Diagnostic value of ultrasonography in partial ruptures of the Achilles tendon.

We evaluated 37 patients with surgically treated Achilles tendon disorders, comparing findings of preoperative ultrasonography with findings at surgery, to investigate the reliability of ultrasonography in diagnosing partial ruptures of the Achilles tendon. Discontinuity of tendon fibers, focal sonolucencies, and localized tendon swelling were positive findings suggestive of partial ruptures. We found the use of ultrasonography to be safe and reliable, with a sensitivity of 0.94, a specificity of 1.00, and an overall accuracy of 0.95.     

Long-term results after surgical management of partial Achilles tendon ruptures

Although Achilles tendon injuries are common overuse injuries in sports, the exact incidence is unknown, primarily as a result of varying definitions and diagnoses of the underlying pathological changes. Despite numerous studies of treatment of the Achilles tendon injuries, the longterm results are not well known. The results after surgical treatment of chronic partial Achilles tendon ruptures in 64 patients with a follow-up of 6 (1.5–11) years were evaluated in a retrospective study. The ruptures were divided into three groups: (I) proximal (more than 3 cm above the calcaneus), (II) distal and (III) combined (proximal and distal). All patients underwent an operation involving the excision of the devitalized tendon tissue and, in groups (II) and (III), also the excision of the deep Achilles bursa and removal of the dorsal corner of the calcaneus. The functional results were satisfactory in 43 (67%) patients and unsatisfactory in 21 (33%). The results were better in patients with proximal ruptures than in patients with either distal or combined ruptures. Males experienced better results than females. Post-operative immobilization in a plaster cast had no significant influence on the final result. Nine (14%) patients with either a distal or a combined rupture were re-operated on and in seven of them the final result was satisfactory. The conclusion of this study is that partial Achilles tendon ruptures are often difficult to treat and only two out of three patients can be expected to obtain satisfactory results after surgical treatment.     

Soft-tissue radiography, computed tomography, and ultrasonography of partial Achilles tendon ruptures

Ultrasonography (US) was compared with soft-tissue radiography (STR) and computed tomography (CT) for demonstration of partial Achilles tendon ruptures. Thirty-nine patients suffering from chronic localized painful Achilles tendon swelling were examined. The patients had all undergone a previous clinical examination, resulting in a suspicion of a non-healed partial tear in 62 out of the 78 tendons. STR showed unspecific tendon pathology such as thickening and diffuse tendon margins. CT resulted in a better delineation of intra- as well as extratendinous abnormalities compared to STR. Various pathologic changes were seen on CT in 54 tendons and in 29 of these, localized intratendinous hypodensities indicated partial ruptures. At US, abnormal changes were observed in 69 tendons, of which 54 had discontinuity of tendon fibers, focal hypoechoic areas, and localized swelling indicating partial ruptures. In 9 cases with surgically proven partial ruptures, US was correct in all cases, while CT was false-negative in 3. STR only showed localized swelling. It was concluded that US was a better method than STR and CT for the detection of partial ruptures and the US findings correlated well with the surgical findings.     

Partial Achilles tendon tears.

Persistent pain in the Achilles tendon is often caused by partial ruptures leading to a hypoxic state in the tissues, insufficient healing, and a remaining, immature, and painful scar. The rupture is caused by overuse and conservatively treated with orthotic devices to reduce tendon load and physiotherapy to correct training errors and strength the muscle-tendon unit. Significant partial ruptures seem to respond poorly to conservative measures and do not improve with time. Surgical treatment with excision of degenerated tissue which leads to complete pain relief and full restoration of function with long-standing effects in most cases is why persistent Achilles tendon pain due to partial rupture preferably should be treated surgically.     

Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging

Objectives: The aim of this study was to determine whether ultrasound can correctly visualise partial ruptures of the proximal Achilles tendon. Method: This was a prospective study in which all chronic Achilles tendon injury patients seen at three centres in Germany from 1998 to 2003 were screened. All patients with clinical and/or sonographic signs of abnormalities in the region of the proximal third of the Achilles tendon and tendomuscular junction were included in the analysis. Each of these cases was evaluated by ultrasound following an assessment protocol. Patients with ambiguous ultrasound findings and/or clinical signs were additionally assessed by magnetic resonance imaging (MRI). Results: Sonomorphologic changes suggestive of an abnormality in the proximal third of the Achilles tendon were detected in 13 out of 320 patients (4.2%) with recurring Achilles tendon complaints. Thirteen patients had clinical signs but no sonographic changes in the tendon. The sonographic diagnosis was correct in 19 cases. In six of the 26 cases studied, MRI was needed to establish the correct diagnosis of partial intratendinous rupture of the proximal Achilles tendon. Sensitivity was 0.5, specificity was 0.81, and the overall agreement of the ultrasound examination was 61.5%. All patients were asymptomatic at follow up at a mean of 14 months (range 12–17 months) after surgery. Conclusions: Ultrasound is a useful tool for evaluation of proximal Achilles tendon complaints. However, ultrasound is not sufficiently reliable for diagnosis of all pathologies, especially partial ruptures of the Achilles tendon. Thus, the definitive diagnosis must be established by MRI.     

