderate depression, and 6.9% for severe depression. A history of mental health disorder and the inability to work during the period of postoperative immobilization were independently associated with greater depressive symptoms. Conclusion: The majority of patients undergoing operative treatment of Achilles ruptures and ankle fractures develop postoperative symptoms of mild to moderate depression that normalize after several months. Patients with a history of mental health disorder or who cannot work while immobilized postoperatively are at greatest risk. Level of Evidence: Level II, prospective cohort study. [ABSTRACT FROM AUTHOR]

Background: Following conservative management for acute Achilles tendon (AT) ruptures, the tendon may heal in continuity, and some patients may present with an elongated Achilles tendon–gastrosoleus complex. This study investigated the efficacy and feasibility of a novel minimally invasive technique, which we named "check-rein procedure", in patients with intact and elongated AT following conservative management for AT ruptures. Methods: All patients who underwent the check-rein procedure for elongation of the gastrosoleus–AT complex by one experienced surgeon were prospectively enrolled. The AT resting angle (ATRA) and AT rupture score (ATRS) were assessed at baseline and repeated at 2-year follow-up, as were calf circumference and isometric plantarflexion strength of both ankles. Results: Forty-three patients (43 procedures) were analysed. The mean time elapsed from injury to surgery was 28.7 ± 7.9 weeks. The mean age at surgery was 38.5 ± 5.7 years. At the last follow-up, ATRS, ATRA, isometric strength difference, and calf circumference of the affected side were increased (P < 0.0001). The rate of the return to sport was 98% (42 of 43). No wound complications or rupture were experienced by any patient. Conclusion: The check-rein technique for AT elongation after conservative management of AT tears is effective and feasible to restore tendon length and calf function. The surgical outcome was influenced by the preoperative performance status, and longer time elapsed from injury to surgery worsens the outcomes. [ABSTRACT FROM AUTHOR]

Background: During management of Achilles tendon rupture, determination of tendon-end approximation, either clinically or by ultrasound is difficult, following brace application of during loading. The Radiographic Achilles Tendon Loading Angle (RadATLA) is proposed as a method of measuring ankle position whilst loading in a brace during the management of Achilles tendon rupture. This study aims to determine the reliability and reproducibility of the RadATLA.Methods: A loaded true lateral ankle radiograph including the fifth metatarsal head was taken when wearing a brace at the 6-week time point in 18 patients (19 ankles). following Achilles tendon repair or reconstruction. The RadATLA was compared with the Tibio-talar angle, other radiographic and clinical measures used to quantify foot and ankle position during the first 6 weeks of early rehabilitation in a resting position and during loading.Results: The intra-rater reliability of both angles was found to be good (>0.8). The RadATLA was found to have an excellent intra-rater reliability with Intra-class correlation of (ICC) 0.992-0.996 (95%CI 0.889-0.999), standard error of the measurement (SEM) 1.03-3.65 and Minimal Detectable Change (MDC) 2.86-10.12. The inter-rater reliability was good with ICC of 0.798-0.969 (95%CI-0.03 to 0.964), SEM 2.9-7.6, and MDC 8.1-20.9. The RadATLA loaded at 6 weeks in all patients was at mean (SD) (range) 41.9˚ (16.5), (18.5-75.9). There was a significant difference between the patients in the Repair group compared with patients in the Reconstruction group both in RadATLA loaded at 6 weeks: 35.6˚ (11.2), (18.5-56.5) versus 55.5˚ (19), (20-75.9), (p = 0.01). The amount loaded in all patients was at mean (SD) (range) 29.2Kg (17.7), (2-56) and the percentage Body Weight was 30.7% (19), (2.1-63.2). There were no differences between the groups neither in amount loaded nor in percentage Body weight (p = 0.614-0.651).Conclusions: The RadATLA is a reliable and reproducible angle and can be used to determine the position of the ankle, when loaded in a brace during rehabilitation following Achilles tendon rupture. [ABSTRACT FROM AUTHOR]

