Augmentation vs Nonaugmentation Techniques for Open Repairs of Achilles Tendon Ruptures with Early Functional Treatment: A Prospective Randomized Study

A prospective randomized study was conducted in order to compare augmentation technique versus nonaugmentation technique, followed by early functional postoperative treatment, for operative repair of Achilles tendon ruptures. Twenty-four consecutive patients were assigned to two groups. Group I included 12 patients treated with Lindholm augmentation technique, whereas group II included 12 patients treated with modified Kessler end-to-end repair. Thereafter, these patients had postoperative management with a below-knee-cast for three weeks. The physioteraphy was initiated immediately after the cast was removed. Full weight bearing was allowed after five weeks postoperatively in the both groups. Two patients had reruptures in group II, whereas group I had prolonged operative time significantly. The patients with reruptures underwent reoperations and at the most final follow-up, it was observed that they could not resume to sporting activities. The other objective and subjective results were similar between two groups. Because of quite high rerupture rate in the group of patients treated with nonaugmentation technique, we favor functional postoperative treatment with early ankle movement in the patients treated with augmentation technique for the management of acute rupture of the Achilles tendon.

Key Points

• A prospective randomized study was conducted in order to compare augmentation technique versus nonaugmentation technique, followed by early functional postoperative treatment, for operative repair of Achilles tendon ruptures.
• Group I included 12 patients treated with Lindholm augmentation technique, whereas group II included 12 patients treated with modified Kessler end-to-end repair.
• Functional postoperative treatment with early ankle movement in the patients treated with augmentation for the management of acute rupture of the Achilles tendon is recommended.

Key words: Achilles tendon, surgical procedure, early ambulation     

Mechanical evaluation of different techniques for Achilles tendon repair

Introduction One aim of the surgical treatment of acute Achilles tendon ruptures is to obtain a maximum primary stability of the sutured tendon. Therefore, we investigated the primary stability of sutured human Achilles tendons depending on different applied techniques. Methods The strength of 60 repaired cadaveric human Achilles tendons was tested depending on either the suture technique (Bunnell or Kessler), the suture material (PDS-thread or PDS-cord) or an additional plantaris tendon augmentation (PDS-thread with or without augmentation). Following anatomic reconstruction the repaired specimens were loaded to failure. Results The use of Bunnell's technique resulted in a stronger primary suture stability compared to Kessler's technique. Sutures carried out with a PDS-thread were of lower strength than those accomplished with a PDS-cord (Bunnell: thread 139 N ± 29.8; cord 291 N ± 55.2/Kessler: thread 137 N ± 37.3; cord 180 N ± 41.1). Sutures performed according to Bunnell's technique with a PDS-thread and an additional autologous plantaris tendon augmentation reached the highest primary stability (326 N ± 124.9). Conclusions The findings identify the Achilles tendon suture with a PDS-cord according to Bunnell's technique as a mechanically strong method. A plantaris tendon augmentation in addition to a PDS-thread can even add more stability to the Achilles tendon suture.     

Diagnosis and treatment of acute ruptures of the Achilles tendon. Current concepts review

Subcutaneous rupture of the Achilles tendon seems to have become more common in recent years. This results from a combination of more awareness in the medical field and greater participation in physical activities by the general population. The causes of Achilles tendon rupture are multifactorial and still unclear. The diagnosis can be made based on physical examination; special diagnostic studies are rarely necessary. The literature on ruptures of the Achilles tendon and associated treatment has expanded over the past decade. The lack of a universal, consistent protocol for subjective and objective evaluation following treatment of Achilles tendon rupture has prevented any comparison of results. There is still controversy concerning the best treatment. From a literature review, it appears that a satisfactory outcome may be achieved with either nonoperative or operative treatment but surgical repair appears to provide better functional capacity. Lower rerupture rates and slightly improved strength and functional ability may be expected with surgical treatment; however, the rate of minor complications is higher than with nonoperative treatment. Reports in the literature indicate that in active, young, very demanding individuals, surgical repair should be considered, with nonsurgical treatment reserved for elderly or sedentary patients. There is no single, uniformly accepted surgical technique for Achilles tendon repair. Most acute ruptures have been treated successfully with simple end-to-end suture, although various augmentation procedures have been combined with simple suture with satisfactory outcomes. To minimize the complications typically associated with open surgery, percutaneous techniques to repair the ruptured Achilles tendon have been advocated, and the results are reported to be promising, although not without failures and complications. Several recent studies have reported functional benefits of early postoperative tendon mobilization in well-motivated patients, since treatment results are determined not only by the method of repair but also, and perhaps more importantly, by the early postoperative functional rehabilitation.     