The role of recreational sport activity in Achilles tendon rupture. A clinical, pathoanatomical, and sociological study of 292 cases

During the last few decades, the incidence of tendon ruptures has increased in civilized countries. Our material comprises 749 patients who had 832 tendon ruptures treated surgically between 1972 and 1985. There were no competitive athletes among the patients studied. There were 292 single ruptures of the Achilles tendon, 274 of the proximal biceps brachii, 113 of the extensor pollicis longus, and 70 of other tendons. Forty-eight patients had multiple ruptures and 35 patients had reruptures. Achilles tendon ruptures often occurred in recreational sports activities (59%), in contrast to other tendon ruptures (2%; P less than 0.001). The mean age for patients who had Achilles tendon rupture was 35.2 years and for patients with other ruptures, 50.7 years (P less than 0.001). There was a connection between the high incidence of blood group O and tendon ruptures (P less than 0.001). In cases of multiple ruptures and reruptures, the frequency of blood group O was 71%. Sixty-two point three percent of the patients with Achilles tendon rupture were professionals or white collar workers, which is markedly more than in the Hungarian population (12.7%; P less than 0.001). Two hundred and six Achilles tendon ruptures were studied histologically, and all cases displayed pathological alterations. The results indicate that complete rupture of the Achilles tendon is usually a sequel to a sedentary life-style and participation in sports activities.     

Xerography in the study of Achilles paratendinopathies and tendinopathies

The authors report their experience in the examination of Achilles tendon, performed with xeroradiography, in 120 young men, affected by Achilles tendon diseases caused by sports. With xeroradiography it is possible to diagnose tendinosis with peritendinitis and pure tendinosis not revealed by clinical examination; radiological diagnostic contribution is particularly important in partial and old ruptures. The necessity is remarked to employ xeroradiography in association with ultrasound to correctly classify the various forms of Achilles tendinopathies and paratendinopathies.     

Achilles tendon: US examination

Real-time ultrasonography (US) using linear-array probes and a stand-off pad as a "waterpath" was performed to evaluate the Achilles tendon in 67 patients (including 24 athletes) believed to have acute or chronic traumatic or inflammatory pathologic conditions. Tendons in 23 patients appeared normal on US scans. The 44 abnormal tendons comprised five complete and four partial ruptures, seven instances of postoperative change, and 28 cases of tendinitis. US depiction of the inner structure of the tendon resulted in the diagnosis of focal abnormalities, including partial ruptures, nodules, and calcifications. Tendinitis was characterized by enlargement and decreased echogenicity of the tendon. The normal US appearance of the Achilles tendon is described.     

Etiology and pathophysiology of tendon ruptures in sports

Of all spontaneous tendon ruptures, complete Achilles tendon tears are most closely associated with sports activities (1–3). Schönbauer (3) reported that 75% of all ruptures of the Achilles tendon are related to sports. In Plecko & Passl (2) the number was 60%. In our material of 430 cases, the number of sports-related Achilles ruptures was very similar (62%), while only 2% of ruptures of other tendons were sports-related (P<0.001) (1). Also, the majority of Achilles reruptures occurred in sports. The ruptures occurred most often in soccer (34%), track and field (16%) and basketball (14%). The distribution of Achilles ruptures according to different sports varies considerably from country to country, according to the national sport traditions. For example, in northern and middle Europe, soccer, tennis, track and field, indoor ball games, downhill skiing, and gymnastics are the most common; and in North America, football, basketball, baseball, tennis and downhill skiing dominate the statistics (1, 2, 4). In sports, some Achilles ruptures are not spontaneous or degeneration-induced but may occur as a consequence of the remarkably high forces that are involved in the performance (2). Ruptures in the high jump or triple jump are good examples. In such cases, failure in the neuromuscular protective mechanisms due to fatigue or disturbed co-ordination can frequently be found. The spontaneous complete rupture of the supraspinatus tendon of the rotator cuff does not occur very frequently in sports. Those sports that include high-energy throwing movements, such as American and Finnish baseball, American football, rugby and discus and javelin throwing, may, however, produce this injury. Partial tears and inflammations of the rotator cuff complex are much more frequent in throwing sports. The complete rupture of the proximal long head of the biceps brachii tendon is rare among competitive and recreational athletes. In our material, under 2% of these ruptures were associated with sports activities (5). The rupture (avulsion) of the distal tendon of the biceps muscle is rare. In sports, gymnastics, body building and weight lifting have been said to be able to produce this injury (6). In general, complete ruptures of the quadriceps tendon and the patellar tendon occur most often in older individuals. In our study, the mean age of these patients was 65 years (5). However, these injuries do also occur in younger age groups, especially in athletes. In athletes, the rupture most frequently occurs in high-power sports events, such as high jump, basketball and weight lifting, at the age of 15-30 years. A chronic patellar apicitis (jumper's knee) may predispose rupture of the tendon (7). As is the case with the rotator cuff complex, overuse inflammation and partial tears of the quadriceps and patellar tendons are one of the most characteristic athletic injuries. Complete spontaneous ruptures of other tendons in sports are rare, although the literature does provide case studies from almost every tendon the human body possesses (8–18).     