Chronic Achilles tendon ruptures can result in tendon lengthening and significant functional deficits including gait abnormalities and diminished push-off strength. Surgical intervention is typically required to restore Achilles tension and improve ankle plantarflexion strength. A variety of surgical reconstruction techniques exist depending on the size of the defect and amount of associated tendinosis. For smaller tendon defects 2 to 3 cm in size, primary end-to-end repair using an open incision and multiple locking sutures is an established technique. However, a longer skin incision and increased soft tissue dissection is required, and failure at the suture-tendon interface has been reported that can result in postoperative tendon elongation and persistent weakness. In this report, we describe a novel technique to reconstruct chronic midsubstance Achilles tendon ruptures using a small incision with knotless repair of the tendon secured directly to the calcaneus. This technique minimizes wound healing complications, increases construct fixation strength, and allows for early range of motion and rehabilitation. Level of Evidence: Level V, Expert Opinion. [ABSTRACT FROM AUTHOR]

We report on the outcome of acute Achilles tendon ruptures by a single surgeon using open and percutaneous techniques was performed. This prospective study included 186 patients with 188 ruptured Achilles tendons. A traditional open technique was primarily performed on patients from January 2001 to December 2011. From January 2012 to January 2018, a percutaneous repair was primarily performed. Outcome measures included the Roles and Maudsley (RM) score, ability to perform a single leg heel raise, calf atrophy and return to activity. There were 149 males (average age 42.5 ± 12.7 years) and 39 females (average age 41.7 ± 11.4 years). Of the 188 ruptured tendons (92 repairs on the right Achilles and 96 on the left), 103 were repaired percutaneously and 85 had open repairs. There were 18 (9.6%) complications. Three re-ruptures occurred, one following open and two following percutaneous repairs, all within 12 weeks of the original repair. Two patients developed a Venousthromboembolism (1.0%). Thirteen patients had suture reactions; three infections (1.6%), 11 wound complications (5.8%), and 3 required surgical excision of the suture material (1.6%). Non-absorbable sutures were associated with more wound complications and were more frequently used in open repairs (p =.003). Patients who underwent open repair experienced more wound complications (p =.0001). Patients who underwent percutaneous repair using absorbable suture experienced a lower rate of overall complications (p =.0007). Basketball (n = 29) was the most common sport during which ruptures occurred. Return to activity (RTA) was 8.2 ± 2.9 months. There was no difference for RTA between males and females (p =.54) and RM scores (p =.69), nor surgical technique, and no difference for RTA based on the desired activity (p =.47). 123 of the 188 patients returned to their desired activity (65.5%). There was a statistically significant evidence of a positive association between inability to perform heel-raises and decreased activity (p =.01). [ABSTRACT FROM AUTHOR]

Background: Despite the literature on acute Achilles tendon ruptures, there remains a lack of consensus regarding the optimal treatment. The purpose of this survey study was to investigate treatment preferences among Army orthopaedic surgeons when presented with a standardized case of an acute Achilles rupture and determine if surgeon factors correlated with treatment preference.Methods: A hypothetical case of a 37-year-old male with history, physical exam, and imaging consistent with an Achilles rupture was sent to board-certified Army orthopaedic surgeons to determine their preferred management. Demographic data was collected to include: practice setting, years from residency graduation, and completion of fellowship. Correlations analyzed between demographics and treatment preferences.Results: Sixty-two surgeons responded. 62% of respondents selected surgical intervention. Of these, 59% chose a traditional open technique. 50% of respondents were general orthopaedic. There was a correlation between fellowship training and operative management (P = 0.042). Within the operative management group there was no statistical difference (P > 0.05) in need for further imaging, technique used, post-operative immobilization, length of immobilization, weight-bearing protocol, and time to release to running. The majority of non-operative responders would splint/cast in plantarflexion or CAM boot with heel lift for < 3 weeks (50%) and keep non-weight bearing for < 4 weeks (63%). Only 38% of respondents would use DVT chemoprophylaxis.Conclusion: When provided with a hypothetic case of an acute Achilles tendon rupture, queried Army orthopaedic surgeons would more often treat with a surgical procedure. This difference in treatment is secondary to training, fellowship or other. This propensity of surgical management, likely stems from the highly active population and the desire to return to duty. [ABSTRACT FROM AUTHOR]

