Ultrasound-guided percutaneous longitudinal tenotomy for the management of patellar tendinopathy

Thirty-eight athletes with unilateral patellar tendinopathy (17 with a tendinopathy of the main body of the tendon, and 21 with an insertional tendinopathy) underwent ultrasound-guided multiple percutaneous longitudinal tenotomy under local anaesthetic infiltration after failure of conservative management. Thirty-four patients were reviewed at least 24 months after the operation. Sixteen patients were rated excellent, nine good, eight fair, and five poor. Nine of the 13 patients with a fair or poor result had an insertional tendinopathy, and eight of them underwent a formal exploration of the patellar tendon. Before the operation, there were some areas of altered echogenicity at and around the site of involvement. These were still visible 6 wk after surgery in 70% of the patients. At the latest follow-up, in the patients with an excellent or good result, the tendon was generally isoechogenic but slightly thicker (P = 0.06) than the normal contralateral. In the patients with a fair or poor result, the tendon was significantly thicker than the contralateral (P = 0.03), and showed some areas of mixed echogenicity. In the patients in whom the procedure was successful, the thicker operated tendon did not interfere with physical training. Bilateral isokinetic peak torque (Nm), average work (Joules), and average power (Watts) were tested at 90 degrees x s(-1). Immediately before the operation, there was no significant difference in peak torque, but total work and average power were significantly lower in the limb to be operated (0.01 < P < 0.05). By the end of the study, although peak torque was, on average, within 7% of the unoperated limb, total work and average power were still significantly lower than in the unoperated limb (0.01 < P < 0.04). Percutaneous longitudinal internal tenotomy is simple, can be performed on an outpatient basis, requires minimal follow-up care, does not hinder further surgery should it be unsuccessful, and, in our experience, has produced no significant complications. In our hands, it has become the first line operative intervention in the treatment of chronic patellar tendinopathy after failure of conservative management. However, patients should be advised that, if they suffer from an tendinopathy at the attachment of the patellar tendon at the lower pole of the patella, a formal surgical exploration with stripping of the paratenon is preferable.     

Imaging in the assessment and management of Achilles tendinopathy and paratendinitis

Achilles tendinopathy is a common overuse injury in patients engaged in athletic activities. Tendon degeneration is often accompanied by paratendinitis. Radiologists are frequently asked to use imaging techniques to evaluate patients with problems at or around the Achilles tendon. The main imaging modalities used in the assessment of Achilles tendon disorders are plain radiography, ultrasound, and magnetic resonance imaging. In recent years, ultrasound has also been used to guide minimally invasive local treatments for Achilles tendinopathy, which may prevent the need for surgery if conservative treatments have failed. In this article, we review the imaging features of Achilles tendinopathy and consider the relative strengths and weaknesses of the various imaging techniques. The role of imaging in directing patient management is also discussed, with particular focus on ultrasound-guided treatments.     

Chondral metaplasia in calcific insertional tendinopathy of the Achilles tendon.

OBJECTIVE: To ascertain whether tendon samples harvested from patients with calcific insertional Achilles tendinopathy showed features of failed healing response, and whether abnormal quantities of type II collagen had been produced in that area by these tenocytes. DESIGN: Comparative laboratory study. DESIGN: University teaching hospitals. PATIENTS: Tendon samples were harvested from eight otherwise healthy male individuals (average age 47.5+/-8.4 years, range 38 to 60) who were operated for calcific insertional Achilles tendinopathy and from nine male patients who died of cardiovascular events (mean age 63.1+/-10.9 years) while in hospital. INTERVENTIONS: Open surgery for calcific insertional Achilles tendinopathy. MAIN OUTCOME MEASURE: Semi-quantitative histochemical, immunohistochemical, and immunocytochemical methods to ascertain whether tendinopathic tendons were morphologically different from control tendons, and whether abnormal types of collagen were produced. RESULTS: Tenocytes from tendons from patients with calcific insertional Achilles tendinopathy exhibit chondral metaplasia, and produce abnormally high quantities of collagen type II and III. CONCLUSIONS: The altered production of collagen may be one reason for the histopathological alterations described in the present study. Areas of calcific insertional Achilles tendinopathy have been subjected to abnormal loads. These tendons may be less resistant to tensile forces. Further studies should investigate why some tendons undergo these changes.     