跟腱再断裂的手术治疗15例报告

目的了解跟腱再断裂的临床表现及再手术的方法与疗效。方法15例跟腱再断裂的患者在我所进行手术治疗,术中全面观察跟腱再断裂的表现,根据不同的断裂情况选择手术方式。结果15例患者再断裂部位均为跟骨结节上3~4cm,均为原断裂部位。跟腱断端瘢痕化增粗,粘连明显。其中12例为横行断裂,2例为短马尾状断裂,1例为大部分撕裂。15例患者中9例为闭合性再断裂,6例为开放性再断裂。10例患者坚持随访至少1年,按Amer-Lindholm评分优良率为70%。结论跟腱再断裂均发生在原断裂部位,断端瘢痕化,粘连明显,多为横行断裂,急诊再手术缝合修补效果满意。     

Histopathological findings in spontaneous tendon ruptures

A spontaneous rupture of a tendon may be definied as a rupture that occurs during movement and activity, that should not and usually does not damage the involved musculotendinous units (1). Spontaneous tendon ruptures were uncommon before the 1950s. Böhler found only 25 Achilles tendon ruptures in Wien between 1925 and 1948 (2). Mösender & Klatnek treated 20 Achilles tendon ruptures between 1953 and 1956, but 105 ruptures between 1964 and 1967 (3). Lawrence et al. found only 31 Achilles tendon ruptures in Boston during a period of 55 years (1900-1954) (4). During the recent decades tendon ruptures have, however, become relatively common in developed countries, especially in Europe and North America. A high incidence of tendon ruptures has been reported in Austria, Denmark, Finland, Germany, Hungary, Sweden, Switzerland and the USA; somewhat lower incidences have been reported in Canada, France, Great Britain and Spain. On the other hand, Greece, Japan, the Netherlands and Portugal have reported a clearly lower incidence. Interestingly, Achilles tendon ruptures are a rarity in developing countries, ecpecially in Africa and East-Asia (5). In many developed countries, the increases in the rupture incidence have been dramatic. In the National Institute of Traumatology in Budapest, Hungary, the number of patients with an Achilles tendon rupture increased 285% in men and 500% in women between two successive 7-year periods, 1972-1978 and 1979–1985(5).     

Endoscopy, assisted percutaneous repair of the Achilles tendon ruptures: a cadaveric and clinical study

Endoscopy-assisted percutaneous repair of Achilles tendon ruptures were investigated in a cadaveric and clinical study. Sixteen above-knee fresh amputation specimens in which different types of Achilles tendon ruptures were created were repaired percutaneously with the visualization of the tendon ends by endoscopy. Neither malalignment nor damage to the neurovascular structures was observed. Eleven patients were treated in this way. No reruptures, wound problems, or neurovascular injury were observed. All patients returned to daily activities 10-11 weeks after the repair. This technique seems to overcome certain problems of conservative, surgical, or percutaneous repair of the Achilles tendon ruptures.     

Ultrasonic morphology of the normal Achilles tendon and pattern of pathological changes

The anatomical structure of the Achilles tendon causes a fibrillary echo texture with fine, parallel echogenic lines. The peritendineum outlining the tendon can be delineated. Achilles tendon ruptures can easily be detected by ultrasound, as can the structural changes in achillodynia. The typical sonographic patterns of rupture of the Achilles tendon and achillodynia are demonstrated.     

Magnetic resonance imaging in acute tendon ruptures

The diagnosis of acute tendon ruptures of the extensor mechanism of the knee or the Achilles tendon of the ankle may usually be made by clinical means. Massive soft tissue swelling accompanying these injuries often obscures the findings, however. Magnetic resonance imaging (MRI) can rapidly demonstrate these tendon ruptures. Examples of the use of MRI for quadriceps tendon, and Achilles tendon rupture are presented.     