Objectives: Studies have shown that patients enrolled in Medicaid have difficulty obtaining access to care compared with patients with private insurance. Whether variables such as geographic location, state expansion versus nonexpansion, and private versus academic affiliation affect access to care among foot and ankle surgery patients enrolled in Medicaid has not been previously established. The purpose of this study was to assess the differences in access to care between patients who are privately insured and those with Medicaid in need of foot and ankle consultation. Secondary objectives include assessment of whether access to care for foot and ankle patients with Medicaid differs between those with acute and chronic conditions, Medicaid expanded and unexpanded states, geographic regions within the United States, and academic versus private practices.Methods: Twenty providers from each of five Medicaid-expanded and five nonexpanded states in different US geographic regions were randomly chosen via the American Orthopaedic Foot & Ankle Society directory. One investigator contacted each office requesting the earliest available appointment for their fictitious relative's acute Achilles tendon rupture or hallux valgus. Investigator insurance was stated to be Medicaid for half of the telephone calls and Blue Cross Blue Shield (BCBS) for the other half. Appointment success rate and average time to appointment were compared between private insurance and Medicaid. Results were further compared across geographic regions, between private and academic practices, and between urgent acute injury (Achilles rupture) and chronic nonurgent injury (hallux valgus).Results: Appointments were successful for all 100 (100%) calls made with BCBS as the insurer, in comparison to 73 of 100 calls (73%) with Medicaid (P < 0.001). Both acute and chronic injury had significantly higher success rates with BCBS than Medicaid (P < 0.001). The appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ 0.01) in all of the geographic regions. The success rate with Medicaid (66.7%) was significantly lower than with BCBS (100.0%, P < 0.001) for private practice offices, but not for academic practices.Conclusions: Patients with Medicaid experience fewer options when obtaining appointments for common nonemergent foot and ankle problems and may experience less difficulty scheduling appointments at academic rather than private institutions. The medical community should continue to seek and identify potential interventions which can improve access to orthopedic care for all patients and increase the visibility of practices that accept Medicaid. [ABSTRACT FROM AUTHOR]

The Achilles tendon is vital for walking and running, but it's also the most frequently ruptured tendon. Ruptures often occur without direct trauma and present with acute posterior ankle/heel pain. Various factors like age, biomechanical properties, degeneration, and mechanical factors influence susceptibility to rupture. Mechanisms of injury vary, including weight-bearing forefoot pushing off and sudden dorsiflexion of the ankle. Management goals focus on minimizing morbidity, swift recovery, and preventing complications through tailored interventions. Systemic lupus erythematosus (SLE) can also contribute to tendon rupture, especially with prolonged corticosteroid use. A 32-year-old female presented to the ER after injuring her left foot during a basketball game. She was diagnosed with an Achilles tendon rupture and underwent surgery to repair it. However, she experienced delayed wound closure and needed a skin graft. Two months later, she suffered another rupture in a different location, requiring a tendon transfer surgery. She was finally diagnosed with SLE after tests by the Rheumatology Department. Treatment commenced, and she began rehabilitation four weeks post-surgery. Surgical management of ruptured Achilles tendon involves techniques like open repair, percutaneous repair, mini-open repair, and augmentative repair. Open repair involves a direct approach with a posteromedial incision to align tendon stumps using various stitching techniques. Conservative treatment involves immobilization and non-weight-bearing for at least four weeks post surgery. For rare cases of Achilles tendon rupture caused by lupus, treatment focuses on managing the underlying disease with medications like hydroxychloroquine and glucocorticosteroids. Comprehensive evaluation, including musculoskeletal assessment, is crucial for lupus patients. SLE needs to be considered as a potential cause, especially in cases of recurrent ruptures or additional musculoskeletal symptoms. Surgical management should be tailored to individual patient needs, while also considering surgeon proficiency and preferences., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Jiménez-Yarza et al.)

