State University of Medicine and Pharmacy [602269]

State University of Medicine and Pharmacy
"Nicolae Testemițanu"

Thesis

State University of Medicine and Pharmacy
"Nicolae Testemițanu"

FACULTY OF MEDICINE
Department of Orthopedics and Traumatology

License Thesis
PERCUTANEOUS REPAIR OF ACUTE
ACHILLES TENDON RUPTURE

Presented by :

Massarwi R oba , Group 1637

Direction and guidance:

P.h.D , Dr. Vitalie Chirilă

2015

© Copyright by Massarwi R oba
All Rights Reserved

Summary

I hereby declare that the license thesis “Percutaneous repair of acute Achilles tendon
rupture ” is written by me and has never been submitted to another university or
institution of higher education in the country or abroad . all sources used, are given in the
paper with the rules for avoiding plagiarism .

…………………… ……………………………….
Date Massarwi R oba

I

DEDICATION

I dedicate this thesis to the memory of my uncle Dr.Abed El Latif
Massarwi, may his soul R.I.P, I hope he will be proud of me.

Also i dedicate this thesis to my lovely parents for their support
during my medical study; without their love and sacrifices this thesis
wouldn’t be done .

II

CERTIFICATION

The undersigned certifies that he has read and hereby recommends for
acceptance of the dissertation entitled “ Percutaneous repair of acute
Achilles tendon rupture “ , in fulfillment of the requirements for Thesis of
Medicine in the department of “Orthopedics and Traumatology “ of the
State University of Medicine and Pharmacy “ Nicolae Testemițanu „ .

______________________
Dr. Nicolae Cap roș

______________________
Date

______________________
Dr. Vitalie Chirilă

______________________
Date

III

Table of Contents

STATMENTS I
DEDICATION II
CERTIFICATION III

Abstract ……………………………………………………………………. 1

Introduction ……………………………………… ……. …… …….……….. 3

Materials and methods ………………………………….…………….….. 9

Results …… ……………………………………………….………………. … 14

Discussion ……………………………………….………….………….. …. 23

Clinical case …………………………………………………………….…. 29

Appendix
Appendix A: Questionnaire ………….……………………..…… ……..…. 30
Appendix B: Modifi ed Boyden Score.……………………………….. ……. 32
Appendix C: Ankle -hindfoot scale/AOFAS ……………… ………………… 34

Bibliography ………………………………….…….………..……………. . 36

Abstract

Background: The Achilles tendon, the thickest and strongest in the human body
is created by the merging of the tendon parts of the Soleus and Gastrocnemius
muscles, located in the posterior area of the shin.
75% of the severe Achilles tendon ruptures relate to physica l activity. The
increased incidence of such ruptures over the past years results from increased
recreational sports and physical activities in the general population. There are
several options for treating an Achilles tendon rupture, and no unanimous
agree ment as to the best method. There is a conservative treatment based on
plastering of the ankle and sole for an extended period of time, open surgical
treatment exposing the rupture area and suturing the tendon edges, and
percutaneous surgical treatment wi th several small incisions above and below the
rupture area and suturing through them.
The main problems in the treatment of Achilles tendon ruptures are the high rate
of repeated ruptures after conservative treatment and complications relating to
infecti on and healing in the open surgery treatment. The advantages of the
percutaneous surgical approach, which is minimally invasive are better
functioning, low rate of repeated ruptures, reducing complications related to open
surgery, better cosmetic results a nd rapid healing.
Objectives : Evaluating the results of percutaneous repair of acute Achilles tendon
rupture.
Methods : The study included 62 patients treated with percutaneous repair of
acute Achilles tendon rupture in the Chaim Sheba Medical Center at Tel –
Hashomer over the past eight years. The assessment of the surgical procedure
results included a number of variables: General epidemiologic information on the
patient and the injury; subjective assessment of pain, rigidity and functioning;
objective asses sment including determination of motion ranges, stability and
alignment, and isokinetic evaluation with Cybex dynamometer. The Modified
Boyden Score and the American Orthopaedic Foot and Angle Society Scale were
used.

Main results : The evaluation of the su rgical treatment showed good functioning
results with almost no limitation of recreational activities, and general satisfaction
of the patients with the treatment.
Changes in the mobility range of the repaired angle were minimal.
An isokinetic examination with Cybex showed slight changes in the motion range
at 90° plantarflexion between the healthy and injured feet, with no changes
detected at 30° or 240° plantar or in dorsiflexion power in all velocities.
Complication rate was low, superficial infection de tected in three patients and
repeated rupture in one.
The general average score of the modified Boyden score was 74.6 and the general
average score of the Ankle and Hindfoot Scale was 93.5.
Conclusions : The percutaneous repair method which is simple, quick and
performed under local anesthetic has excellent functional results and low
complication rate as compared to literature reports on other treatment methods.
These results make it another treatment option and even suggest making it the
option of choice as compared to the conservative and open surgery approaches for
the acute Achilles tendon rupture. This is the first study in Israel to examine the
results of this treatment method for acute Achilles tendon rupture.

Introduction

The Achilles tendon, the thickest and strongest in the human body is created by
the merging of the tendon parts of the Soleus and Gastrocnemius muscles, located
in the posterior area of the shin.
Towards the heelbone, the Achilles tendon becomes gradually rounded (in cross –
section) up to about 4 cm proximal to the heelbone, where it becomes flatter2. The
tendon fibers rotate by 90°, so that the medial fibers at the proximal edge of the
tendon, become the posterior ones at the distal edge. This enables leng thening and
elasticity, required for proper mobility.
The holding point of the tendon in the calcaneus consists of the tendon, a layer of
hyalinic cartiladge and a bone area not covered by periosteum. In addition a
subcutaneous bursa is possible between th e skin and the tendon, reducing friction
between the tendon and the adjacent tissues, as well as a retro calcaneal bursa
between the tendon and the calcaneus.
Histologically, collagen fibers comprise 70% of the tendon’s dry weight. Mostly
this is Collagen type I, and the rest are elastin fibers. The tendon fibers are
bundled in fascicles enveloped in the epitenon, and separated from the paratenon
by a thin liquid layer, enabling motion with minimal friction. In a previously
ruptured tendon, collagen III fib ers may be found, which are less resistant to
stretching. This may be the reason for repeated ruptures.