Achilles tendon disorders in athletes

Achilles tendon disorders are among the more common maladies seen by sports medicine physicians. Understanding the anatomy and biomechanics of the Achilles tendon and contiguous structures is essential to the diagnosis and treatment of Achilles tendon overuse injuries. Posterior heel pain is multifactorial and includes paratenonitis, tendinosis, tendinosis with partial rupture, insertional tendinitis, retrocalcaneal bursitis, and subcutaneous tendo-Achilles bursitis. Each of these entities is distinct, but they often occur in combination. Although most cases of this disorder are successfully treated nonoperatively, a small subgroup of recalcitrant cases may benefit from surgical intervention. Complete ruptures in active, athletic persons should be treated operatively in most cases and result in predictably good outcomes. There may be some cases that escape early recognition and require a reconstructive procedure to salvage a potentially severe functional deficit.     

Real-time sonoelastography of the Achilles tendon: pattern description in healthy subjects and patients with surgically repaired complete ruptures

Objective

The purpose of this study is to describe the elastographic appearance of the Achilles tendon in healthy subjects and patients with surgically repaired complete ruptures.

Materials and methods

Nineteen Achilles tendons of 16 amateur footballers with surgically repaired complete ruptures and their contralateral asymptomatic Achilles tendons were assessed with ultrasound and real-time sonoelastography. Additionally, 40 asymptomatic Achilles tendons of 20 healthy amateur footballers were assessed. The Achilles tendons were divided into the distal, middle, and proximal thirds for elastographic image evaluation. Tendons were classified into three main types according to the elasticity features: type 1, blue (hardest tissue); type 2, blue/green (hard tissue); or type 3, green (intermediate tissue). In addition, three subtypes were determined: homogeneous, relatively homogeneous, and heterogeneous.

Results

Most of the Achilles tendons of the patients with surgically repaired complete ruptures were detected to have type 2 elasticity (64.9%), and the remaining had type 1 (35.1%). In contrast, most of the healthy tendons had type 2 (64.2%), and the remaining had either a type 3 (20.8%) or a type 1 (15%) elastographic pattern. All of the ruptured tendons had a heterogeneous structure, whereas all of the healthy Achilles tendons had a homogeneous or relatively homogeneous structure.

Conclusion

In sonoelastography, the recognition of normal tendon structure will be useful in assessing pathologies of the Achilles tendon. Additionally, in patients with excellent American Orthopedic Foot and Ankle Society (AOFAS) scores and surgically repaired complete ruptures, a hard and heterogeneous pattern of tendon structure may be a natural consequence of tendon healing.     

Sonographic appearance of nonoperatively treated Achilles tendon ruptures

Objective. This report describes the gray-scale and color Doppler sonographic appearance of healed Achilles tendon ruptures that have been treated nonoperatively. Design and patients. Eleven patients with acute Achilles tendon ruptures were studied with sonography in the acute setting and following nonoperative management of their torn tendon. Results. On sonographic examination, healed tendons treated nonoperatively are characterized by mild residual distortion of the normal fibrillar architecture of the tendon, anterior bulging or irregularity of the healed tendon, and a hypoechoic area about the site of rupture. Less frequent observations include mildly increased color flow and calcification at the rupture site. The previously described findings of acute tears, including hematomas, gaps at the rupture site, hyperemic torn tendon ends, and markedly distorted fibrillar architecture, were seen to have resolved in this series. Conclusion. The Achilles tendon tear treated nonoperatively has a different sonographic appearance from that of a normal or acutely ruptured tendon. Received: 24 November 1999 Revision requested: 23 January 2000 Revision received: 8 February 2000 Accepted: 8 February 2000     

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.     

Achilles tendon: MR imaging at 1.5 T

Thirty magnetic resonance (MR) examinations of the Achilles tendon were performed: 20 from patients without suspected tendon abnormalities; ten from patients with suspected tendon abnormalities. The appearance of the normal Achilles tendon is hypointense and flattened. Partial tears appeared as high-signal intratendinous collections, complete acute ruptures appeared as tendinous discontinuity, and uncomplicated surgical repairs appeared as areas of tendinous continuity with inhomogeneous signal in the operative site. Chronic tendinitis appeared as a diffuse thickening of the tendon. MR imaging of the Achilles tendon at 1.5 T enabled the determination of the degree of tendinous continuity, which may help with diagnosis, treatment, and the pacing of rehabilitation.     

Operative treatment of chronic distal biceps tendon ruptures

Chronic biceps tendon ruptures typically involve tendon retraction, scarring, and even compromised tissue. Indirect repair, such as tenodesis to the brachialis, does not provide optimal functional recovery. Chronic biceps tendon ruptures can be reconstructed with autogenous grafts (semitendinosis, tensor fascia lata) or allografts (typically Achilles tendon). The complications associated with these grafts include harvest site morbidity and graft incorporation. Using a vascularized local soft tissue source could minimize complications of graft reconstructions. The authors provide a novel reconstructive technique, reconstruction using the lacertus fibrosis, as a local graft source for chronic distal biceps tendon ruptures.