Importance: Men have a higher risk of Achilles tendon (AT) injury, and the impact of morphological and mechanical sex differences may play a role., Aim: The aim of this study is to systematically review the literature to determine whether there are sex-specific differences in AT morphological and mechanical properties and analyze how these differences may impact AT injury in both men and women., Evidence Review: A systematic literature search of articles published between 2001 and 2021, in the MEDLINE, EMBASE, and Cochrane databases was performed during May 2022 according to PRISMA. The primary outcome measures included sex-related differences in the mechanical and morphological properties of the Achilles tendon. Secondary outcomes included impact of sex on Achilles tendon properties and adaptation., Findings: Nineteen studies with a total of 1,143 participants (613 men and 530 women) were included in this systematic review. Men had increased measurements when compared with women in the following: AT length, thickness, cross-sectional area (CSA), stiffness, peak force, loading rate, and voluntary muscle contraction. Women had an increase in CSA deformation, strain, and compliance., Conclusions and Relevance: Our study demonstrates that men have an increased AT length, thickness, and CSA, indicating that men may be subjected biomechanically to higher loads in their day-to-day activities. In addition, men have lower deformation and compliance properties, along with increased AT stiffness, reducing their capacity to adapt during loading, potentially increasing their risk of injury., Level of Evidence: IV., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: James Calder reports a relationship with Arthrex Inc that includes: consulting or advisory and speaking and lecture fees. James Calder reports a relationship with Bone Joint Journal that includes: board membership. James Calder reports a relationship with Innovate Orthopaedics Ltd that includes: equity or stocks. James Calder reports a relationship with Knee Surgery, Sports Traumatology, and Arthroscopy that includes: board membership. James Calder reports a relationship with Smith and Nephew Inc that includes: consulting or advisory. John Kennedy reports a relationship with Arthrex Inc that includes: consulting or advisory. John Kennedy reports a relationship with Isto Biologics that includes: consulting or advisory. John Kennedy reports a relationship with European Society for Sports Traumatology, Knee Surgery and Arthroscopy that includes: board membership. John Kennedy reports a relationship with American Orthopaedic Foot and Ankle Society that includes: board membership. John Kennedy reports a relationship with International Society for Cartilage Repair of the Ankle that includes: board membership. John Kennedy reports a relationship with Arthroscopy Association of North America that includes: board membership. John Kennedy reports a relationship with Ankle and Foot Associates that includes: board membership. Gino Kerkhoffs reports a relationship with European Society for Sports Traumatology, Knee Surgery and Arthroscopy that includes: board membership. Gino Kerkhoffs reports a relationship with fa. Heel that includes: non-financial support., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

The optimal treatment of Achilles tendon ruptures (ATRs) is a subject of some debate amongst orthopedic surgeons. Many patients' understanding of Achilles injuries is limited and may be more informed by popular culture than anything objective. We sought to assess patient perceptions of ATRs using a proprietary questionnaire and correlate that with demographic information and the health literacy of the patient. Patients presenting with an Achilles tendon injury were asked to fill out a demographic form, the Literacy in Musculoskeletal Problems (LiMP) survey, to assess musculoskeletal health literacy, and a 22-question survey on ATRs designed to assess patient knowledge and perception of ATRs. Seventy percent of patients responded that surgery with or without other modalities is the most appropriate treatment for ATRs, while only 20% of patients responded that nonoperative treatment is most appropriate. Perceptions of treatment were not associated with demographic data or LiMP scores and appear to be biased to some degree towards surgery. In a setting in which the optimal treatment has not been fully worked out by surgeons, it is difficult to tell what influence patient perceptions may have on treatment, although it is possible these patient perceptions may cause surgeons to be more surgically aggressive. [ABSTRACT FROM AUTHOR]

Achilles tendon rupture is a debilitating injury with a protracted and sometimes incomplete recovery. The surgical method of Achilles tendon repair, like open repair with or without augmentation, has a higher complication rate like delayed tendon healing (since paratenon integrity is destroyed in open repair technique which delays or hampers the tendon healing). Wound healing problems like suture granuloma, deep infection, skin edge necrosis, superficial dehiscence, pressure ulcer, and blisters may occur. Here we developed a newer hybrid technique (open exposures of the tendon and percutaneous tenodesis through calcaneum) for Achilles tendon repair to minimize the complications and enhance the tendon healing. Excellent results were observed with this hybrid technique. [ABSTRACT FROM AUTHOR]

Aim: In this study, we aimed to evaluate the effect of the use of the oral polytendon complex (Tendoflex Mega-Farma Pharmaceutical Company) as a nutritional supplement after the open repair of Achilles tendon rupture cases on clinical outcomes. Material and Methods: This study included 29 consecutive patients with Achilles tendon ruptures who had undergone open repair of the Achilles tendon and took postoperative oral Tendoflex treatment as a dietary supplement. Patients have been followed up in the postoperative 8th 12th and 48th weeks. The ranges of motions and visual analog scale (VAS) score for pain was noted. The Achilles tendon Total Rupture Score(ATRS) was also pointed out at the last follow up. Results: There were no cases of re-rupture. There were no cases of infection and or nerve injury. 48th week follow up results were plantar flexion 47.1 degrees, dorsiflexion 17.8 degrees, eversion 17.1degrees, inversion 28.2 degrees with a mean VAS score of 0.6 and a mean ATRS of 93. Conclusion: The open repair of Achilles tendon ruptures has certain advantages like lower re-rupture rates and lower iatrogenic neural injury rates. Including Tendoflex to the treatment protocol, may also have prevented re-ruptures and provided rapid amelioration of pain. [ABSTRACT FROM AUTHOR]