The blood supply to the tendon comes from several sources: the muscles, the
holding point in the calcaneus, and directly from several blood vessels cr ossing
the paratenon into the tendon mass.

Hypocrates, in the first documented description of an Achilles rupture wrote: ‘this
tendon, if bruised or cut, causes the most acute fevers, induces choking, deranges
the mind and at length brings death’. {2}

An epidemiologic review of the frequency of Achilles tendon ruptures it variance
was found between reports, but it is evident that ruptures are more frequent since
the 1950’s, because of increased recreational sports and physical activities. About
75% of a ll Achilles tendon ruptures relate to physical activity, mainly those that
require sudden acceleration and jumping. Many reports show that at the time of
rupture, about 60% of the patients were engaged in ball games.{3,1,11,19,22 }
Most acute Achilles tend on ruptures occur in men (at a ratio of 6:1), mainly
between the ages 30 -40, the rupture is usually unilateral, with a higher incidence
rate for the left leg. 80% of the ruptures occur 2 -6 cm above the holding point of
the Achilles tendon and the calcaneus . Many studies relate this finding to the
reduced blood supply in this area{1,2}.

The pathophysiological mechanism leading to the rupture is unknown for most
patients. Two main theories offer explanations:

a. Chronic degenerative changes in the tendon, as a result of faulty blood
supply which may be age, illness or trauma -dependent. The rate of tendon
regeneration is not high enough to repair the accumulated damage due to
repeated micro -trauma to the tendon, to the point that it weakens and fully
ruptures. T his is the most common theory. Cetti et al. (2003) show collagen
degeneration, necrosis of tenocytes, and acute inflammation in all the
Achilles tendons examined, after acute rupture{20}.
b. The mechanical theory – suggested by Ingils & Sculco in 1981 relates the
tendon rupture to the failure of the inhibitor mechanism of the muscle –
tendon unit, preventing a too strong of uncoordinated muscular contraction.

Additional factors known to be related to Achilles tendon rupture are the use of
anabol ic steroids, systemic steroids or through direct injection to the tendon,
quinolone antibiotics and systemic inflammatory diseases such as RA and SLE.

The injury mechanism:

Arner & Lindholm have suggested three possible mechanisms for the rupture of
the Achilles tendon which do not result from direct trauma: pushing with the leg
carrying the weight while straightening the knee (such as in running or jumping),
a sudden strong dorsiflexion (fall from a chair, ladder or into a pit), and a strong
dorsiflexion of the ankle in the plantarflexion position (jumping, falling from a
height) {1}.

The diagnosis of the Achilles tendon rupture is usually based on the typical
anamnesis of a strong, sudden pain, often accompanied by a snap, the inability to
put weight on the injured leg and the inability to actively bend the ankle, in the
absence of a history of direct trauma{2,8}.
In examining the patient shortly after the injury, a gap may be seen and felt,
suggesting the rupture area in the tendon, and as a result of the activity of the
Peronei and Tibialis posterior methods an active movement plantarflexion is
possible, also the ability to stand on one’s toes in the early stages. Often, hours
after the injury, edema or a hematoma may fill the gap and make the diagnos is
more difficult.
There are several clinical tests in the physical examination, which assist in the
diagnosis of an Achilles tendon rupture: the calf -squeeze (named after Thompson,
and is the best known method, where the examiner manually squeezes the
patient’s shin muscles. When the Achilles tendon is whole, a plantarflexion of the
ankle is apparent. If the Achilles tendon is ruptured, there will be no movement,
or minimal movement). There is also the Matles test, the O’Brien needle test and
Copeland’s sp hyngmomanometer test{4,2,12 }.

In case of doubt, imaging such as ultrasound or MRI may be used to confirm the
diagnosis{2,4}.
There are several treatment options of the acute rupture of the Achilles tendon,
and no unanimous agreement as to the best treatment option.
The treatment options may be divided to three different approaches: conservative
treatment, open surgical repair, and percutaneous treatment.

1. The classical conservative treatment is based on plastering the ankle and
sole for extended pe riods of time and different positions of plantarflexion of
the ankle. This method reduces the risks of surgery. The functioning results
expected is good, but the rate of repeated ruptures is high (9.8 -13%). In
addition, an extension of the tendon is possib le, leading to relative
weakness of the plantarflexion power of the ankle{1,10-13,22 }.

2. Open surgical repair – about 30 different surgical techniques have been
described{13}, mainly involving a full exposure of the rupture area, sewing
the tendon edges b y various techniques, and often reinforcing the sewing by
exogenic and autogenic materials.
This approach has been the method of choice for the past two decades for
athletes, young people and patients suffering from chronic ruptures of the
Achilles tendon. It provides an excellent functional result with relatively
quick rehabilitation.
Since there are many surgical and post -surgical techniques, there are
differences in the extent of complication of the different series. The rate of
recurring ruptures is bet ween 1.4% -3.5%, complications relating to
infection and wound healing problems 5.3% -14.6%, and general
complications (pain, sensory problems, extension or shortening of the
tendon, blood clots or embolisms) at a rate of 5.7% -8.9%{13,11,10,22 }.

