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.     

Complete Achilles tendon ruptures.

Achilles tendon ruptures can be treated nonsurgically in the nonathletic or low-end recreational athletic patient, particularly those more than 50 years of age, provided the treating physician does not delay in the diagnosis and treatment (preferably less than 48 hrs and possibly less than 1 week). The patient should be advised of the higher incidence of re-rupture of the tendon when treated nonsurgically. Surgical treatment is recommended for patients who are young and athletic. This is particularly true because the major criticism of surgical treatment has been the complication rate, which has decreased to a low level and to a mild degree, usually not significantly affecting the repair over time. Surgical treatment in these individuals seems to be superior not only in regard to re-rupture but also in assuring the correct apposition of the tendon ends and in placing the necessary tension on the tendon to secure appropriate orientation of the collagen fibers. This in turn allows them to regain full strength, power, endurance, and an early return to sports. Surgery is also recommended for late diagnosed ruptures where there is significant lengthening of the tendon. Surgical technique should involve a medial incision to avoid the sural nerve, absorbable suture, and augmentation with fascia or tendon where there is a gap or late rupture. Postoperatively, the immobilization should be 7 to 10 days in a splint. A walking boot with early motion in plantar flexion or a short leg cast with the tendon under slight tension should thereafter be used for 4 to 5 weeks. An early and well-supervised rehabilitation program should be initiated to restore the patient to the preinjury activity level.     

Surgical repair of Achilles tendon ruptures

We evaluated the surgical results of 42 consecutive patients with spontaneous rupture of the Achilles tendon treated from 1973 to 1984 to determine the causes of rupture and to evaluate our treatment methods. Patients were divided into early and late repair groups and their charts reviewed to determine common clinical features. A new method of repair with early functional range of motion exercises before casting was used and compared to other techniques in common use. Thirty-one patients were contacted for long-term followup (average, 4.7 years). Twenty-three of these patients returned for intensive reevaluation and Cybex testing. We found a high incidence of gout (14.3%) and previous steroid injections (7.1%) in our patients. Good results were obtained from the four surgical methods used. There were no reruptures and only 7% of the patients experienced minor wound problems. Patients treated with early functional range of motion exercises averaged 12.5 degrees more dorsiflexion at the time of cast removal and did not require adjunctive protective devices. Long-term results, however, revealed equilibration of range of motion and near normal function in all repair techniques with 88% of all patients returning to preinjury activity levels.     

Long-term outcomes of muscle volume and Achilles tendon length after Achilles tendon ruptures

Purpose

The best treatment for Achilles tendon (AT) ruptures remains controversial. Long-term follow-up with radiological and clinical measurements is needed.

Methods

In this retrospective multicentre cohort study, patients (n = 52) were assessed at a mean of 91 months follow-up after unilateral AT rupture treated by open, percutaneous or conservative (non-surgical) treatment. Demographic parameters, time off work, maximum calf circumference and clinical scores (ATRS, Hannover, AOFAS) were evaluated. Muscle volume and cross-sectional area of the calf and AT length were measured on MR images and were compared between groups and to each patient’s healthy contralateral leg.

Results

Reduced muscle volume was found across all groups with a higher muscle volume in the conservative (729.9 ± 130.3 cm³) compared to the percutaneous group (675.9 ± 207.4 cm³, p = 0.04). AT length was longer in the affected leg (198.4 ± 24.1 vs. 180.6 ± 25.0 mm, p < 0.0001) without difference in subgroup analysis. Clinically measured ankle dorsiflexion showed poor correlation with AT length (R ² = 0.07, p = 0.008). Muscle volume strongly correlated with the cross-sectional area (R ² = 0.6, p < 0.0001) but showed a weak correlation with the Hannover score (R ² = 0.08, p = 0.048). Maximum calf circumference correlated with muscle volume (R ² = 0.42, p < 0.0001).

Conclusions

No significant difference between the treatment groups was found in muscle volume, AT length, clinical measures or days off work. Cross-sectional area and maximum calf circumference are cost-effective measurements and a good approximation of muscle volume and can thus be used in a clinical setting while clinical dorsiflexion should not be used.

Level of evidence

III.     

Magnetic resonance imaging of Achilles tendon ruptures

Preoperative magnetic resonance images of three acute Achilles tendon ruptures were correlated with the findings observed during surgical repair of the tendon. Specific comparisons were made regarding the condition (shredded, uniform, etc.) and orientation (antegrade, retrograde, etc.) of the torn fibers, and the width of the diastasis (with and without ankle flexion) between the ends of the tendon. Magnetic resonance imaging (MRI) accurately assessed all of these parameters.     