Magnetic resonance imaging in chronic Achilles tendinopathy.

The main objective of this thesis was to evaluate and monitor the morphological response following treatment interventions in patients with chronic Achilles tendinopathy by using different MRI techniques. For this purpose, we investigated different types of sequences, including gadolinium contrast medium-enhanced T1-WI images (CME T1-WI), and developed a precise method to measure tendon volume and mean intratendinous signal of the Achilles tendon. Study I aimed at evaluating 15 patients with chronic, painful Achilles tendinosis, before and 2 years after surgical treatment. There was marked regression of the intratendinous signal postoperatively. The most sensitive sequence for depicting an intratendinous lesion in this study was CME T1-WI images. They showed a regression of the intratendinous signal abnormality from 13/15 patients preoperatively to 4/15 postoperatively. The clinical outcome was excellent in eight, good in five, fair in one and poor in one patient. In study II, the early contrast agent enhancement in the dynamically enhanced MRI signal (DEMRI) was correlated with the histopathologic findings in 15 patients with chronic Achilles tendinopathy. Early contrast enhancement (within the first 72s) was seen in DEMRI in the symptomatic Achilles tendons, with a significant difference compared to the asymptomatic contralateral tendons. Increased severity of tendon changes, including fiber structure abnormality, increased vascularity, rounding of nuclei, and increased amount of glycosaminoglycans, correlated to CME. In study III, we developed a computerized 3-D seed-growing MRI technique to measure tendon volume and mean intratendinous signal. This technique showed an excellent inter- and intra-observer reliability. The technique was also used to follow up prospectively the tendon adaptation and healing described in studies IV-VI. In study IV, using serial MRI during a period of 1 year, we evaluated the biological effect of tendon repair following iatrogenic tendon injury by five transversal ultrasound-guided core biopsies employing a needle technique in chronic Achilles tendinopathy. Alterations found during healing, such as tendon volume and intratendinous reactive changes, could be monitored by MR imaging, and subsided as noted in the 7- and 12-month follow-ups. In study V, we evaluated the effect of treatment with a 3-month, daily performed, heavy-loaded calf-muscle strength training program in 25 patients who had been suffering from chronic, painful Achilles tendinopathy. Tendon volume decreased by 14%, and the mean intratendinous signal by 23%. The clinical outcome was improved. In study VI, we revealed tendon adaptation immediately following calf-muscle strength training. An MRI examination within 30min of the performed exercises resulted in increased total tendon volume (12%) and mean intratendinous signal (31%). CONCLUSION: MRI techniques can be used as an adjunct to clinical evaluation by monitoring morphological effects following different treatment interventions, thereby adding evidence in clinical studies on patients with chronic Achilles tendinopathy.     

Blood flow of the Achilles tendon during military training

The purpose of this study was to evaluate the vascular response of the Achilles tendon as indicated by power Doppler activity during a military training program of 6 weeks. 49 male military recruits (98 tendons) volunteered for this study. Before and during the military training program, the Achilles tendons were screened with gray-scale ultrasonography and power Doppler US. Reactive tendinopathies of the Achilles tendons were registered by means of a clinical examination, VAS-scores and VISA-A scores. The US examination, the clinical examination, VAS-scores and VISA-A scores showed that 13/98 tendons developed a reactive tendinopathy. 3 of these 13 symptomatic tendons showed intratendinous Doppler activity. In these tendons, pain was always present before the vascular response of the Achilles tendon. Both pain and hypervascularisation remained visible till the end of the basic military training. In 5 asymptomatic tendons with no structural changes of the tendon, a vascular response was seen during one single measurement. It can be hypothesized that there is no relationship between the vascular response of the Achilles tendon and the pain in a reactive tendinopathy. In a reactive tendinopathy, other pain mechanisms must be investigated in future research.     

Achilles tendinopathy: some aspects of basic science and clinical management

Achilles tendinopathy is prevalent and potentially incapacitating in athletes involved in running sports. It is a degenerative, not an inflammatory, condition. Most patients respond to conservative measures if the condition is recognised early. Surgery usually involves removal of adhesions and degenerated areas and decompression of the tendon by tenotomy or measures that influence the local circulation.     

Free gracilis tendon graft in neglected tears of the achilles tendon.