3. Percutaneous repair was first described by Ma & Griffith in 1977. This
surgical technique is based on six small incisions, three lateral and three
medial to the rupture, above and below the rupture area and threading the
suture through them{6}.
The advantages of this minimally invasive method are: prevention of the
major complications related to open and invasive repair under general
anesthetics, good functional outcomes, relatively low rate of repeated
ruptures, good cosmetic results and rapid h ealing. The disadvantages are
possible damage to the sural nerve due to the lateral cuts, at a rate of 0 –
16.7%, and slightly higher rates of repeated ruptures as compared to the
open repair method.

In 1999 Webb & Bannister described a new percutaneous me thod. This technique
is based on three incisions in the median posterior line of the shin, above the
tendon, and closeness of the rupture edges by means of two nylon box stitches.
This method aims to reduce the rate of damage to the sural nerve by making t he
incisions in the median line, since the nerve is on the lateral side of the tendon7.

In general, the summary of studies relating to the percutaneous repair of the
Achilles tendon ruptures, by means of surgical and post -surgical protocols, it
appears t hat the rate of repeated ruptures is 3 -6.6%, complications relating to
infection and wound healing problems 4.9% -9.9%, and general complications at a
rate of 9.3% -15.6%{7,13,22 }.

Even in the post -surgical treatment, there is no single agreed -upon protoco l. Many
comparative studies were published, comparing the various treatment methods.
Most researchers favor plastering for about six weeks, but others advocate
shorter periods. In addition, in relation to weight carrying varies from full,
immediate weight carrying after surgery, to carrying weight after more extended
periods. Some recommend the use of shoes, arch supports and other rehabilitation
auxiliaries, as part of the post -surgical treatment protocols.

Since there are many treatment options for Achilles tendon ruptures, and no
agreement on the best option, the objective (and importance) of the current study
is the e valuation of the percutaneous treatment method. This simple technique is
quick and may be performed under local anesthetics. Many of the studies
published on the subject suffer from mediocre methodological quality{7,10,22 } and
there is no uniformity in the method of assessing the various methods. In the
current study we evaluated to the percutaneous method in patients treated at the
Chaim Sheba Medical Center at Tel -Hashomer over the past years, by
epidemiologic data, subjective and objective parameters (ph ysical examination)
and isokinetic evaluation. The results may be weighed by numerical values
according to accepted scoring methods.

Materials and Methods

a. The percutaneous repair method – after a rupture in the Achilles tendon is
diagnosed and the variou s treatment options explained to the patient, if he
agrees to the percutaneous repair method, the patient is referred to surgery
in the surgical ambulatory center at the Tel -Hashomer hospital.
The operation is performed when the patient is prone, both legs sterilized in
preparation for the surgery. The area is anesthetized by local injection of
Lidocane 2% and Marcaine 0.5%. Then three small stab wounds are
performed, proximal, distal and above the rupture area, two PDS 1 or
Ticorn 5 sutures by box configur ation. The tying of the sutures is done in
comparison with the extend of calf bending of the healthy leg, in order to
avoid tension in the ruptured leg, or relative elongation of the tendon. The
stabs are sutured by nylon 4 -0 thread (See Appendix F). Durin g the past
years, PDS are almost exclusively used to reduce the creation of
granulomas in the suture area.

After surgery, the patient is put in plaster for three weeks in a plantarflexion
gravitational position, with instruction not to tread on the operat ed leg.
After three weeks the patient is examined and the repair assessed by feeling
the rupture area and examination for scar tissues. The patient is then put in
plaster again for additional three weeks in a neutral position, and treading is
allowed, acco rding to the extent of the pain. After a total of six weeks the
plaster is removed, and the patient undergoes physiotherapy treatments for
three months, with initial active and then passive activation of the ankle.

b. Evaluating the treatment outcomes – in order to comprehensively assess the
treatment outcomes, we have examined a large number of variables, divided
into a number of major groups: general epidemiologic information,
subjective evaluation, objective evaluation and isokinetic assessment. Som e
of the studies in this area used an independent scoring method to evaluate
the results. There are many scoring methods as there are treatment options,
and no consistently used single evaluation method.
The components of the subjective, objective and isok inetic evaluations were
quantified by means of two recently published scoring methods.

The first is the Ankle and Hindfoot Scale, developed by the American
Orthopaedic Foot and Ankle Society for the clinical assessment of the condition
of hindfoot patient s. The second was the Modified Boyden Score, published by
Leppilahti et al. in 1998, developed to specifically assess the results of treatment
of Achilles tendon ruptures{15-17} :

1. Epidemiologic Information: age, gender, work habits, frequency of physical
activity before the injury, nature of activity at the time of the injury, which
leg was injured, length of time from the time of injury to diagnosis, time of
return to full physical activity post -surgery, extent of complications – all
these were determined by fulfilling the q uestionnaire .

2. Subjective evaluation : pain (including Visual Analog Scale – VAS) in
routine and peak physical activity, rigidity, functioning (limited daily and
recreational activities, need for support, maximal walking distance, copi ng
with walking on different walking surfaces, limitations in wearing shoes,
difficulties in driving), extent of satisfaction from surgery.

3. Objective evaluation : Physical examination including checking the surgical
scars, sensation in the sural dispersion, measuring the range of movement
on the Sagittal plane (flexion/extension), measuring differences in motion
range between ankles, hindfoot movement range (eversion/inversion),

determination of ankle -hindfoot stability, anterior -posterior, varus -valgus),
and alignment.