Magnetic resonance imaging, chest radiography, computed tomography and ultrasonography in malignant lymphoma

Magnetic resonance imaging (MRI) was compared with chest radiography, computed tomography (CT) and ultrasonography (US) for demonstration of spleen and liver engagement and enlarged lymph nodes in patients with malignant lymphoma. The investigation comprised 24 patients with Hodgkin's disease (HD) and 39 with non-Hodgkin lymphoma (NHL). MRI demonstrated enlarged lymph nodes, distinctly separated from vessels, fat, muscle, liver and occasionally also pancreas without any contrast medium. The distinction between lymph nodes and spleen was, however, poor in the images. In the mediastinum, MRI was superior to chest radiography and had an accuracy similar to that of CT. In the abdomen and the pelvis MRI had slight advantages over CT in detection of enlarged lymph nodes. Compared with US the MRI results were similar in the abdomen and somewhat better in the pelvis. MRI and US were better than CT in revealing HD infiltrates in the spleen. Infiltration of NHL in the spleen was slightly better disclosed at US than at CT and MRI; most of the NHL infiltration, confirmed at histopathology, could, however, not be revealed with any of the modalities, except when the size of the spleen was considered. Regions in the spleen, displayed with low image intensity in the T2 weighted image, were most likely due to increased amount of fibrotic tissue in the lymphomatous lesions. Good demonstration of lymph nodes and lymphomatous lesions in the spleen with MRI required two sequences; one with short TR and TE (T1 weighted image) and one with long TR and TE (T2 weighted image).     

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     

112例急性跟腱断裂的手术疗效分析

目的探讨手术治疗急性跟腱断裂的疗效和并发症。方法对2009年1月～2012年12月收治的112例急性跟腱断裂患者,采用单纯端端缝合修补89例,腓肠肌筋膜瓣加强修补23例。男性98例,女性14例;年龄23～48岁,平均37岁。闭合性损伤101例,开放性损伤11例。结果本组112例,平均随访时间为14．5个月（6～18个月）。根据美国足踝骨科协会（AOFAS）评分标准,平均分为92．2分（74～100分）。其中优63例,良39例,可10例。踝关节活动度患足为（55．2±7．1）°,健足（57．1±5．8）°,两者无显著差异（t=0．101）。采用单纯端端缝合修补患者的AOFAS评分为90．9±10．3,加强修补患者的AOFAS评分为93．6±9．9,两者无显著差异（t=0．389）。踝关节活动范围分别为（54．2±9．3）°和（56．1±7．8）°,两者也无显著差异（t=0．764）。切口表浅感染5例,深部感染1例,跟腱再断裂2例。结论手术治疗急性跟腱断裂疗效可靠、并发症少。     

Tissue expansion for repair of severely complicated Achilles tendon ruptures

We report on two patients with severely complicated Achilles tendon ruptures (ATR), including re-rupture, postoperative deep infection and subsequent tissue loss. Tissue expansion was used to facilitate tendon reconstruction and to ensure good healing potential with skin closure without tension. Tissue expansion is a valid option in patients with complicated ATR. The outcome for the two patients described here was good, with improved function and no major complications.     

Ultrasound and color Doppler ultrasound of acute and subacute Achilles tendon ruptures

Acute rupture of the Achilles tendon is one of many foot and ankle injuries that may present to the emergency department. Using ultrasound and color Doppler ultrasound, the radiologist can determine which acutely injured patients require operative management and which can be treated nonoperatively. Nonoperative management can be used in those patients with closely apposed tendon ends. This article reviews the use of gray-scale ultrasound in evaluating the appearance of the torn Achilles tendon. The use of color Doppler ultrasound for distinguishing torn tendon ends from hematoma and granulation tissue is discussed.     

Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography,computed tomography and ultrasonography

Objective

The purpose of this study was to compare the sensitivity for detecting foreign bodies among conventional plain radiography, CT and ultrasonography in in vitro models.

Methods

Seven different materials were selected as foreign bodies with dimensions of approximately 1×1×0.1 cm. These materials were metal, glass, wood, stone, acrylic, graphite and Bakelite. These foreign bodies were placed into a sheep''s head between the corpus mandible and muscle, in the tongue and in the maxillary sinus. Conventional plain radiography, CT and ultrasonography imaging methods were compared to investigate their sensitivity for detecting these foreign bodies.

Results

Metal, glass and stone can be detected with all the visualization techniques used in the study in all of the zones. In contrast to this, foreign bodies with low radiopacity, which could be detected in air with CT, became less visible or almost invisible in muscle tissue and between bone and muscle tissue. The performance of ultrasonography for visualizing foreign bodies with low radiopacity is relatively better than CT.

Conclusions

Ultrasonography detects and localizes superficial foreign bodies with low radiopacity in the tissues of the body more effectively than CT and conventional plain radiography. However, CT is a more effective technique for visualization of foreign bodies in air than ultrasound and conventional plain radiography.     

Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study

A comparative study between percutaneous repair and open surgical repair of acute spontaneous Achilles tendon ruptures in young athletic patients is presented. Twenty-seven patients with acute Achilles ruptures were evaluated objectively and with subjective questionnaires. Fifteen of the patients were treated by reconstruction with a gastrocsoleus fascial graft (followup, 4.6 years) and 12 treated by percutaneous repair (followup, 1.8 years). Subjectively, both groups were very satisfied with the results of their treatment. Cybex II dynamometer measuring strength, power, and endurance revealed no statistical significant differences between groups, even in light of the shorter followup of the percutaneous group. The percutaneous repairs demonstrated significantly more symmetry in injured/uninjured tendon size than did the open surgical repairs. Two reruptures occurred in the percutaneous group. No other complications were noted. After evaluation of both subjective and objective data we recommend percutaneous repair in the recreational athlete and in patients concerned with cosmesis. Open repair is recommended for all high-caliber athletes who cannot afford any chance of rerupture.