Early Motion of the Ankle After Operative Treatment of a Rupture of the Achilles Tendon. A Prospective, Randomized Clinical and Radiographic Study*

Abstract

Background: Different regimens of early motion of the ankle after operative treatment of a ruptured Achilles tendon have been suggested since the late 1980s. However, as far as we know, no controlled studies comparing these regimens with conventional immobilization in a cast have been reported. Methods: In a prospective study, seventy-one patients who had an acute rupture of the Achilles tendon were randomized to either conventional postoperative management with a cast for eight weeks or early restricted motion of the ankle in a below-the-knee brace for six weeks. The brace was modified with an elastic band on the posterior surface, in a manner similar to the principle of Kleinert traction. Metal markers were placed in the tendon, and the separation between them was measured on serial radiographs during the first twelve weeks postoperatively. The patients were assessed clinically when the cast or brace was removed, at twelve weeks postoperatively, and at a median of sixteen months postoperatively. Results: The separation between the markers at twelve weeks postoperatively was nearly identical in the two groups, with a median separation of 11.5 millimeters (range, zero to thirty-three millimeters) in the patients managed with early motion of the ankle and nine millimeters (range, one to forty-one millimeters) in the patients managed with a cast. The separation was primarily correlated with the initial tautness of the repair (r[S] = 0.45). No patient had excessive lengthening of the tendon. The patients managed with early motion had a smaller initial loss in the range of motion, and they returned to work and sports activities sooner than those managed with a cast. Furthermore, there were fewer visible adhesions between the repaired tendon and the skin in the patients managed with early motion, and these patients were subjectively more satisfied with the overall result. The patients in both groups recovered a median of 89 percent of strength of plantar flexion compared with that of the noninjured limb, as measured with an isometric strain-gauge at 15 degrees of dorsiflexion. The heel-rise index was similar for both groups: 0.88 for the patients managed with early motion and 0.89 for those managed with a cast. Conclusions: Early restricted motion appears to shorten the time needed for rehabilitation. There were no complications related to early motion in these patients. However, early unloaded exercises did not prevent muscle atrophy. *No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly

“…This finding is in accordance with most previous studies showing a permanent deficit in isometric plantar flexion strength after AT ruptures [7,14,17,18,41,43,51,55] in mixed populations. In our patients, the decrease in isometric strength of the gastrosoleus complex compared to the unaffected limb remains more pronounced than that reported in the general population with acute AT ruptures [56], despite the active rehabilitation program.…”

Mini-invasive surgical repair of the Achilles tendon—does it reduce post-operative morbidity?

“…Wound complication and atrophy of the calf muscles after an injury to the tendo Achilles are reported to alter the outcome [2][3][4][5][6][7][8][9]. We observed two major wound complications and five cases of delayed wound healing in the open repair group, which had been reported earlier in the literature [4].…”

“…Open surgery with delayed rehabilitation following rupture of the Achilles tendon may produce disuse atrophy very quickly, which is difficult to reverse [7]. We noted two patients reported to have 50% loss of muscle bulk as compared to the other side in the open repair group.…”

“…The ability to bear weight within the orthosis certainly encouraged some patients to return to activity. We advocated early loading of a healing tendo Achilles after minimally invasive repair to prevent detrimental alterations in muscle characteristics and the favourable influence on maturation of collagen fibres within the tendon as reported [7].…”

Achilles tendon ruptures

“…As early as 1999, Mortensen et al [83] compared acute Achilles repairs in 2 groups: patients who had conventional casting for 8 weeks vs patients who were placed in a belowthe-knee brace and allowed to undergo early restricted motion. The early motion group returned to work and/or sports sooner than the immobilization group.…”