The Webb-Bannister Percutaneous Technique for Acute Achilles’ Tendon Ruptures: A Functional and MRI Assessment

This was a study of 57 patients treated for Achilles' tendon rupture between 1994 and 2002: 35 with an open repair and 22 with the Webb-Bannister percutaneous technique. The aim of the study was to evaluate this percutaneous method as compared to other percutaneous and open techniques, with respect to functional result and complications. In addition, postoperative MRI was performed on 40 patients in order to determine whether there were any correlations between clinical results and MRI findings. No significant differences were found between the 2 surgical methods with respect to clinical and functional results, and no wound dehiscence or infections were found in the Webb-Bannister group. There was an 8.6% incidence of wound complications in the open repair group. Similarly, return to work times were not significantly different between the groups (4 months for open repair and 3.75 months for percutaneous repair). Two patients experienced re-rupture after open repair and there was 1 re-rupture following the Webb-Bannister technique. Early weight bearing and the use of the percutaneous repair did correlate to increased postoperative tendon lengthening, though this did not appear to have any clinical consequence. MRI did not appear to be of any value in the clinical or functional evaluation, but it demonstrated a relationship between increased tendon diameter and tendon elongation (P=.0038). In those patients with thicker tendon repair sites, the dorsiflexion tended to exceed the uninjured leg. The functional results of the Webb-Bannister technique were comparable to the open repair. This technique is an effective treatment for acute ruptures less wound complications.     

Results of surgical treatment of rupture of the Achilles tendon (author's transl)

32 ruptures of the achilles tendon were treated surgically in the surgical department of the St. Katharinen-Hospital during the period 1. 1. 1975 to 1. 3. 1980. These cases comprised 28 subcutaneous complete ruptures and 4 open tendon injuries. 29 fresh and 3 old ruptures were operated. The article describes the surgical technique. The median, arcuate incision, the end-to-end suture according to Bunnell with Dexon and, if possible, an interlacing suture with the plantaris tendon, appear to be the essential measures. This is followed by immobilization in a plaster case for a period of 6 weeks. The patients remained hospitalized for a period of 2 weeks after the operation; they were unable to work for 10 weeks, and unable to actively participate in sports for 19 weeks. Half a year to 5 years after the operation, 25 patients were subjected to follow-up examinations. No early or late infection had occurred, and there was also no rerupture or thrombosis. There was also no adherence to tendon and skin. Using the assessment scheme according to B.G. Weber, the functional result must be classified as "good" with all patients.     

Neglected rupture of the Achilles tendon treated with peroneus brevis transfer: A functional assessment of 5 cases

The purpose of this study was to review the clinical results of 5 patients who underwent repair of a chronic Achilles tendon rupture using a combination of peroneus brevis transfer and plantaris tendon augmentation. The technique belongs to the group of local tendon transfer procedures making use of the transferred peroneus brevis tendon as strengthening material together with the plantaris tendon as suturing material. There were 4 males and 1 female with an average age of 49.4 years and an average time to presentation postinjury of 19.8 weeks (range 5-40 wk). All patients underwent Cybex strength testing before and approximately 1 year after surgery. This testing demonstrated a postoperative improvement in peak plantarflexion torque (Newton-meters/body weight) in all cases. The peak torque of plantar flexion increased in all patients (range, 21%-410%). Four patients were found to have an increase of the dorsal flexors peak torque (range, 31%-290%), whereas one patient showed a decrease (-37%). No patient experienced wound closure complications, postoperative pain, or functional limitations. In spite the possibility of residual lateral ankle instability, we found this modification to be a valuable innovation that offers a very good functional result, low morbidity, technical advantages to the surgeon and, most important, a durable and satisfactory result for the patients.     