Background: The incidence of Achilles ruptures has been on the rise in National Collegiate Athletic Association (NCAA) football players, but the career impact of this injury is not fully understood. In this study, we analyzed a large series of Achilles tendon injuries in NCAA Football Bowl Subdivision (FBS) defensive football players who required repair in order to determine their return to play, performance, and career outcomes afterward. Methods: FBS defensive football players who required Achilles repair from 2010 to 2016 were identified. The return to play of the eligible underclassmen athletes was then determined and the preinjury and postoperative performances of players who met criteria were compared with matched controls. The number of underclassmen who went on to participate in the National Football League (NFL) Combine or play in at least 1 NFL game was also determined and compared with controls. Results: Fifty-seven total Achilles ruptures were identified, 40 of which occurred in underclassmen, who returned at a rate of 92.5%. Of the players who met performance criteria, only defensive backs differed from matched controls in terms of solo tackling (P =.025) and total tackling (P =.038), while still increasing compared with preoperative performance. Only 5.0% of underclassmen performed at NFL Combine and only 7.5% competed in at least 1 NFL game (20.0% and 21.3%, respectively, for matched controls). Conclusion: Defensive FBS players returned at a high rate following Achilles rupture and did not seem to experience a significant drop-off in performance upon return. An Achilles rupture did appear to impact their chances of playing professionally in the future, however. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Currently, Achilles tendon rupture repair is surgically addressed with an open or minimally invasive approach using a heavy, nonabsorbable suture in a locking stitch configuration. However, these sutures have low stiffness and a propensity to stretch, which can result in gapping at the repair site. Our study compares a new multifilament stainless steel cable-crimp repair method to a standard Krackow repair using multistrand, ultra-high molecular weight polyethylene polyester sutures. Eight matched pairs of cadavers were randomly assigned for Achilles tendon repair using either Krackow technique with polyethylene polyester sutures or the multifilament stainless steel cable-crimp technique. Each repair was cyclically loaded from 10 to 50 N for 100 loading cycles, followed by a linear increase in load until complete failure of the repair. During cyclic loading, 4 of the 8 Krackow polyethylene polyester suture repairs failed, whereas none of the multifilament stainless steel cable crimp repairs failed. Load to failure was greater for the multifilament stainless steel cable crimp repairs (321.03 ± 118.71 N) than for the Krackow polyethylene polyester suture repairs (132.47 ± 103.39 N, p =.0078). The ultimate tensile strength of the multifilament stainless steel cable crimp repairs was also greater than that of the Krackow polyethylene polyester suture repairs (485.69 ± 47.93 N vs 378.71 ± 107.23 N, respectively, p =.12). The mode of failure was by suture breakage at the crimp for all cable-crimp repairs and by suture breakage at the knot, within the tendon, or suture pullout for the polyethylene polyester suture repairs. The multifilament stainless steel cable crimp construct may be a better alternative for Achilles tendon rupture repairs. [ABSTRACT FROM AUTHOR]

The Achilles tendon is the largest, and most commonly torn tendon in the body. The Achilles is usually torn at a region of relative hypo-vascularity proximal to its insertion. However, partial thickness tears and other pathologies often occur at its insertion on the calcaneus. Anatomically, the insertion is a confluence of the gastrocnemius and soleus muscles that fuse to form a myotendinous unit on the posterosuperior aspect of the calcaneus. This review aims to reveal the insertional footprint as individual fascicular components attaching to facets of calcaneal tuberosity. Understanding this anatomy is essential for interpreting tear patterns and surgical implications. [ABSTRACT FROM AUTHOR]

Introduction The Achilles tendon ruptures are common traumatic injuries. Treatment is usually surgical. Surgery may be open or percutaneous. The aim of this study is to evaluate the clinical and functional outcomes in patients with acute Achilles ruptures treated by minimally invasive Dresden technique. Material and methods A prospective study of 15 patients with acute Achilles tendon ruptures. Intraoperative characteristics, hospitalization, functional outcomes and evaluation according to AOFAS score were evaluated. The average follow-up was 18 months. Results The results are listed based on the surgical time, hospital stay, time to surgery, weight load and postoperative protocol. The AOFAS at five months was 94.66 points. Return to work activity: 3.53 average months. Return to sport: 6.53 months Conclusions The percutaneous technique for the repair of acute Achilles tendon rupture is a good choice, presenting good performance and low complication rate.

