Achilles Tendon Injuries: Comparison of Different Conservative and Surgical Treatment and Rehabilitation

Despite its high incidence and the great development of literature, there is still controversy about the optimal management of Achilles tendon rupture. The several techniques proposed to treat acute ruptures can essentially be classifi ed into: conservative management (cast immobilization or functional bracing), open repair, minimally invasive technique and percutaneous repair with or without augmentation. Although chronic ruptures represent a different chapter, the ideal treatment seems to be surgical too (debridement, local tissue transfer, augmentation and synthetic grafts). In this paper we reviewed the literature on acute injuries. Review Article Achilles Tendon Injuries: Comparison of Different Conservative and Surgical Treatment and Rehabilitation Alessandro Bistolfi , Jessica Zanovello, Elisa Lioce, Lorenzo Morino, Raul Cerlon, Alessandro Aprato* and Giuseppe Massazza Medical school, University of Turin, Turin, Italy *Address for Correspondence: Alessandro Aprato, Medical School, University of Turin, Viale 25 Aprile 137 int 6 10131 Torino, Italy, Tel: +39 338 6880640;  January 2017 Approved: 13  21 February 2017  Bistolfi A, et al.  Bistolfi A, Zanovello J, Lioce E, Morino L, Cerlon R, et al.  Comparison of Different Conservative and Surgical Treatment and Rehabilitation.  2017; 1: 039-053.  The Achilles is the strongest and the largest tendon in the body and it can normally withstand several times a subject’s body weight. Achilles tendon rupture is frequent and it has been shown to cause signi icant morbidity and, regardless of treatment, major functional de icits persist 1 year after acute Achilles tendon rupture  and only 50-60% of elite athletes return to pre-injury levels following the rupture . Most Achilles tendon rupture is promptly diagnosed, but at irst exam physicians may miss up to 20% of these lesions . The de inition of an old, chronic or neglected rupture is variable: the most used timeframe is 4 to 10 weeks . The diagnosis of chronic rupture can be more dif icult because the gap palpable in acute ruptures is no longer present and it has been replaced by ibrous scar tissue. Typically chronic rupture occur 2 to 6 cm above the calcaneal insertion with extensive scar tissue deposition between the retracted tendon stumps , and the blood supply to this area is poor. In this lesion the tendon end usually has been retracted so the management must be different from the acute lesion’s one. Despite its high incidence and the great development of literature about this topic, there is still controversy about the optimal management of Achilles tendon rupture [6]. The several techniques proposed to treat acute ruptures can essentially be classi ied into: conservative management (cast immobilization or functional bracing), open repair, minimally invasive technique and percutaneous repair [7] with or without augmentation. Chronic ruptures represent a different chapter and the ideal treatment seems to be surgical : the techniques frequently used are debridement, local tissue transfer, augmentation and synthetic grafts [8].  Comparison of Different Conservative and Surgical Treatment and Rehabilitation Published: February 21, 2017 040 Conservative treatment using a short leg resting cast in an equinus position is probably justi ied for elderly patients who have lower functional requirements or increased risk of surgical healing, such as individuals with diabetes mellitus or in treatment with immunosuppressive drugs. In the conservative treatment, traditionally the ankle is immobilized in maximal plantar lexion, so as to re-approximate the two stumps, and a cast is worn to enable the tendon tissue to undergo biological repair. Advantages include the avoidance of surgical complications [9-11] and hospitalization, and the cost minimization. However, conservative treatment is associated with high rate of tendon re-rupture (up to 20%) . Operative treatment can ensure tendon approximation and improve healing, and thus leads to a lower re-rupture rate (about 2-5%). However, complications such as wound infections, skin tethering, sural nerve damage and hypertrophic scar have been reported to range up to 34% [13]. The clinically most commonly used suture techniques for ruptured Achilles tendon are the Bunnell [14,15] and Kessler techniques [16-18]. Minimally invasive surgical techniques (using limited incisions or percutaneous techniques) are considered to reduce the risk of operative complications and appear successful in preventing re-rupture in cohort studies [19,20]. Ma and Grif ith originally described the percutaneous repair, which is a closed procedure performed under local anesthesia using various surgical techniques and instruments. The advantages in this technique are reduced rate of complications such as infections, nerve lesions or re-ruptures [21]. The surgical repair of a rupture of the Achilles tendon with the AchillonTM device and immediate weight-bearing has shown fewer complications and faster rehabilitation [22]. A thoughtful, comprehensive and responsive rehabilitation program is necessary after the operative treatment of acute Achilles lesions. First of all, the purposes of the rehabilitation program are to obtain a reduction of pain and swelling; secondly, progress toward the gradual recovery of ankle motion and power; lastly, the restoration of coordinated activity and safe return to daily life and athletic activity [23]. An important point to considerer is the immediate postoperative management, which includes immobilization of the ankle and limited or prohibited weight-bearing [24].