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In this multicenter trial involving patients with acute Achilles’ tendon rupture, surgery (open repair or minimally invasive surgery) did not result in better outcomes than nonoperative treatment at 12 months.

Purpose Functional weight-bearing mobilization may improve repair of Achilles tendon rupture (ATR), but the underlying mechanisms and outcome were unknown. We hypothesized that functional weight-bearing mobilization by means of increased metabolism could improve both early and long-term healing. Methods In this prospective randomized controlled trial, patients with acute ATR were randomized to either direct post-operative functional weight-bearing mobilization ( n  = 27) in an orthosis or to non-weight-bearing ( n  = 29) plaster cast immobilization. During the first two post-operative weeks, 15°–30° of plantar flexion was allowed and encouraged in the functional weight-bearing mobilization group. At 2 weeks, patients in the non-weight-bearing cast immobilization group received a stiff orthosis, while the functional weight-bearing mobilization group continued with increased range of motion. At 6 weeks, all patients discontinued immobilization. At 2 weeks, healing metabolites and markers of procollagen type I (PINP) and III (PIIINP) were examined using microdialysis. At 6 and 12 months, functional outcome using heel-rise test was assessed. Results Healing tendons of both groups exhibited increased levels of metabolites glutamate, lactate , pyruvate, and of PIIINP (all p  < 0.05). Patients in functional weight-bearing mobilization group demonstrated significantly higher concentrations of glutamate compared to the non-weight-bearing cast immobilization group ( p  = 0.045).The upregulated glutamate levels were significantly correlated with the concentrations of PINP ( r  = 0.5,  p  = 0.002) as well as with improved functional outcome at 6 months ( r  = 0.4; p  = 0.014). Heel-rise tests at 6 and 12 months did not display any differences between the two groups. Conclusions Functional weight-bearing mobilization enhanced the early healing response of ATR. In addition, early ankle range of motion was improved without the risk of Achilles tendon elongation and without altering long-term functional outcome. The relationship between functional weight-bearing mobilization-induced upregulation of glutamate and enhanced healing suggests novel opportunities to optimize post-operative rehabilitation.

Purpose The purpose of this prospective randomized controlled study was to evaluate the long-term results after an acute Achilles tendon rupture in patients treated surgically or non-surgically. The focus was to evaluate whether any improvements occurred between the one and 2-year evaluation. Method Eighty-one patients (67 men, 14 women) with a mean (SD) age of 42 (9.1) were included in this study. Forty-two patients were treated surgically, and 39 treated non-surgically otherwise the treatment was identical for the two groups. All patients were evaluated using the Achilles tendon Total Rupture Score (ATRS), the Physical Activity Scale (PAS) and validated functional tests one and 2 years after injury. Results There were significant functional deficits on the injured side compared with the contralateral side 2 years after Achilles tendon rupture, regardless of treatment. Only minor improvements, even though statistically significant, occurred between the 1- and 2-year evaluations. The physical activity level remained significantly reduced as compared with prior to injury, but the ATRS mean was relatively high in both groups (89 and 90). Conclusion This long-term follow-up indicates that the majority of patients with an Achilles tendon rupture have not fully recovered (in regards to symptoms, physical activity level and function) 2 years after injury regardless of surgical or non-surgical treatment. Furthermore, only minor improvements occur between the 1- and 2-year evaluations. This indicates that to enhance the final outcome the focus should be on improvements in treatment within the first year. The patients appear to have adjusted to their impairments since the patient-reported outcome is relatively high in spite of functional deficits and lower activity level compared with pre-injury. Level of evidence Prospective randomized study, Level I.