Achilles tendon suturing and reconstruction with the plantaris muscle

The authors present the first experience in the treatment of fresh ruptures of the Achilles tendon by their own surgical technique--suture end to end with augmentation using plantaris tendon graft. The results were evaluated on a small group of 9 patients (average age 45 years) operated on in the period of 1999-2000. The most important criterion was the subjective evaluation of the patient and the post-operative limitation in sport, job and ordinary activity. We did not record any preoperative or post-operative complication and the limitation of the range of motion was negligible with regard to the needs of the patient. The authors are aware of the fact that post-operative follow-up of the patients is relatively short-term. The surgical technique is described in detail.     

不剥离骨膜法肋骨钉内固定治疗多发肋骨骨折的随机对照研究

目的 分别运用Achillon吻合器和改良Kessler缝合法治疗急性闭合性跟腱断裂,随访比较患者的临床效果和功能恢复情况.方法从2009年3月至2012年2月,随机采用 Achillon吻合器微创修复与改良Kessler缝合法治疗49例急性闭合性跟腱断裂.其中Achillon 微创修复28例,改良Kessler法缝合21例.两组均无需行拇长屈肌或腓肠肌延长术.本研究平均随访21个月,分别在术后1周、第6个月、第12个月、随访结束期4个时间段,对两组患者的手术时间、住院时间、切口长度、踝关节运动范围、美国足踝外科协会（AOFAS）踝-后足疗效评分进行评价.结果在术后1周内,Achillon组发生1例神经损伤,改良Kessler组发生2例创口浅表感染,1例延迟愈合.两组并发症发生率差异无统计学意义（P=0.41）.在第6月,Achillon组AOFAS评分要优于改良Kessler组,第12月时两组无明显差异.术后两组踝关节运动范围,差异无统计学意义.截止随访结束时,所有患者均恢复到受伤前运动水平.结论两种缝合方法均能取得良好的疗效,相比改良Kessler缝合法,采用Achillon吻合器具有切口小、住院时间短、功能恢复快、术后美观等优点.     

Rupture of the Achilles tendon--fibrin gluing or suture?]

The rise of recreational sports activities and the incidence of ruptures of the Achilles tendons has increased simultaneously. Recently the use of fibrin sealing for surgical therapy of ruptured Achilles tendons has emerged as an alternative technique. Between 1982 and 1989 62 consecutive patients were operated for unilateral Achilles tendon rupture. Following causes for ruptures are known: 36 indirect traumas in sport (74%), 9 direct blunt injuries at occupational work (18%), 3 traffic-accidents (11%) and 1 rupture after operation of a Haglund exostosis. 25 patients (56%) were treated by suture technique and 20 patients (44%) with fibrin sealant. The mean long term follow-up of 49 months is known of 49 patients. There were 3 (12%) postoperative infections in the suture group and none in the fibrin group. After suturing the Achilles tendon 3 (12%) reruptures occurred 8-10 weeks after tendon repair and 1 (5%) rerupture after fibrin sealing. All reruptures are caused by a new adequate trauma. The time of return to social and recreational activities was 9 months in the suture group and 7 months in the fibrin group. The functional and cosmetic results after use of fibrin was significant better, and the long-term results were very satisfactory. We prefer fibrin sealing for the treatment of acute ruptures of Achilles tendons.     

Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes

PURPOSE: To retrospectively review the clinical outcome and incidence of post-operative complications after open end-to-end repair of acute Achilles tendon ruptures. METHODS: Seventy consecutive patients (74 open Achilles tendon repairs) operated on between 1989 and 2002 were identified for inclusion in this investigation. The medical records were reviewed and patients were contacted for a follow up interview in order to survey their post-operative function. Outcome scores were calculated based on the Boyden outcome and AOFAS ankle-hindfoot scoring systems. Post-operative complications were documented during the chart review and follow up interview, including an additional nine patients (nine repairs), who were not included in the clinical evaluation portion of the study. RESULTS: Fifty-two patients (54 repairs) were successfully contacted and completed the follow up interview. Within this cohort there were 44 males and 8 females with a mean age of 41 years. Achilles tendon rupture in this population was attributable to participation in athletic activity in 87% of cases. At a mean post-operative follow up of 45 months, 96% of cases achieved an overall Boyden outcome score of good to excellent. The mean AOFAS ankle-hindfoot score was 96, with 74% of cases scoring greater than 90. Forty-two cases (78%) reported no pain and 40 cases (74%) reported no activity limitations. Fourteen post-operative complications were identified after 83 open Achilles tendon repairs, resulting in an institutional complication rate of 16.8%. The complications included four superficial wound infections, five deep wound infections requiring irrigation and debridement, one heel ulcer secondary to post-operative boot wear, three partial Achilles tendon re-ruptures, and one complete Achilles tendon re-rupture. CONCLUSION: Our results demonstrate that open end-to-end repair of acute Achilles tendon ruptures provides long-term functional outcomes with consistent good to excellent results. However, this high clinical success rate was associated with a relatively high incidence of post-operative complications. With careful attention to the surgical wound and patient adherence to post-operative rehabilitation protocols, operative repair of acute Achilles tendon ruptures is a reliable treatment for active patients.     

Repair of acute and chronic distal biceps tendon ruptures using the EndoButton

There are many ways to repair distal biceps tendon ruptures with no outcome studies demonstrating superiority of a specific technique. There are few studies reporting on the repair of acute and chronic distal biceps tendon ruptures using the EndoButton via an anterior single-incision approach. We report on 27 patients who underwent distal biceps tendon repair with an EndoButton. The average age was 50.1 years (range, 36–78). There were 17 acute repairs (within 4 weeks of injury), nine chronic repairs (greater than 4 weeks), and one revision of a previous acute repair. All chronic repairs were repaired without the need for graft augmentation. Patients were assessed postoperatively using the ASES elbow outcome instrument and isokinetic flexion and supination strength and endurance testing. Eight control subjects were also tested for comparison. At an average follow-up of 30.9 months, 26 of 27 patients returned to their previous employment and activity level. The average ASES elbow score was 98.2 (range, 81–100). Compared with the contralateral extremity, there was no loss of motion. Average flexion strength recovery was 101% and mean supination strength recovery was 99%. There was no significant difference in function or strength with repair of acute versus chronic ruptures. Using the EndoButton technique, acute and chronic distal biceps tendon ruptures can be repaired safely with excellent clinical results.     

Rupture of the subscapularis tendon after shoulder arthroplasty: diagnosis, treatment, and outcome

The purpose of this study was to document the diagnosis, surgical treatment, and functional outcome in patients with subscapularis ruptures after shoulder arthroplasty. Prospective objective and subjective data were collected on 7 patients with symptomatic rupture of the subscapularis tendon after shoulder arthroplasty. Presenting signs and symptoms included pain, weakness in internal rotation, increased external rotation, and anterior instability. All patients were treated with surgical repair of the ruptured tendon. Four required repair augmentation with a transfer of the pectoralis major tendon. After subscapularis repair and pectoralis transfer, 2 patients continued to have anterior instability and required an additional operation to address the instability. At a mean follow-up of 2.3 years (range, 18-55 months), the mean American Shoulder and Elbow Surgeons shoulder score in this study group was 63.2. The mean patient satisfaction rating, on a 10-point scale, was 6.2. Factors associated with post-arthroplasty subscapularis ruptures included subscapularis lengthening techniques used to address internal rotation contracture and previous surgery that violated the subscapularis tendon. Symptomatic subscapularis rupture after shoulder arthroplasty introduces the need for additional surgery and a period of protected or delayed rehabilitation after arthroplasty. Although symptoms were adequately addressed with appropriate surgical treatment, decreased functional outcomes were observed.     