• The addition of three absorbable sutures thread result in significantly reduction of the tendon stretching in the preload phase. • The addition of three absorbable sutures increased the rigidity and maximum load force until rupture of the construct. • The results of the Triple Shoelace demonstrating that the technique is feasible for repair and allows for earlier postoperative rehabilitation. • The order of suture knots on triple shoelace did not show statistical significance on the ultimate load force, creep or stiffness of the system. • The group2 suture achieved better distribution of tension in all threads promoting a marginal improvement in the construction of the suture tendon. The biomechanical assessment of tendon repair is essential for the evaluation of different tendon suturing techniques. The shoelace suture technique with absorbable Vicryl® is a modified technique of Achilles tendon repair that may have biomechanical advantages depending on the number of threads used and the direction of the suture. To evaluate the creep under constant pre-load, the stiffness, the maximum strength, and the failure mode for three different configurations of the shoelace suture in a bovine tendon biomechanical model. Controlled Laboratory Study. 36 bovine Achilles tendon specimens were acquired and divided into three test groups of 12 Achilles tendons each. A model of the calcaneal tendon rupture was created through a transverse cut with a scalpel, performed 5 centimeters proximal to the calcaneal bone insertion. Group 1 was repaired using the simple shoelace technique with just one suture. Group 2 was repaired using the shoelace technique with three sutures individually sutured from distal to proximal at the site of rupture. Group 3 was repaired using the shoelace technique with three sutures individually sutured from proximal to distal at the site of rupture. System creep after constant pre-load was 5.9 ± 2.5 mm, 3.0 ± 0.4 mm and 2.9 ± 0.4 mm for groups 1, 2 and 3, respectively. The system's stiffness was 23.2 ± 2.8 N/mm, 30.3 ± 1.1 N/mm and 29.8 ± 2.3 N/mm for groups 1, 2 and 3, respectively. In the final load-to-failure test, the ultimate load force (ULF) was 158.2 ± 27.5 N, 346.5 ± 47.6 N and 358.1 ± 41.6 N for groups 1, 2 and 3, respectively. There was statistical significance in the comparative tests between groups 1-2 and 1-3 in terms of means of creep, system stiffness and maximum system strength. No statistically significant difference was found between groups 2 and 3 when analyzing creep, system stiffness and ULF. Suture breakage was the prevalent mode of failure for all tested groups. The shoelace with three sutures significantly reduced creep in the preloading phase and increased the stiffness and ultimate load force. The biomechanical results demonstrate better overall mechanical performance of the technique than the simple shoelace technique. The better mechanical performance indicates that the shoelace with three sutures could result in early postoperative rehabilitation. This study indicates that the shoelace suture technique with three sutures is biomechanically strong and stiff, being a possible therapeutic option to be used. [ABSTRACT FROM AUTHOR]

Background: Rupture of the Achilles tendon may result in reduced functional activity and reduced plantar flexion strength. These changes may arise from elongation of the Achilles tendon. An observational study was performed to quantify the Achilles tendon resting angle (ATRA) in patients following Achilles tendon rupture, surgical repair, and rehabilitation, respectively. Methods: Between May 2012 and January 2013, 26 consecutive patients (17 men), with a mean (standard deviation, SD) age of 42 (8) years were included and evaluated following injury, repair, and at 6 weeks, 3 months, 6 months, 9 months, and 12 months, respectively (rehabilitation period). The outcome was measured using the ATRA, Achilles tendon total rupture score (ATRS), and heel-rise test. Results: Following rupture, the mean (SD) absolute ATRA was 55 (8)° for the injured side compared with 43 (7)° (p