4. Isokinetic evaluation of the gastrocnemius muscles by means of Cybex{1,17-
19} (Appendix E). For the Modified Boyden score we shall score the results
(differences in percentages) according to a predetermined key .
Isokinetic moveme nt is equal velocity movement for the whole range of
movement. The change in the joint position in degress per fixed time unit.
This is not physiologic movement, but the use of the isokinetic movement
principle enables the quantitative evaluation of muscle performance.
The instrument consists of an arm attached to a dynamometer (determining
force or moment) and the force exerted by the patient, moving the arm at a
predetermined velocity. The dynamometer measures the moment difference
between the force exert ed by the patient, and the resistance of the arm
which prevents moving it beyond the predetermined velocity. As a result, a
moment curve is obtained, for the change in the joint position in degrees,
which enables the derivation of various data.

We related to the maximal force measured at the peak=torque. The system
is considered safe because the level of resistance exerted by the machine
equals that exerted by the patient, therefore there is no situation of injury as
a result of using force beyon d the patient’s ability. In the isokinetic
examination of an injured limb, the pain causes the reduction of force
exerted by the muscles, as a defense mechanism of the body, thus
preventing injury.

Before the examination the patient performs ergometric warming on the
bicycle for 10 minutes, and then a series of stretchings. The patient lies
prone, knees straight, and the sole attached to a footplate. The measurement
of peak torque for dorsal and plantarflexion of the ankle we performed for
three angle v elocities (30°, 90° and 240° per second), for both legs. The
examination of the patient in three velocities enables a more comprehensive
and precise assessment of the functioning of the posterior thigh muscle. The
angle velocity of 30°/sec measures the ton ic functioning of the muscle, as in
the standing position, while the 90°/sec and 240°/sec velocities measure the
phasic functioning of the muscle such as in walking, running or hopping.
For each velocity the patient performs four training runs and five
measurement runs from which the average peak torque is calculated.
For each patient we calculated the difference in results between the injured
and healthy legs in percentages for the three angle velocities.

c. The study population – between the years 9002 and 2010 62 patients were
operated by the percutaneous method at the Chaim Sheba Medical Center at
Tel-Hashomer. In most patients the clinical diagnosis was based on the
typical anamnesis and appropriate physical examination. In the minority of
patients, wh ere there was doubt about the diagnosis, or where considerable
time has elapsed since the injury, we used a US image of the Achilles
tendon to confirm the diagnosis. After data collection from the archives, the
patients were invited to the hospital accordi ng to the following criteria:
1. Consent for participation in the study
2. Minimal time of one year from the time of surgery to the examination of
the patient in the study.

Criteria for non -inclusion:
1. The rupture was caused by direct trauma/open rupture
2. The pat ient suffers from a systemic disease such as diabetes, rheumatoid
arthritis etc.
3. The patient is taking steroids
4. The patient suffers from a pathology in the uninjured leg (neurological,
orthopedic problems, surgery etc.)

5. The patient has previously suffered a rupture of the Achilles tendon.
A total of 9 patients were ruled out based on the above criteria. We were
unable to locate 10 patients based on their personal data in the archive files.
Of the rest, 26 patients came to the hospital for an interview, phys ical
examination and isokinetic assessment (response rate of about 60%).
The examination of the patients was done with the authorization of the
institutional Helsinki committee and signature on an informed consent
form.
d. Statistical processing – the variabl es, questionnaire results and scoring were
entered on an Excel data sheet. Data processing was done using the SAS
program. For the comparison of the continuous variables we used the
Wilcoxon signed rank test. We used a biostatistician for the statistical
processing.

Results

The average age of the patients at the time of the tendon rupture was 43.1 years
(range 24 -58, SD 9.1). 88% of the patients were male, and in 61% the tendon
rupture was in the left foot.
The average time between the date of the operation and the study examination
was 32.2 months (range 12 -80, SD 18.2).
Level of physical activity in the study group before the injury: 50% of the subjects
were engaged in physical activity several times per week, 11.5% one a week,
7.5% on ce a month, and 31% were not engaged in physical activity at all.
The average time elapsed since the injury to the diagnosis of a rupture in the
Achilles tendon was 4 days, but in over 60% of the cases, the diagnosis was
achieved in less than 24 hours. Th e delay in diagnosis was usually caused by late
referral to the hospital.
Over 62% of the Achilles tendon ruptured occurred during physical activity,
mostly sports ( football ) (Figure 1).

Figure 1: Distribution of the nature of the physical activity at the time of rupture of the
Achilles tendon.
After the surgery, on average 5.2 months were required to return to the pre –
surgery level of operation of the patients.

Assessment of the extent of pain felt by the patients, was performed separately
from the qu estionnaires, using VAS. This assessment related to two points in time
in the lives of the patients: the extent of pain felt in daily life in the performance
of routine activities, and the extent of pain at the peak of the physical activity.
Average VAS sc ore the patients feel routinely was 0.4 (range 0 -4, SD 1.1)
Average VAS score the patients feel at the peak of the physical activity was 1.9
(range 0 -8, SD 2.7).

Motion range
Several differences were found in the passive motion range between the healthy
and the operated limb, as measured by Cybex, and summarized in the following
table:
Table 1: Differences in motion range between the operated and healthy limbs as measured
by Cybex .
62% 15% 6% 14% 3%
sports
sudden flexion
tendon stress
repeated
rupture
fall down Distribution by Etiology

Average
value Range Standard deviation
plantarflexion in
the operated limb 35.3° 9°-47° 8.4
plantarflexion in the
healthy limb 38.1° 23°-57° 9.1
dorsiflexion in the
operated limb -28.3° -10°- -42° 7.1
dorsiflexion in
healthy -24.2° -10°- -37° 7.1
In the operated limb, the average loss of plantarflexion was 5.1° (range 0 -22, SD
5.2).
The average addition in dorsiflexion in the operated limb was 8.2° (range 0 -25,
SD 6.9) as measured in comparison with the health limb, for each individual
patient.
Both values were of statistical significance (p<0.0001).
In comparing the whole range of ankle mobility on both sides, the results are
summarized in the following table:
Table 2: The range of motion amplitude of the ankle in the healthy and the operated limb
Range of motion
amplitude Average Range Standard
deviation
Operated side 63.5° 21°-81° 13.1 Statistical
significance
P<0.0001 Healthy side 62.3° 40°-70° 10.7

The amplitude of motion range in the ankle of the operated limb was slightly
larger (one degree) than that of the healthy leg. This difference is statistically
significant.