Eine vereinfachte Methode zur Therapie der Quadrizepssehnenruptur mittels transpatellarer PDS-Kordel

Quadriceps tendon ruptures are relatively unusual injuries caused by direct or more frequently indirect trauma. Since complete ruptures lead to loss of active extension of the knee joint, operative treatment is usually indicated. Several techniques are described in the literature. However, relatively little is known about the functional outcome after operative treatment of acute quadriceps tendon ruptures. We present a new operative technique using a 1.3-mm PDS cord passed through a transverse drill hole in the proximal pole of the patella. We operated ten consecutive cases of complete quadriceps tendon ruptures with the technique described between January 2000 and June 2003. Eight of ten patients were evaluated after a mean follow-up time of 38 months by physical examination, IKDC Subjective score, Lysholm and Tegner score as well as an isokinetic test of the quadriceps strength. No complications were noted in this period. The average postoperative scores were 87 (IKDC), 98 (Lysholm), and 4.5 (Tegner). Isokinetic testing showed an average of 25% quadriceps strength deficit. The operative treatment of complete quadriceps tendon ruptures using a PDS cord through a drill hole in the patella is a safe and effective technique permitting functional postoperative treatment.     

The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment

BACKGROUND: There is still controversy regarding the optimal surgical technique and post-operative treatment of acute Achilles tendon ruptures. We evaluated a treatment protocol for Achilles tendon ruptures consisting of a minimally invasive Achilles tendon repair combined with early full weight bearing. METHODS: A consecutive group of 163 patients was prospectively followed during a 6 year period (1998-2004) in one university hospital and five teaching hospitals. Data were collected during the outpatient department visits at 1, 3, 5, and 7 weeks, 4 months and 12 months after the intervention. Outcome parameters were the incidence of re-rupture, other complications, the functional outcome and the period of sick leave concerning work and sport. RESULTS: The patient group consisted of 128 men (79%) and 35 women (21%). The mean operating time was 41 min. In 9 patients (5.5%) a major complication occurred, necessitating 5 surgical re-interventions (2 for re-ruptures, 2 for infections and 1 for tendon necrosis). Fifteen patients (9.2%) suffered from dysfunction of the sural nerve. The median time of returning to work was 28 days (range 1-368) and the median time of returning to sport was 167 days (range 31-489). The majority of patients (150; 92%) were satisfied with the results. CONCLUSION: Minimally invasive Achilles tendon repair in combination with a functional rehabilitation program is a safe and quick procedure with a low rate of re-rupture and a high level of patient satisfaction.     

Rupture of the patellar tendon: a review of 68 cases and a retrospective study of 29 ruptures comparing two methods of augmentation

Rupture of the patellar tendon is a rare injury requiring acute repair to reestablish knee extensor continuity and to allow early motion. Different pathomechanisms have been postulated, and multiple techniques for repair have been described in the literature. Firstly, the current study reviews the epidemiology, pathomechanism, and risk factors. Secondly, we compare the outcome of two augmentation techniques after end-to-end sutures: reinforcement with either a wire cerclage or a PDS cord. In the first part of the study, the medical records of 66 patients with 68 ruptures were reviewed. For the second part, 33 patients were included who had no prior injury to the extensor mechanism of the knee and had suffered an indirect, low-velocity injury followed by immediate repair. Twenty-seven patients with 29 ruptures of the patellar tendon returned for follow-up. Follow-up averaged 8.1 years (range 1-16 years). In the follow-up group, 22 ruptures had augmentation with a wire cerclage (group A), and 7 ruptures had augmentation with a 2-mm PDS cord (group B). Follow-up evaluation consisted of a subjective questionnaire, a physical and radiographic examination, the Hospital for Special Surgery Knee Score, and the Insall-Salvati ratio. Nineteen patients underwent Cybex isokinetic strength testing of the quadriceps. Indirect, low-velocity injuries occurred most often in the 30–40 year age group, whereas complex knee traumas or knee luxations were more evenly distributed. In 10 of 46 patients with an indirect, low-velocity injury, there was a history of prior injury and illness to the extensor mechanism of the knee, compared with 1 of 22 patients with a high-velocity complex knee trauma. In the follow-up group, no patient sustained a rerupture. Two of 22 patients had an extension lag in group A compared with no extension lag in group B. Average flexion in group A was 130° (SD 29°) compared with 137° (SD 12°) in group B. The average Hospital for Special Surgery Knee Score was 92 (SD 17) in group A and 96 (SD 12) in group B. Three patients were dissatisfied. All had radiographic signs of retropatellar osteoarthritis. In contrast, 9 of 26 patients who were satisfied with their result had radiographic signs of retropatellar osteoarthritis. A postoperative difference in the Insall-Salvati ratio did not correlate with the development of osteoarthritis. Both augmentation techniques are reliable and demostrate good intermediate to long-term results. The outcome did not show significant differences. To avoid reoperation for removal of the cerclage wire, a PDS cord can be used. The infection rate seems to be higher in the PDS group. A larger prospective study group is necessary to determine whether this phenomenon can be reproduced. Received: 17 January 2001     