Background: Achilles tendon insertional sleeve avulsions occur when the Achilles distal tendon sleeve ruptures off of its insertion into the calcaneal tuberosity, sometimes with a small bony fragment from calcific tendinosis. Little evidence exists describing the outcomes and rerupture rate after operative management of Achilles tendon sleeve avulsions. Methods: A retrospective chart review was performed to identify patients who sustained an Achilles sleeve avulsion injury treated with operative repair between October 2005 and July 2014. A cohort of 16 patients from the general population and 12 professional athletes were included in the study. The primary outcome variable was rerupture of the Achilles tendon or need for revision surgery. Secondary outcome variables included the Coughlin Satisfaction Scale, visual VR-12, and Foot and Ankle Ability Measure (FAAM). Results: In the general population cohort, median follow-up was 8.1 years (range, 3.2-11.1 years). The median FAAM Activities of Daily Living score was 100 (range, 42.9-106), and the median FAAM Sports score was 100 (range, 7.1-103.6). The median VR-12 Mental Component Score was 66.9 (range, 45.6-71.8), and the median VR-12 Physical Component Score was 53 (range, 30.8-57.5). In the cohort of professional athletes, preceding insertional Achilles symptoms were present in 91.7% (11/12) of athletes for more than 9 months prior to rupture. All athletes returned to play with an average time of 13.4 months. No patients sustained a rerupture in the follow-up period. Conclusion: Operative repair of Achilles tendon sleeve avulsions was safe and effective with high patient satisfaction and good clinical outcomes in patients from the general population. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Background: Open Achilles tendon surgery with the patient in the supine position potentially avoids the complications of the prone position, but the safety and viability of the supine position for this procedure are not known. The aim of this study was to test the hypothesis that supine positioning for open repair of acute Achilles tendon ruptures would be safe, with low wound and neurologic complication rates. Methods: Supine position safety in acute Achilles tendon repair was investigated. Consecutive cases of supine Achilles tendon surgical repair performed by one surgeon from 2010 to 2015 were retrospectively reviewed. Patients were included if they were surgically treated with primary repair in the supine position within 15 days of injury and did not undergo concomitant surgery. A paramedian incision 1 cm medial to the Achilles sheath was used. Initial chart review identified 161 patients who underwent any type of Achilles tendon surgery in the supine position, of whom 45 patients met the inclusion criteria. This group included 39 men and 6 women with an average age of 41 years (range, 20–66 years). Median length of follow-up was 116 days (range, 25–1,589 days). Average body mass index was 29 kg/m2 (range, 23–36 kg/m2). Results: There were no infections, sural nerve injuries, or reruptures. Conclusions: The supine position was safe for primary open Achilles tendon repair, with no wound or neurologic complications. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

We present a case report with 1-year follow-up data of a 57-year-old male soccer referee who had sustained an acute triple Achilles tendon rupture injury during a game. His triple Achilles tendon rupture consisted of a rupture of the proximal watershed region, a rupture of the main body (mid-watershed area), and an avulsion-type rupture of insertional calcific tendinosis. The patient was treated surgically with primary repair of the tendon, including tenodesis with anchors. Postoperative treatment included non-weightbearing for 4 weeks and protected weightbearing until 10 weeks postoperative, followed by formal physical therapy, which incorporated an “antigravity” treadmill. The patient was able to return to full activity after 26 weeks, including running and refereeing, without limitations. [ABSTRACT FROM AUTHOR]

Background: Following Achilles tendon rupture, tendon elongation leads to long term deficits in calf function. A surrogate measure of Achilles tendon length, Achilles tendon resting angle (ATRA), has been described but has not been validated against length measured using ultrasound. Therefore, the purpose of this study was to validate the ATRA against ultrasound. Secondarily, this study aimed to identify the relationship of other factors (tendon mechanical properties, heel-rise test performance) to the ATRA. Methods: Individuals following unilateral Achilles tendon rupture were included. ATRA was measured in knee flexed and extended positions. Tendon elongation was measured using extended field of view ultrasound imaging. Continuous shear wave elastography quantified tendon mechanical properties. The relationship between variables was tested using Spearman’s ρ. Subgroup analysis was used to compare subjects with less then or greater than 1 year following rupture. A total of 42 participants (with a mean of 18.2 months following rupture [SD = 35.9]) were included. Results: Tendon elongation related with relative ATRA with knee flexed (ρ = .491, P = .001) and knee extended (ρ = 0.501, P = .001) positions. In individuals greater than 1 year following rupture, relative ATRA with the knee flexed related to shear modulus (ρ = .800, P = .01) and total work on the heel-rise test (ρ = –.782, P = .008) relative to the uninjured side. Conclusion: Relative ATRA in both knee flexed and knee extended positions has a moderate relationship to tendon elongation within the first year following rupture. After 1 year, the relative ATRA with knee flexed may be a better indicator of tendon elongation and also related to tendon mechanical properties and heel-rise test performance. Level of Evidence: Level III, case-control study. [ABSTRACT FROM AUTHOR]