Scoring scales
General score of the Modified Boyden Score – 74.6 (range 50 -95, SD 11.8)
General score of AOFAS (Ankle and hindfoot scale) – 93.5 (range 62 -100, SD
9.7).
Detail s of the Modified Boyden Score .

Table 3: Detailed Modified Boyden Score .
Clinical factor Average
score Maximal
score Score
range in
series Standard
deviation
1. Pain 12.6 15 5-15 3.9
2. Rigidity 11.8 15 5-15 3.5
3. Weakness of the sural
muscle (subjective) 11.6 15 515 3.5
4. Limitations in footwear 8.6 10 0-10 2.7
5. Difference in motion range
between ankles 13 15 0-15 4.1
6. Extent of patient satisfaction
with the surgery 13.2 15 5-15 2.8
7. Muscle force in isokinetic
measurement (Appendix C) 3.8 10 0-10 3.6
8. Final score (summary of
scores) 74.6 100 50-96 11.8

The results of the surgical procedure are evaluated using the Ankle and Hindfoot
Scale, according to several clinical factors. Each subject is scored according to the
above factors. The smaller the defect, the higher the score. For example, a high
level of pain will get the score 0 out of 40, and a subject who suffers no pain will
get the maximal score – 40.

Results of the Isokinetic evaluation of the sural muscles with Cybex –
The following figure represents the results of the test for plantar flexion for the
three angular speeds measured .

Figure 2: Comparing force measurement in plantarflexion of the ankle in the operated leg
as compared to the healthy one, in the various angular velocities.

The figure shows that the lower the angular velocity, the greater the force
measured. For each velocity, the force in the operated leg is somewhat smaller
than that of the healthy leg (as detailed in Table 6), but the differences are
relatively small and l ack statistical significance.
Angular velocity
(°/sec) Average
difference between
the operated and
the healthy sides
(%) Standard deviation Statistical
significance
30 7.9 21.5 No significance
(p=0.533)
90 16.2 18.6 Significance
(P<0.0001)
0 5 10 15 20 25 30 35
30 90 240 30.3
20.7
12.6 32.3
20.8
12.1 Mean peak torque N/M
angular velocity (deg/sec) Plantarflexion
healthy
operated

240 10 30 No significance
(p=0.1445)
Table 6: Summary of the differences in the force measured between the operated and the
healthy leg, in plantarflexion position of the ankle, for the various angular velocities.

Only for the angular velocity 90°/sec it was signifi cantly found that the operated
leg is weaker on average by 16% than the healthy leg .
The following figure represents the results of the dorsiflexion examination, for the
three angular velocities measured.

Figure 3: Comparing force measurement in dorsifl exion of the ankle in the operated leg as
compared to the healthy one, in the various angular velocities.

It is apparent that the lower the angular velocity, the higher the force measured in
the dorsiflexion position (unrelated to the contraction of the p osterior shin
muscles and the shortening of the Achilles tendon) the differences in the extent of
force measured, between the operated and the healthy leg are lower for the various
velocities, and sometimes the force in the operated leg is greater. The fol lowing is
a summary of the differences in the dorsiflexion position:

0 5 10 15 20 25 30 35
30 90 240 30.3
20.7
12.6 32.3
20.8
12.1 Mean peak torque N/m
angular velocity (deg/sec) Dorsiflexion
healthy
operated

Table 7: Summary of the differences in the force measured between the operated
and the healthy leg, in dorsiflexion position of the ankle, for the various angular
velocities.
Angular velocity
(°/sec) Average
difference between
the operated and
the healthy sides
(%) Standard deviation Statistical
significance
30 -6.4 18.9 No significance
(p=0.524)
90 -1.9 19.7 No significance
(P<=0.8801)
240 2.7 32.3 No significance
(p=0.5038)
(A negative difference means that the operated leg was stronger).

In the dorsiflexion position no statistically significant difference was found
between the two sides for any of the velocities measured.
In addition, in some of the subjects during the isokine tic examination it was found
that during plantarflexion of the ankle, the active range of motion in the operated
leg was smaller, even in cases where there was no difference in the passive range
of motion (namely with no elongation or contraction of the Ac hilles tendon) (see
discussion).
Example:

In the picture we see some of the output of the results of the isokinetic
examination in plantarflexion of the ankle.
Blue – the healthy side
Red – the operated side
The x axis shows a yellow sign pointing to the difference in active motion range.
Extent of complications:
The post -operative complications were divided to those related to the wound, and
general complications. Each category was divided into minor and maj or
complications.
Extent of complications for the study subjects*
Table 8: Extent of different complications in the stud subjects
Complications related to the wound General complications
Minor: Minor:
Superficial
infection 4.8%
(3/62) Sensation
disorders (sural
damage) 12.9%
(8/62)
Hematoma 0% Repeated rupture 1.6%
(1/62)
Problems in
wound healing 0%
Adhesions in the
scar area 0%
Granulomas in the
sutures 8%
(5/62)

Skin necrosis 0%
Major : Major:
Deep infection 0% DVT 0%
Fistula 0% PE 0%
* The data is based on the sheets of the whole series of 62 patients operated on
Estimates of pain complications and elongation/shortening of the Achilles tendon
by using VAS and physical examination were conducted separately on the
subjects who came following the invitation to the hospital for the purpose of the
study (Table 9).