Percutaneous repair of acute closed ruptured achilles tendon: a new technique.

The technique of percutaneous suturing repair of acute closed rupture of the Achilles tendon, as described in this article, can be performed under local anesthesia without using an arterioconstrictive tourniquet. Eighteen patients have been successfully treated with this technique, 12 having been closely followed for more than 12 months, and 8 for more than 24 months. Preliminarly, this technique for repairing acute closed Achilles tendon ruptures appears more promising than open surgical repair or short leg equinus casts alone due to tendon continuity restoration, tendon strength restoration,and minimization of postoperative complications.     

Rupture of the Achilles tendon. Results of 10 years' follow-up after surgical treatment. A retrospective study

From 1972 to 1980, 153 patients with acute rupture of the Achilles tendon were treated operatively in the Trauma Department of Hannover Medical School, 127 of whom were assessed postoperatively according to the Trillat scale at an average of 9.8 years after injury. Consideration of the tendon ruptures showed that 80% had occurred during sports activities, 86% were in males, and the highest incidence was in the age group 31-40 years (45%). In 67% an indirect trauma was present, and 35% of the patients had a history of antecedent pain and discomfort. In 77 patients the tendon was examined histologically within 24 h of injury. There was no histological evidence of antecedent pathology or degenerative condition in those cases with direct/indirect trauma, whereas in 11 of 13 cases without a history of trauma degenerative changes were observed. The operative procedure of the primary simple end-to-end suture with absorbable material showed fewer wound complications (8.4%) than were seen in the other group, in which non-absorbable sutures were used or secondary reconstructive procedures applied (3 of 8). The results obtained with primary operative tendon suturing were evaluated according to the Trillat scale as excellent in 68.8%; as good, in 20.8%; as satisfactory in 8.8%; and as poor in 1.6%. During a 10-year follow-up after primary tendon suture rerupture occurred in 2% of cases.     

Achilles Tendon Repair with Acellular Tissue Graft Augmentation in Neglected Ruptures

Neglected Achilles tendon rupture injuries present surgical challenges because of the quality and quantity of tendon tissue during repair combined with the magnitude of mechanical forces placed on this tendon. The purpose of this study was to evaluate the effects of an acellular human dermal tissue matrix, GRAFTJACKET, as an augmentation material in neglected Achilles tendon repair. Nine patients with neglected Achilles tendon ruptures were evaluated and followed up for a minimum of 20 months. Primary repair was followed by augmentation with the graft and suturing circumferentially around the tendon. Patients were placed in an early, functional rehabilitation program with postoperative evaluation at 3, 6, and 12 months. Outcome scores were calculated based on the American Orthopaedic Foot and Ankle Society ankle-hindfoot scoring system. At 20 to 30 months postoperative follow-up range, there has been no incidence of re-rupture or recurrent pain. The average return-to-activity time was 15.2 +/- 1.7 weeks. The results from this retrospective clinical series suggest that using an acellular human dermal tissue matrix to augment neglected Achilles tendon rupture primary repair offers desirable return-to-activity time points and viable surgical alternative over previously reported surgical options.     

