Total Achilles tendon rupture. A review.

There are only a few epidemiological studies on the incidence of Achilles tendon (AT) ruptures. These show an increase in incidence in the West during the past few decades. The main reason is probably the increased 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 chronic degeneration of the tendon and failure of the inhibitory mechanism of the musculotendinous unit. There are reports of AT ruptures related to the use of corticosteroids, either systemically or locally, but the role of corticosteroids in large patient series is marginal. In addition, 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 nor surgical treatment and postoperative cast immobilisation versus early functional treatment. Although conservative treatment has its own supporters, surgical treatment seems to have been the method of choice in the late 1980s and the 1990s in athletes and young people and in cases of delayed ruptures. Early ruptures in non-athletes can also be treated conservatively. In small series of compliant, well motivated patients, functional postoperative treatment has been reported to be well tolerated, safe and effective. The lack of a universal, consistent protocol for subjective and objective evaluation of AT ruptures has prevented any direct comparison of the results. The results have been often assessed according to the criteria of Lindholm or Percy and Conochie, but no scoring is available for the analysis. We assessed a new scoring method and analysed the prognostic factors related to the results. There is also no single, uniformly accepted surgical technique. Although early ruptures have been treated successfully with simple end-to-end suture, many authors have combined simple tendon suture with plastic procedures of various types. No randomised study comparing simple suture technique and repair with augmentation could be found in the literature. The major complaint against surgical 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 treat with minor procedures. For instance, large postoperative skin and soft tissue defects in the Achilles region can be treated successfully with a microvascular free flap reconstruction. The complications of conservative treatment include mostly reruptures and residual lengthening of the tendon, which may result in significant calf muscle weakness. It has been postulated that a physically inactive lifestyle leads to a decrease in tendon vascularisation, while maintenance of a continuous level of activity counteracts the structural changes within the musculotendinous unit induced by inactivity and aging. Proper warm-up and stretching are essential for preventing musculotendinous injuries, but improper or excessive stretching or warming-up can predispose to these injuries.