TOTAL ACHILLES-TENDON RUPTURE - A REVIEW

There are only a few epidemiological studies on the incidence of Achil les tendon (AT) ruptures. These show an increase in incidence in the W est during the past few decades. The main reason is probably the incre ased popularity of recreational sports among middle-aged people. Ball games constitute the cause of over 60% of AT ruptures in many series. The 2 most frequently discussed pathophysiological theories involve ch ronic degeneration of the tendon and failure of the inhibitory mechani sm of the musculotendinous unit. There are reports of AT ruptures rela ted to the use of corticosteroids, either systemically or locally, but the role of corticosteroids in large patient series is marginal. In a ddition, recent studies do not confirm earlier findings of blood group O dominance in patients with AT rupture. Comparable series have been published with surgical versus nonsurgical treatment and postoperative cast immobilisation versus early functional treatment. Although conse rvation treatment has its own supporters, surgical treatment seems to have been the method of choice in the late 1980s and the 1990s in athl etes and young people and in cases of delayed ruptures. Early ruptures in non-athletes can also be treated conservatively. In small series o f compliant, well motivated patients, functional postoperative treatme nt has been reported to be well tolerated, safe and effective. The lac k of a universal, consistent protocol for subjective and objective eva luation of AT ruptures has prevented any direct comparison of the resu lts. The results have been often assessed according to the criteria of Lindholm or Percy and Conochie, but no scoring is available for the a nalysis. We assessed a new scoring method and analysed the prognostic factors related to the results. There is also no single, uniformly acc epted surgical technique. Although early ruptures have been treated su ccessfully with simple end-to-end suture, many authors have combined s imple tendon suture with plastic procedures of various types. No rando mised study comparing simple suture technique and repair with augmenta tion could be found in the literature.The major complaint against surg ical treatment has been the high rate of complications. Most are minor wound complications, which delay improvement but do not influence the final outcome. Major complications are rare, but often difficult to t reat with minor procedures. For instance, large postoperative skin and soft tissue defects in the Achilles region can be treated successfull y with a microvascular free flap reconstruction. The complications of conservative treatment include mostly reruptures and residual lengthen ing of the tendon, which may result in significant calf muscle weaknes s. It has been postulated that a physically inactive lifestyle leads t o a decrease in tendon vascularisation, while maintenance of a continu ous level of activity counteracts the structural changes within the mu sculotendinous unit induced by inactivity and aging. Proper warm-up an d stretching are essential for preventing musculotendinous injuries, b ut improper or excessive stretching or warming-up can predispose to th ese injuries.