Surgical treatment of distal triceps ruptures

BACKGROUND: Distal triceps tendon ruptures occur rarely, and the diagnosis is often missed when the injury is acute. The literature provides little guidance regarding treatment or the outcome of treatment of these injuries. The goal of this report was to present our experience with the diagnosis, timing and technique of surgical treatment, and outcome of treatment of distal triceps tendon ruptures in twenty-two patients. None of the ruptures followed joint replacement. METHODS: Twenty-three procedures were performed in twenty-two patients with an average age of forty-seven years. The average duration of follow-up was ninety-three months (range, seven to 264 months). Data were obtained by a retrospective review of records and radiographs before and after surgery. Also, thirteen patients returned for follow-up and were examined clinically. Six additional patients responded to a telephone questionnaire. One patient was lost to follow-up, and two had died. Formal biomechanical evaluation of isokinetic strength and isokinetic work was performed in eight patients, at an average of eighty-eight months after surgery. Isokinetic strength data were available from the charts of two additional patients. RESULTS: Ten of the triceps tendon ruptures were initially misdiagnosed. At the time of diagnosis, triceps weakness with a decreased active range of motion was found in most patients, and a palpable defect in the tendon was noted after sixteen ruptures. Operative findings revealed a complete tendon rupture in eight cases and partial injuries in fifteen. Fourteen primary repairs and nine reconstructions of various types were performed. Three of the primary repairs were followed by rerupture. At the time of follow-up, the range of elbow motion averaged 10 degrees to 136 degrees. All but two elbows had a functional range of motion; however, the lack of a functional range in the two elbows was probably due to posttraumatic arthritis and not to the triceps tendon rupture. Triceps strength was noted to be 4/5 or 5/5 on manual testing in all examined subjects. Isokinetic testing of ten patients showed that peak strength was, on the average, 82% of that of the untreated extremity. Testing showed the average endurance of the involved extremity to be 99% of that of the uninvolved arm. The results after repair and reconstruction were comparable, but the patients' recovery was slower after reconstruction. CONCLUSIONS: The diagnosis of distal triceps tendon rupture is often missed when the injury is acute because of swelling and pain. Primary repair of the ruptured tendon is always possible when it is performed within three weeks after the injury. When the diagnosis is in doubt immediately after an injury, the patient should be followed closely and should be reexamined after the swelling and pain have diminished so that treatment can be instituted before the end of this three-week period. Reconstruction of the tendon is a much more complex, challenging procedure, and the postoperative recovery is slower. Thus, we believe that early surgical repair, within three weeks after the injury, is the treatment of choice for distal triceps tendon ruptures. of evidence.     

Quadrizepssehneninsuffizienzen und -rupturen

Quadriceps tendon injuries and insufficiencies in total knee arthroplasty are rare, but are followed by a devastating complication that left untreated leads to a complete loss of function of the knee. This review article summarizes the functional anatomy, risk factors, and the prevalence and diagnosis of quadriceps tendon injuries, in addition to the possible management options for partial and complete ruptures. The treatment options are adapted according to the extent of the loss of function (partial, complete) and the duration of the injury (acute vs chronic). Furthermore, the choice of treatment should take into account the quality and availability of primary tissue, the patient’s general health, along with their likely functional requirements. Conservative treatment is often justified in partial ruptures with good results. Complete ruptures require surgical intervention and multiple operative techniques are described. Treatment options for acute ruptures include direct primary repair with autogenous or synthetic tissue augmentation. In the case of chronic insufficiency and a lack of soft-tissue surroundings, reconstruction with the aid of a muscle flap or allograft tissue can be considered. All surgical intervention techniques used so far have been fraught with complications and rarely lead to satisfactory results. A new surgical approach to the reconstruction and augmentation of the extensor mechanism consists of the use of a synthetic mesh. The technique is described here in detail.