IntroductionOptimal postoperative rehabilitation regimen for acute Achilles tendon rupture (AATR) remains unclear. It is important to evaluate whether early functional weight-bearing rehabilitation program after minimally invasive repair results in an earlier return to pre-injury activity but increases the risk of re-rupture.Materials and methodsThis was a prospective randomized controlled trial involving 68 AATR patients undergoing minimally invasive surgery. 34 patients were enrolled in early weight‑bearing mobilization accelerated rehabilitation group (AR group); 34 patients were enrolled in the traditional rehabilitation (TR) group. Outcomes measures included American Orthopaedic Foot and Ankle Society Score (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS) score before surgery and 3, 6, and 12 months after surgery, incidence rate of Achilles tendon re-rupture and total complications, length of hospital stay, time return to work and sports. ResultsThere was no significant difference in preoperative basic data between the two groups. However, AOFAS score and ATRS score were better in AR group than TR group at 3 months postoperatively (92.4 ± 3.5 vs 88.3 ± 4.5, P < 0.01; 91.1 ± 4.4 vs 88.9 ± 3.4, P = 0.03, respectively), the mean length of hospital stay (4.7 ± 1.5 vs 7.6 ± 2.0 days, P < 0.01) and time return to work (4.5 ± 1.0 vs 7.5 ± 1.6 weeks, P < 0.01) were shorter in AR group than in TR group. No statistical significance was calculated in patient-reported outcomes during the rest of the follow-up time and complications.ConclusionEarly accelerated rehabilitation with weight-bearing in patients with AATR after minimally invasive surgery results in better early functional outcomes and shows similar security and feasibility.Registration No.: ChiCTR2100043398.

Background Calcific insertional Achilles tendinopathy (CIAT) is a rare and challenging condition characterized by calcium hydroxyapatite deposition at the Achilles tendon’s calcaneal insertion. While typically affecting older individuals, its occurrence in younger patients is uncommon, particularly with large calcific lesions. Case presentation We report a rare case of a 36-year-old male presenting with progressive left Achilles tendon insertional pain and swelling. The patient had a history of Achilles tendon lengthening surgery in childhood. Imaging revealed large, multifocal calcific deposits within the tendon. Surgical intervention involved a posterior midline longitudinal approach with complete debridement of calcified lesions, Haglund deformity resection, and flexor hallucis longus (FHL) tendon transfer. Histopathology showed myxoid degeneration, neovascularization, and mature ossified tissue. At 3-month follow-up, the patient exhibited significant improvement in pain, function, and range of motion. Conclusion This case highlights a rare presentation of delayed, extensive CIAT in a young adult likely related to previous surgical trauma and poor intraoperative hemostasis. It underscores the importance of recognizing the long-term sequelae of childhood tendon surgery and demonstrates the efficacy of a combined surgical strategy incorporating calcific debridement, Haglund resection, and FHL transfer for restoring function.

Purpose An Achilles tendon rupture is a common injury that typically affects people in the middle of their working lives. The injury has a negative impact in terms of both morbidity for the individual and the risk of substantial sick leave. The aim of this study was to investigate the cost-effectiveness of surgical compared with non-surgical management in patients with an acute Achilles tendon rupture. Methods One hundred patients (86 men, 14 women; mean age, 40 years) with an acute Achilles tendon rupture were randomised (1:1) to either surgical treatment or non-surgical treatment, both with an accelerated rehabilitation protocol (surgical n  = 49, non-surgical n  = 51). One of the surgical patients was excluded due to a partial re-rupture and five surgical patients were lost to the 1-year economic follow-up. One patient was excluded due to incorrect inclusion and one was lost to the 1-year follow-up in the non-surgical group. The cost was divided into direct and indirect costs. The direct cost is the actual cost of health care, whereas the indirect cost is the production loss related to the impact of the patient’s injury in terms of lost ability to work. The health benefits were assessed using quality-adjusted life years (QALYs). Sampling uncertainty was assessed by means of non-parametric boot-strapping. Results Pre-injury, the groups were comparable in terms of demographic data and health-related quality of life (HRQoL). The mean cost of surgical management was €7332 compared with €6008 for non-surgical management ( p  = 0.024). The mean number of QALYs during the 1-year time period was 0.89 and 0.86 in the surgical and non-surgical groups respectively. The (incremental) cost-effectiveness ratio was €45,855. Based on bootstrapping, the cost-effectiveness acceptability curve shows that the surgical treatment is 57% likely to be cost-effective at a threshold value of €50,000 per QALY. Conclusions Surgical treatment was more expensive compared with non-surgical management. The cost-effectiveness results give a weak support (57% likelihood) for the surgical treatment to be cost-effective at a willingness to pay per QALY threshold of €50,000. This is support for surgical treatment; however, additionally cost-effectiveness studies alongside RCTs are important to clarify which treatment option is preferred from a cost-effectiveness perspective. Level of evidence I.