OBJECTIVE: To report the results of a longitudinal study on reconstruction of neglected Achilles tendon rupture using a free autologous gracilis tendon graft. DESIGN: Cohort study. PARTICIPANTS: Twenty-one patients underwent surgery for a neglected rupture of the Achilles tendon occurring between 65 days and 9 months before the operation. METHODS: All participants were prospectively followed up for 2 years, and final review was performed at 28.4 +/- 3.5 months from the operation. Functional (anthropometric measurements, isometric strength, return to activities) and clinical assessment was performed. RESULTS: No patients experienced any problems in the wound used to harvest the tendon of gracilis. Five patients were managed conservatively following a superficial infection of the Achilles tendon surgical wound. No patients developed a deep vein thrombosis or sustained a rerupture. All patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp. The maximum calf circumference remained significantly decreased in the operated leg at final review. The operated limb was significantly less strong than the nonoperated one. CONCLUSIONS: The management of neglected tears of the Achilles tendon by free gracilis tendon grafting is safe but technically demanding. It affords good recovery, even in patients with a neglected rupture of a duration of 9 months. These patients should be warned that they are at risk for postoperative complications, and that their ankle plantar flexion strength can remain reduced.     

Open and arthroscopic patellar tenotomy for chronic patellar tendinopathy. A retrospective outcome study. Victorian Institute of Sport Tendon Study Group

Chronic patellar tendinopathy often requires surgical treatment. We compared the outcomes in 25 subjects (29 tendons) who had had open patellar tenotomy and 23 subjects (25 tendons) who had had arthroscopic patellar tenotomy at a mean follow-up of 3.8 and 4.3 years, respectively. At follow-up, outcomes in the open and arthroscopic groups were as follows: 1) symptomatic benefit was seen in 81% of open and 96% of arthroscopic tenotomy patients, 2) sporting success was seen in 54% of open and 46% of arthroscopic tenotomy patients, 3) median time to return to preinjury level of activity was 10 months for open and 6 months for arthroscopic tenotomy patients, and 4) median Victorian Institute of Sport Assessment score at follow-up was 88 for open and 77 for arthroscopic tenotomy patients. There were no significant differences between groups for all outcomes. The appearance of the tendon on sonography remained abnormal in over 70% of subjects at follow-up, and sonographic appearance did not correlate with clinical outcome. Thus, arthroscopic patellar tenotomy was as successful as the traditional open procedure. Both procedures provided virtually all subjects with symptomatic benefit, but only about half the subjects who underwent either open or arthroscopic patellar tenotomy were competing at their former sporting level at follow-up.     

Ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon: a non-reliable technique

Purpose

To evaluate the feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon via a keyhole incision.

Methods

This was an anatomical study performed on twelve embalmed cadaveric shoulder joints. The rotator cuff and the position of the long head of the biceps tendon were explored by ultrasound prior to beginning the procedure. The biceps tenotomy was performed under ultrasound guidance by a highly experienced sonographer who was trained in shoulder tendon exploration. Arthroscopic exploration of the shoulder was performed immediately after the percutaneous biceps tenotomy to assess the quality and the location of the biceps tenotomy.

Results

Three out of twelve tendons (25%) were completely sectioned at the level of the glenoid insertion. More seriously, iatrogenic lesions of the cartilage of the humeral head, the supraspinatus tendon and the subscapularis tendon were observed.

Conclusion

This study shows that ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon is not reliable.     

Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy

Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented.     

Evaluation of sonoelastography in Achilles tendon of healthy volunteers and patients with symptomatic Achilles tendon

Aim and objectives: To assess the role of SEL in evaluation of Achilles tendon. Methodology: This study included 40 healthy volunteers and 40 patients with symptomatic Achilles tendon. All patients were examined by conventional B-mode ultrasound, sonoelastography and MRI. Results: Achilles tendons of the volunteers were characterized by hard texture with higher strain ratios than those of the patients with Achilles tendinopathy. No significant differences could be detected between SR of male and female volunteers yet significant differences could be detected in the volunteer group above and below forty being lower with softer tendon properties in the group above forty with a cut-off value of ≤1.84 between healthy and diseased group. Sonoelastography had the sensitivity of 89.1% and specificity of 96.1% for diagnosis of tendinopathy with results superior to those of conventional B-mode ultrasonography. Conclusion: SEL is a reliable tool in the evaluation of Achilles tendinopathy with sensitivity and specificity superior to B-mode US. Strain ratio provides excellent non-invasive diagnostic data adds strongly in more objective evaluation of Achilles tendon properties.     

Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI

BACKGROUND: Satisfactory treatment results have been reported after eccentric calf muscle strength training in patients with chronic Achilles tendinopathy. HYPOTHESIS: Magnetic resonance imaging may be a useful adjunct in the evaluation of the effect of 3 months of eccentric calf muscle strength training. STUDY DESIGN: Prospective cohort study. METHODS: Using magnetic resonance imaging, the Achilles tendons were investigated in 25 patients (16 men and 9 women) ranging in age from 28 to 70 years (median, 51 years) before and after training. Five different magnetic resonance imaging sequences were used. Tendon volume and mean intratendinous signal were calculated using a new seed-growing technique showing 99.3% and 96.6% intraobserver reliability, respectively. The clinical outcome was categorized according to pain level and performance using a questionnaire completed by the patient. RESULTS: The eccentric training resulted in a 14% (mean) decrease of tendon volume measured on T1-weighted images, from 6.6 +/- 3.1 cm3 to 5.8 +/- 2.3 cm3 (P < .05). The intratendinous signal in the symptomatic Achilles tendon measured on proton density-weighted images decreased 23% (mean), from 227 +/- 77 signal units to 170 +/- 83 signal units (P < .05). The gadolinium contrast agent-enhanced images did not add further value compared with other sequences. CLINICAL OUTCOME: The clinical outcome was categorized as excellent in 10, good in 3, fair in 5, and poor in 8 patients. The Delta signal correlated significantly with the pain level (P < .05). CONCLUSIONS: Eccentric training resulted in decreased tendon volume and intratendinous signal and was correlated with an improved clinical outcome. Magnetic resonance imaging techniques can be used as an adjunct to clinical evaluation by monitoring morphologic effects in clinical treatment studies of Achilles tendinopathy.     

Doppler ultrasound signal in Achilles tendinopathy reduces immediately after activity

BACKGROUND: A relationship has been identified between vascularization on Doppler ultrasound (Doppler signal) and Achilles tendon pain. Doppler signal may increase minutes after prolonged activity, but the immediate effect is unknown. The aim of the study was to investigate the immediate effect of short term activity on Achilles tendon Doppler signal. Achilles tendinopathy patients (7 patients, 10 tendons) and asymptomatic controls (6 controls, 12 tendons) performed 2 activity tasks; a 2 minute continuous step task and one minute continuous calf raise task. Doppler signal was measured at rest and within a minute after each activity. The presence of Doppler signal was quantified using both semi quantitative (modified Ohberg scale; 0=no signal, 5 = > 90% of pathological area contains Doppler signal) and quantitative methods (pixel number). Doppler signal was present in 90% of symptomatic individuals and in none of the asymptomatic controls. The modified Ohberg scale and pixel number reduced significantly after both activity tasks and heart rate increased significantly (p < 0.05). Doppler signal in Achilles tendinopathy may decrease immediately after activities that load the calf muscle and increase heart rate, suggesting that this activity should be avoided prior to imaging to avoid false negative results.     

Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study

To determine the long-term outcome of patients treated nonoperatively for acute or subchronic (duration of the symptoms before initiation of the treatment less than 6 months) Achilles tendinopathy, we performed a follow-up analysis on 83 of 107 patients an average 8 +/- 2 (SD) years after the initial contact. The analysis included a questionnaire, clinical examination, performance tests, muscle strength measurement, and ultrasonographic examination. Twenty-four of the 83 patients (29%) had to be operated on during the follow-up period. Seventy patients (84%) had full recovery of their activity level, and at 8 years' follow-up 78 patients (94%) were asymptomatic or had only mild pain with strenuous exercise. However, a clear side-to-side difference between the involved and the uninvolved sides was observed on the performance test, clinical examination, and ultrasonography. Also, 34 patients (41%) started to suffer from overuse symptoms in the initially uninvolved Achilles tendon. The results of our 8-year follow-up showed that the long-term prognosis of patients with acute-to-subchronic Achilles tendinopathy is favorable as determined by subjective and functional assessments. In the clinical and ultrasonographic examinations, mild-to-moderate changes were observed rather frequently in both the involved and initially uninvolved Achilles tendons, but the occurrence of these changes was not clearly related to the patients' symptoms.     

Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes

BACKGROUND: Neovascularisation can be detected qualitatively by Power Doppler in Achilles tendinopathy. Quantitative data regarding tendon microcirculation have not been established and may be substantial. PURPOSE: To assess the microcirculation of the Achilles tendon and the paratendon in healthy volunteers as well as in athletes with either midportion or insertional tendinopathy. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In 66 physically active volunteers, parameters of Achilles tendon and paratendon microcirculation, such as tissue oxygen saturation, relative postcapillary venous filling pressures, and microcirculatory blood flow, were determined at rest at 2-mm and 8-mm tissue depths. Forty-one patients never had Achilles pain (25 men, 27 +/- 8 years), 14 patients had insertional pain (7 men, 29 +/- 8 years), and 11 patients had midportion tendinopathy (7 men, 38 +/- 13 years, not significant). RESULTS: Achilles tendon diameter 2 cm and 6 cm proximal to the insertion was increased in symptomatic tendons. Compared with the uninvolved opposite tendon, deep microcirculatory blood flow was significantly elevated at insertional (160 +/- 79 vs 132 +/- 42, P < .05) as well as in midportion tendinopathy (150 +/- 74 vs 119 +/- 34, P < .05). The microcirculation in the uninvolved opposite tendon and the normal athlete controls were not significantly different from each other (132 +/- 42 insertional asymptomatic vs 119 +/- 34 mid-portion vs 120 +/- 48 healthy tendon). Insertional paratendon deep microcirculatory flow was elevated in all groups, whereas tissue oxygen saturation and relative postcapillary venous filling pressures were not significantly different. CONCLUSION: Microcirculatory blood flow is significantly elevated at the point of pain in insertional and midportion tendinopathy. Postcapillary venous filling pressures are increased at both the midportion Achilles tendon and the midportion paratendon, whereas tissue oxygen saturation is not different among the studied groups. We found no evidence of an abnormal microcirculation of the asymptomatic limb in Achilles tendinopathy.     

High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon

ObjectivesSeveral substances are routinely injected in and around tendons. The present study evaluated the long term effects of high volume image guided injection (HVIGI) of normal saline, local anaesthetic and aprotinin in athletic patients with resistant tendinopathy of the main body of the Achilles tendon.DesignCase series.MethodsThe study included a series of 94 athletes (69 men and 25 women; average age 37.5 years, range 22–63) with ultrasound confirmed tendinopathy of the main body of the Achilles tendon. All the patients had not improved after at least three months of conservative management. Patients were injected with 10 mL of 0.5% Bupivacaine Hydrochloride, 25 mg aprotinin, and up to 40 mL of injectable normal saline. We prospectively administered the Victorian Institute of Sport Assessment–Achilles tendon (VISA-A) to assess the short- and long-term pain and functional improvement.ResultsAt baseline (n = 94), the VISA-A score was 41.7 ± 23.2 (range 11–60), and had improved to 74.6 ± 21.4 (range 71–100) by 12 months (n = 87) (p = 0.003), with no significant difference between sexes.ConclusionHVIGI with aprotinin significantly reduces pain and improves function in patients with chronic Achilles tendinopathy in the short- and long-term follow up.     

Magnetic resonance signal, rather than tendon volume, correlates to pain and functional impairment in chronic Achilles tendinopathy

PURPOSE: To depict abnormal tendon matrix composition using magnetic resonance imaging (MRI) in chronic Achilles tendinopathy, and correlate intratendinous signal alterations to pain and functional impairment. MATERIAL AND METHODS: MRI of the Achilles tendon was performed on 25 patients with chronic Achilles tendinopathy (median age 50, range 37-71 years). All patients suffered from pain in the mid-portion of the Achilles tendon. Intratendinous signal was calculated from five different sagittal sequences, using a computerized 3D seed-growing technique. Pain and functional impairment were evaluated using a questionnaire completed by patients. RESULTS: Severity of pain and functional impairment correlated to increased mean intratendinous signal in the painful tendon in all MR sequences (P < 0.05, median r = 0.38, range 0.28-0.43 for pain; P < 0.05, median r = 0.48, range 0.29-0.49 for functional impairment). However, tendon volume did not correlate to pain or functional impairment (P > 0.05). Difference in mean intratendinous signal between symptomatic and contralateral asymptomatic tendons was highly significant in all sequences (P < 0.05) except on T2-weighted images (P = 0.6). CONCLUSION: Severity of pain and disability correlated to increased MR signal rather than to tendon volume in patients with unilateral mid-portion chronic Achilles tendinopathy.     

Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy.

OBJECTIVE: Achilles tendinopathy is prevalent in athletes, but can also affect sedentary patients. We studied the effects of eccentric exercises in sedentary non-athletic patients with Achilles tendinopathy. METHODS: Thirty-four sedentary patients (18 males, average age 44 years, range 23-67; 16 females, average age 51 years, range 20-76; average BMI: 28.6+/-4.7, range 22.1-35.4) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance (39+/-S.D. 22.8) and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks. RESULTS: Fifteen patients (44%) did not improve with eccentric exercise regimen. Three patients improved after perintendinous injections aprotinin and local anaesthetic. Surgery was performed in seven patients as 6 months of conservative management failed to produce improvements. The overall average VISA-A scores at latest follow up was 50 (S.D. 26.5). CONCLUSIONS: Eccentric exercises, though effective in nearly 60% of our patients, may not benefit sedentary patients to the same extent reported in athletes.     

Arthroscopically assisted percutaneous repair of fresh closed achilles tendon rupture by Kessler's suture

BACKGROUND: Achilles tendon ruptures are difficult to repair, and the healing rate is low due to this structure's anatomic and physiological characteristics. It is essential to develop new techniques to increase the healing rate and decrease the rate of complications. OBJECTIVE: To propose and evaluate a new percutaneous method of repairing fresh closed Achilles tendon ruptures by Kessler's suture under arthroscopy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty patients were followed at least 12 months in this study. First, the torn ends of the Achilles tendon were debrided during arthroscopy. Then percutaneous repair of the Achilles tendon was performed using Kessler's suture by an inside-out technique. All cases were followed up for an average range of 21 months (range, 12-36 months). All patients were evaluated by clinical examination, magnetic resonance imaging, and the Lindholm scale. RESULTS: The torn ends were well aligned and sutured after the debridement under arthroscopy. According to the Lindholm scale, excellent results were seen in 15 cases and good in 5 cases. No patients had complications such as nerve injury, infection, or re-rupture at follow-up. Magnetic resonance imaging results showed that the ruptured Achilles tendons were repaired and remodeled very well in all patients. CONCLUSION: The present method is an effective surgical technique for repair of a closed rupture of the Achilles tendon. The short-term follow-up results were good, and recovery time was short. Few complications were found in our study cases.     

Surgical treatment of chronic Achilles tendinitis

Between 1977 and 1985, 170 patients suffering from chronic Achilles tendinitis were treated surgically. Ninety-one patients with 143 tendons returned for followup. The duration of preoperative symptoms averaged 18 months. In all cases, conservative treatment was first attempted but failed to alleviate symptoms. Only those patients whose lesions and symptoms were confined to the Achilles tendon segment 2 to 6 cm proximal of the insertion were included in this study. All athletes who had an insertion tendinopathy or a lesion at the musculotendinous junction were excluded from this study. The surgical procedure depended on the lesion. For 93 tendons exhibiting pure peritendinitis, treatment consisted of a simple release of the fascia cruris and the peritenon. For the 50 tendons with tendinosis, a resection of diseased tendon tissue was performed. The defect could be sutured side to side in 26 cases but in the other 24 cases, reinforcement with a turned down tendon flap was necessary because of the extensive debridement. Of the 93 cases in which only dorsal release was performed, results were considered excellent in 54 cases, good in 28, fair in 8, and poor in 3 cases. Of the 26 cases in which side-to-side suture was performed, 15 cases were rated as having excellent results, 4 as good, 4 as fair, and 3 as poor. For the 24 cases in which a turned down tendon flap procedure was performed, the result was excellent in 12 cases, good in 9, fair in 2, and poor in 1 case.(ABSTRACT TRUNCATED AT 250 WORDS)