Table 9: Extent of pa in complications and elongation/shortening of the Achilles tendon in
the study patients (26 patients)
General complications
Minor :
Paina –
Pain in rest/routine 11% (3/26)
Total feeling pain 34% (9/26)
Major :
Elongation of the Achilles tendon 11% (3/26)
Shortening of the Achilles tendon 3.8% (1/26)
a – See later in the results chapter for the extent of pain and limitations of
daily/recreational activities.
b – Elongation/shortening of the Achilles tendon determined where there was
more than 10° difference in motion range between the two sides.

Discussion

There are several treatment options for the acute rupture of the Achilles tendon,
and no agreement as to the best option. The main problems in treating Achilles
tendon ruptures are the high rate of repeated ruptures after the conservative
treatment, and th e complications of infection and problems related to wound
healing in the open surgical procedure. The objective of the current study was the
evaluation of treatment results after the percutaneous treatment.

The study assumption was that this treatment me thod has better functional results
and a lower rate of complications, determined by the examination of a number of
variable groups (epidemiologic information, subjective and objective evaluation,
isokinetic assessment).

The group of subjects in the study (62 patients), mostly men. The rupture occurred
for most of them in the fourth decade of their lives. A higher incidence of ruptures
was found in the left leg Achilles tendon. Over 60% of the subjects were
physically active at least once a week before the injury. Over 80% of the ruptures
occurred during physical activity, and over 50% relate to ball games. All the
above findings coincide with findings of previous studies on the subject{1-
03,10,17,22 }.

The diagnosis of Achilles tendon rupture is based on the typical anamnesis and
the appropriate physical examination. In most cases the diagnosis is not an actual
clinical challenge. For over 60% of the patients the diagnosis was made
immediately upon referral to the hospital, usually in less than 24 hours af ter the
rupture. Most of the patients returned to their former level of activity within a
short average period of 5.2 months. It should be remembered that this time period
includes 1.5 months of plastering, and about three months of physiotherapy. In
Webb et al.7 the average time for return to physical activity was 4 months (range
1.5-12 months), but they do not mention if the patients returned to the same level
of activity as before the injury.

In the quantitative assessment of the extent of pain the patie nts feel, we found that
the level of pain was relatively low. The average VAS score the patients felt in
their daily life routine was 0.4, while the average VAS score for peak physical
exertion was 1.9 .

In comparing the passive motion ranges between the operated and the healthy leg,
a number of differences were found. In the operated leg the average loss of
plantarflexion was 5.1°, and the average addition in dorsiflexion was 8.2°, as
measured in comparison to the health leg for each subject. These result s are
statistically significant (p<0.0001).

When comparing the general amplitude of ankle motion range between the two
sides, the average motion range in the operated leg was 63.5° and in the healthy
leg 62.3°. (statistically significant p<0.0001). These results are somewhat greater
than the range of results in other studies. Scarfi et al. {8} found not statistically
significant differences for the different motion ranges. On the other hand
Leppilahti et al. {17}, reporting an ankle motion range amplitude in the operated leg
of 58°±8°, and in the healthy leg 61° ± 7°, in 11.8 cases there was a difference
greater than 10° in the motion range between the two sides, namely
elongation/shortening of the Achilles tendon. In the work by Fitz et al. {5}, the only
difference found to be statistically different was the loss of 3.6° in plantarflexion
in the operated leg, in 11% of their subjects, but there was no patient with
difference in motion range beyond 10°. The practical significance of the loss of a
number of d egrees in the motion range in the plantarflexion position of the ankle
is not clear, and not discussed in the literature.

No correlation was found between the changes in motion range and the level of
functioning of the subjects, their satisfaction with th e treatment, the questionnaire
scores or the results of the isokinetic assessment.
We believe that although the differences in motion range were statistically
significant, the addition or absence of several degrees does not have a functional
significance out of a total motion amplitude of about 60°.

The extent of various complications documented for the patients in the current
study was low, coinciding with the range of complications documented for other
series, and supporting the claim for making the per cutaneous treatment method
the preferred one for treating an acute rupture of the Achilles tendon.

In the current study, most of the complications were 4.8% superficial infections,
12.9% sensory disorders in sural dispersion, which is a higher percentage than
usually accepted, and we believe to be related to an earlier surgical technique and
the learning curve of the surgeons, 1.6% repeated ruptures and 13.8% cases of
elongation or shortening of the Achilles tendon.

These data are lower than the rate of c omplications involved in open surgery
(repeated ruptures 1.4% -3.5%, infections and would healing problems 5.3% –
14.6%, and general complications 5.7% -8.9%), and from complications related to
the conservative treatment (repeated ruptures 9.8% -13%){13,11,10,2 2}.
The extent of complications in our series is consistent with that of the
percutaneous treatment as published for other series (repeated ruptures 3% -6.6%,
infection and wound healing problems 4.9% -9.9%, and neural damage 0% –
16.7%){5,7,10,11,13,14,17,22, 23}.