Background In recent decades, early rehabilitation after Achilles tendon rupture (ATR) repair has been proposed. The aim of this prospective cohort study was to compare different immobilisation durations in order to determine the optimal duration after open surgery for ATR repair. Methods This study included 1088 patients (mean age, 34.9 ± 5.9 years) who underwent open surgery for acute ATR repair. The patients were categorised into four groups (A, B, C, and D) according to postoperative immobilisation durations of 0, 2, 4, and 6 weeks, respectively. All patients received the same suture technique and a similar rehabilitation protocol after brace removal,; they were clinically examined at 2, 4, 6, 8, 10, 12, 14, and 16 weeks postoperatively, with a final follow-up at a mean of 19.0 months. The primary outcome was the recovery time for the one-leg heel-rise height (OHRH). Secondary outcomes included the time required to return to light exercise (LE) and the recovery times for the range of motion (ROM). Data regarding the surgical duration, complications, the visual analogue scale (VAS) score for pain, the Achilles tendon Total Rupture Score (ATRS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were also collected. Results The recovery times for OHRH, LE, and ROM were significantly shorter in groups A and B than in groups C and D ( P  < 0.001). The VAS scores decreased over time, reaching 0 in all groups by 10 weeks. The mean scores in groups A and B were higher than those in the other groups at 2 and 4 weeks ( P  < 0.001), whereas the opposite was true at 8 weeks ( P  < 0.001). ATRS and the AOFAS Ankle-Hindfoot scale score increased across all groups over time, showing significant between-group differences from weeks 6 to 16 ( P  < 0.001) and weeks 6 to 12 ( P  < 0.001). The mean scores were better in groups A and B than in groups C and D. Thirty-eight complications (3.5%) were observed, including 20 re-ruptures and 18 superficial infections. All complications were resolved at the last follow-up, with no significant between-group differences. Conclusions Immobilisation for 2 weeks after open surgery for ATR repair may be the optimal strategy for early rehabilitation with relatively minimal pain and other complications. Trial registration ClinicalTrials.gov (NCT04663542).

Purpose The hypothesis was that early functional mobilization would reduce the incidence of deep venous thrombosis (DVT) during leg immobilization after Achilles tendon rupture surgery. A secondary aim was to evaluate if the amount of weightbearing and daily steps influenced the risk of sustaining a DVT. Methods One-hundred and fifty patients with Achilles tendon rupture repair were randomized to treatment with early functional mobilization, encouraging full weightbearing and ankle motion in orthosis, or treatment-as-usual, i.e., 2 weeks of unloading in plaster cast followed by 4 weeks weightbearing in orthosis. At 2 and 6 weeks postoperatively, all patients were screened for DVT using compression duplex ultrasound. During the first 2 weeks postoperatively, patient-reported loading, pain and step counts were assessed. Results At 2 weeks, 28/96 (29%) of the patients in early functional mobilization group and 15/49 (31%) in the control group (n.s) had sustained a DVT. At 6 weeks, the DVT rate was 35/94 (37%) in the early functional mobilization and 14/49 (29%) in the control group (n.s). During the first postoperative week, the early functional mobilization group reported low loading and higher experience of pain vs. the control group ( p  = 0.001). Low patient-reported loading ≤ 50% (OR = 4.3; 95% CI 1.28–14.3) was found to be an independent risk factor for DVT, in addition to high BMI and higher age. Conclusions Early functional mobilization does not prevent the high incidence of DVT during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual. The low efficacy of early functional mobilization is mainly explained by postoperative pain and subsequent low weightbearing. To minimize the risk of DVT, patients should be encouraged to load at least 50% of body weight on the injured leg 1 week after surgery. Level of evidence Therapeutic, level 1