Nevertheless the extent of neural damage in our series was higher than the one we
strove for, and in some recent series surgeons have succeeded in achieving lower
rates of neural damage. For example, in the work of Cretnik et al. {21} the extent of
neural damage was 4.5%, Lim et al. {27} – 3% neural damage, Haji et al. {24} –
neural damage of 10.5%. Webb et al.7 who published the surgical method based
on three incisions, aiming at reducing the damage to the sural nerve reported 0%
incidents of neural damage.
The final average score of the Modified Boyden score was 74.6. Leppilahti et
al.17 published the Modified Boyden score in the Clinical Orthopedics in 1998 for
the first time. This scoring method was especiall y developed to evaluate the
results of the treatment of an acute rupture of the Achilles tendon. In their work
there is no final average score, but the distribution of patient percentages by the

following categories: 33.7% excellent results, 45.5% good res ults, 16.8% average
results and 4% low results.

In comparing the distribution percentages of patients according to these categories
in our study, it appears that our study has slightly worse results. While in
Leppilahti et al. the best and excellent resul ts (almost equally distributed) include
80% of the patients, in or study they include only 60% of the patients, with a
higher weight for the good results. The main difference may be attributed to the
relatively large weight in scoring for the muscle force in the isokinetic
measurement.

As detailed in the Materials and Methods section, the force differences in the
isokinetic measurement for planarflexion and dorsiflexion for all three angular
velocities are scored. Then the scoring is translated according t o a predetermined
key (see Appendix C) for the Modified Boyden score in the relevant item. This
internal scoring method is very strict and only a difference of less than 2%
between the operated and the healthy leg is awarded the maximal score, while in
terms of the isokinetic measurement and instrumentation, a difference lower than
10% is considered appropriate even in the healthy population that has not
undergone surgery. Still, this does not explain why the results of Leppilahti et al.
are higher than tho se in the current study.

The final average score of the AOFAS – Ankle & Hindfoot scale was 93.5. This is
an excellent result, showing the high performance level of patients after surgery,
and is consistent with additional studies conducted using the same scoring
method, such as Cretnik et al. who published the average AOFAS score in their
study of percutaneous treatment of Achilles tendon ruptures as 96.
Many studies do not use independent scoring methods at all, and when they do,
the multiplicity of metho ds makes comparison of results difficult. There is still no
single method considered accepted and preferable to all others{1,13,21 }.
The results of the isokinetic measurement for planarflexion at an angular velocity
of 90°/sec showed a statistically significant weakness of the operated foot, at an

average score of 16% of the healthy foot. For the dorsiflexion motion, there were
no statistically significant differences for either of the velociti es measured.
The isokinetic technique is often unavailable logistically and economically for
research use, therefore only some of the published studies used this evaluation
method. Even in studies that used this method, there are considerable differences
in the isokinetic measurement protocols. The isokinetic results in the current study
are not significantly different from those of other studies{5,8,17,19 }.

An accepted premise in isokinetic measurements is that a difference of up to 10%
measured between t he sides examined (for any joint/group of muscles) is normal,
and a difference of less than 20% is acceptable for those who are not professional
athletes. Therefore we assume that although we found a weakness of 16% at a
velocity of 90 measured in the plan arflexion position, this is not functionally
highly significant for the study population in the current study, hence the high
results of functional assessment as seen in the questionnaires and scoring method.
As mentioned in the results section, we saw tha t in a small number of subjects, the
active motion range as measured by the isokinetic instruments during the
performance of the movement, was smaller in the operated leg than in the healthy
one, for the planarflexion position, even in cases where there wa s no difference in
the passive motion range. We found no mention in the various studies of the
considerable shortening of active motion range, and can offer no explanation for
this observation .

The strength of the current study, besides being the first to assess this treatment
method in Israel, is in the variety of methods for assessing the treatment results.
Many studies dealing with treatment options for an acute rupture of the Achilles
tendon did not use independent scoring methods or the isokinetic tec hnology to
assess the strength of the posterior muscles after surgery. The study gathers
epidemiologic, subjective and objective data (including physical examination and
an isokinetic evaluation) in order to assess the treatment results comprehensively
and reliably. The main weakness of the study is the scope of the sample, due to
follow -up difficulties and problems in summoning the patients after such long
periods after the surgery, as well as the logistic and economic resources required.

There is need for an extensive retrospective study (as in most studies the
population is limited, there may be room for a multi -centered study, since the
injury is not very common) which will randomly allocate the subjects to three
possible treatment groups (conservative t reatment, open surgery and percutaneous
repair) and compare them according to the methodological guidelines determined
in the current study. The need for such a study is also apparent in other studies
published in the international literature{1,3,10,13,17, 21,22,2 }.

To summarize, there are still discussions in the international literature as to the
optimal method for treating an acute rupture of the Achilles tendon. In the current
study we managed to show, by the examination of epidemiologic data, subjectiv e
and objective evaluations and an isokinetic assessment with Cybex, that the
percutaneous repair method has very good functional results. This is a technically
simple method which may be performed under local anesthetics, even in a day
care facility. The results were proven by questionnaires and isokinetic evaluation,
the rate of complications is low (very low rate of repeated ruptures, and a low rate
of wound infections). The cosmetic results are very good, and the patient
satisfaction level is high. Thi s method is becoming more popular among the
international orthopedic community, and we believe it should be recommended
unconditionally for the older patient population (avoiding lengthy periods of
plaster casts), as well as for the younger and physically active population. Our
sample, or the literature does not relate specifically to athletes and professional
sports people, therefore the appropriate treatment method for this sub -population
remains open.

Clinical case 1

In Sheba medical center was admitted patient “X” 27 years old man , in 05.07.14 at
14:00 o’clock suffered from swelling in ankle gap of the left leg due to Achilles tendon
rupture , the doctors examine the site of injury by squeezing the calf muscle to confirm
the tendon rupture that caused by dorsiflexion in basketball game .
In musculoskeletal ultrasonography that performed at left leg was visualized tear of the
Achilles tendon , the x -ray done to detect the site of the rupture and in MRI was no signs
for any other complication like hemorrhage , tendinosis and bursitis .
The surgical intervention is done to the patient in hospital after 3 hours of injury in the
left leg , percutaneous Achilles tendon repair techniques performed in left leg , during
the surgery no complication was notice , the tendon is sutured and incision closed .
No complication appear after surgery and the wound heal normally .