BackgroundThe Krackow technique has the advantage of high strength, though it is not minimally invasive. The “Locking Block Modified Krackow” (LBMK) peri-tendon fixation technique was designed for minimally invasive surgery. This study aimed to compare the biomechanics of LBMK with Kessler and Percutaneous Achilles Repair System (PARS) techniques using a simulated early rehabilitation program.Materials and methodsThirty-fresh bovine Achilles tendon specimens were randomly assigned to the LBMK, Kessler, and PARS groups (n = 10). In LBMK group, the main suture configuration was the LBMK technique, and the transverse suture was used as the secondary suture configuration. The Kessler group employed three suture configurations, two sagittal, one coronal plane. In the PARS group, two transverse and one locking sutures were placed at either end of the tendon. Each repaired specimen underwent two cyclic loading protocols (20–100 N, 20–190 N), 500 cycles, followed by measurement of the gap between the tendon ends. All specimens underwent a load-to-failure test at a 25 mm/s stretching rate.ResultsAfter the first loading cycle, the average gaps of the LBMK, Kessler and PARS groups were 0.76 ± 0.44 mm, 1.80 ± 0.82 mm, and 2.66 ± 1.04 mm, respectively. The LBMK group had a significantly reduced gap than the other groups (p < 0.01). The LBMK group gaps were all within 2 mm. The Kessler and PARS groups had six, and two specimens within 2 mm, respectively. After the second loading cycle, the average end gaps of the LBMK, Kessler, and PARS groups were 3.68 ± 1.08 mm, 5.70 ± 0.89 mm and 7.59 ± 1.26 mm, respectively. The LBMK group had a significantly reduced average gap than the other groups (p < 0.01). The maximum load-to-failure was highest 732.8 ± 138 N in the LBMK than the other groups (p < 0.01).ConclusionThe biomechanical strength of the LBMK suture was significantly greater than Kessler and PARS. The reduced gap in the LBMK group suggests superior resistance to gap formation, which may occur during early postoperative rehabilitation.

Background Acute Achilles tendon rupture (AATR) surgical repair debates center on the clinical efficacy of minimally invasive surgery (MIS) versus open surgery (OS), with immobilization duration poorly stratified. This prospective cohort study aimed to compare clinical outcomes of OS and MIS for AATR repair and evaluate the impact of immobilization duration (0, 2, or 4 weeks) on postoperative rehabilitation. Methods A total of 474 patients undergoing surgical repair for acute AATR were stratified into six groups based on surgical approach (OS: 265 cases; MIS: 209 cases) and immobilization duration (0, 2, or 4 weeks). The primary outcomes were postoperative complications, while secondary outcomes included recovery times for Achilles tendon function. Data regarding the operative times, incision lengths, the visual analog scale (VAS) score, the Achilles tendon Total Rupture Score (ATRS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score, and the relative Achilles tendon resting angle (ATRA) were also collected. Results MIS groups demonstrated significantly shorter operative times (34.1–34.4 vs. 45.1–46.1 min, P  < 0.001) and reduced incision lengths (2.2–2.4 vs. 4.5–4.7 cm, P  < 0.001) compared to OS. Postoperative VAS scores were markedly lower in MIS cohorts during the first 2 weeks ( P  < 0.001), with pain resolution comparable across all groups by 8 weeks. Despite the superior early functional recovery in PF (9.1–33.4 vs. 14.6–38.9 days, P  < 0.001), Group D and E exhibited higher re-injury rates compared to OS ( P  < 0.05), in which Group D also demonstrated higher re-operation rates (5.6% vs. 0, P  = 0.038). Prolonged immobilization (4 weeks) delayed functional recovery in both cohorts ( P  < 0.001). While transient differences in AOFAS Ankle-Hindfoot Scale and ATRS scores were observed at intermediate time points, all groups achieved near-maximal functional scores by 48 weeks, with no significant between-group differences ( P  > 0.05). Relative ATRA exhibited no significant intergroup differences at 48 weeks postoperatively ( P  > 0.05). Conclusion MIS for acute Achilles tendon rupture achieves faster early recovery but carries higher re-injury risks, mitigated by 4-week immobilization. OS benefits from shorter (2-week) immobilization. Both approaches yield equivalent long-term functions, emphasizing the need for tailored protocols and refined MIS techniques to optimize outcomes. Trial registration NCT04663542.