Clinical case 2
In Sheba medical center was admitted patient “Y” 22 years old man , in 18.07.14 at
17:30 the patient suffered from immobility of the right foot due to rupture of the tendon
and swelling of ankle gap appear at the site of injury that caused by Falling f rom a
height.
The doctors examine the patient by squeezing calf muscle technique to make sure of the
tendon rupture , the x -ray and ultrasonography was performed to detect the site and
severity of the tendon rupture , in MRI was show no sign of any compli cation such as
tendinosis .
The surgical intervention is done to the patient in Sheba medical center after 4:30 hours
of injury in the right leg , The percutaneous Achilles tendon repair performed to patient
in right leg , the techniques done by make an small incisions in the back of lower leg
and stitching the torn tendon together by suture .
During the surgery and in post -operation period no complication was appeared , and the
wound heal quickly .

Appendix A
Epidemiologic details questionnaire
Name________________________ Subject number ___________________
Age __________________ Gender: m /f

Date of filling the questionnaire ___________________ Date of operation ___________
Leg operated: right / left
 Frequency of physical activity befo re surgery
1. Several times a week
2. Once a week
3. Once a month
4. None at all

 Nature of the patient’s occupation
1. Office
2. Requires mild physical effort
3. Requires high physical effort

 Time elapsed from the injury to the diagnosis _____________________

Nature of activity during injury
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Time to return to fu ll physical activity after surgery:
______________________________________________________________________
 Does the patient experience problems in driving?
Not at all/mildly/to a large extent

Post surgical complicatons

Were there any complications* after the surgery?
Minor complications Major complications
Wound:
Superficial infection
Hematoma
Problems in wound healing

Granulomas in sutures
Skin necrosis Wound:
Deep infection
Fistula
General :
Pain
Sensory disorders
Repeated rupture General :
DVT
PE
Elongation of the Achilles tendon
Shortening of the Achilles tendon

 Quantitative review of operative and nonoperative management of Achilles tendon
ruptures, Am.J.Sports Med. 2002.
From the medical file/anamnesis From the examination
Superficial injection
Hematoma
Problems in wound healing
Granulomas in sutures
Skin necrosis
Repeated ruptures
DVT
PE Sensory problems
Elongation of the Achilles tendon
Shortening of the Achilles tendon

Appendix B
Modified Boyden Score
Clinical factor Score
1. Pain
No pain 15
Slight pain, no limitation in recreational activities 10
Medium pain, limitation in recreational activities, no limitation in
daily activities 5

Severe pain, limitation in all activities 0
2. Rigidity
No rigidity 15
Slight rigidity, no limitation in recreational activities 10
Medium rigidity, limitation in recreational activities, no limitation in
daily activities 5
Severe rigidity, limitation in all activities 0
3. Weakness of the sural muscles (subjective
No weakness 15
Slight weakness, no limitation in recreational activities 10
Medium weakness, limitation in recreational activities, no limitation in
daily activities 5
Severe weakness, limitation in all activities 0
4. Limitations in footwear
No limitation 10
Slight limitation, shortage of shoe types causes discomfort 5
Medium limitation, some of the shoe types cause discomfort 0
5. Differences in motion range between ankles
Intact < 5° 15
Slight limitation (6° -10°) 10
Medium limitation (11° -15°) 5

Severe limitation (≥16°) 0
6. Degree of patient satisfaction of the surgery outcomes
Very satisfied 15
Satisfied with some reservations 10
Satisfied with severe reservations 5
Not satisfied at all 0
7. Muscle force in isokinetic measurement
Excellent 15
Good 10
Average 5
Weak 0
8. Final score (summing points)
Excellent 90-100
Good 75-85
Average 60-70
Low ≤ 55

Appendix C
Ankle -hindfoot scale/AOFAS
Clinical factor Score
1. Pain (40 points)
No pain 40
Slight pain, sometimes 30
Average pain, daily 20
Severe pain, almost uninterrupted 0

2. Functioning (50 points)
Limitation in activity, need of support
No limitation, no support 10
No limitation in daily activities, limitation in recreational activities, no
support 7
Limitation in daily activities, limitation in recreational activities, uses
a walking cane 4
Limitation in all activities, uses a walker, crutches, wheelchair etc. 0

Maximal walking distance in hundreds of meters
Over 6 5
Between 4 -6 4
Between 1 -3 2
Less than 1 0

Walking surfaces
No limitation 5
Slight difficulty on an uneven surface, stairs, descent, ladder 3
Severe difficulty on an uneven surface, stairs, descent, ladder 0

Walking problems
No problem, slight problem 0
Average problem 4
Considerable problem 0

In the physical examination
Sagittal motion (flexion/extension)
In order or slight limitation (≤30°) 8
Average limitation (15° -29°) 4
Considerable limitation (≥15°) 0

Hindfoot motion (inversion/eversion)
In order or slight limitation (75-100%) 6
Average limitation (25 -74% 3
Considerable limitation (≤25%) 0

Ankle -hindfoot stability (varus -valgus)
Stable 8
Not stable 0

3. Axis alignment (10 points)
Good, plantigradient foot, good alignment of heel -hindfoot 10
Reasonable, plantigradient foot, slight nonalighnment of heel –
hindfoot, asymptomatic 5
Not good, non plantigradient foot, severe nonalighnment of heel –
hindfoot, asymptomatic 0

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