The Journal of Bone and Joint Surgery (American). 2009;91:1092-1100.
doi:10.2106/JBJS.G.01089
© 2009 The Journal of Bone and Joint Surgery, Inc.
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Augmented Compared with Nonaugmented Surgical Repair of a Fresh Total Achilles Tendon Rupture

A Prospective Randomized Study

Ari Pajala, MD1, Jarmo Kangas, MD1, Pertti Siira, PhT1, Pasi Ohtonen, MSc1 and Juhana Leppilahti, MD, PhD1

1 Division of Trauma Surgery, Department of Surgery (A.P., J.K., J.L.), Department of Physiotherapy (P.S.), and Department of Surgery and Anesthesiology (P.O.), Oulu University Hospital, PL 21, 90029 OYS, Oulu, Finland. E-mail address for A. Pajala: ari_pajala{at}mail.suomi.net

Investigation performed at Oulu University Hospital, Oulu, Finland

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM/DVD (call our subscription department, at 781-449-9780, to order the CD-ROM or DVD).

Background: Augmented and nonaugmented techniques have been used for the operative repair of a fresh complete Achilles tendon rupture. Augmented techniques have been favored for their stronger pullout strengths but have been avoided because of the risk of wound complications. If proven to be equally good, the nonaugmented technique would be the method of choice. In the present study, we hypothesized that augmentation with a down-turned gastrocnemius fascia flap would not provide better results than would end-to-end suture repair with use of the Krackow locking loop surgical technique.

Methods: Sixty patients with an acute Achilles tendon rupture were randomized preoperatively to receive end-to-end suture repair with use of the Krackow locking loop technique either without augmentation (simple repair group) or with a down-turned gastrocnemius fascia flap as described by Silfverskiöld (augmented repair group). A brace allowed free active plantar flexion of the ankle postoperatively, whereas dorsiflexion was restricted to neutral for the first three weeks. Weight-bearing was limited for six weeks. The follow-up period was one year, and the patients were evaluated in terms of clinical measurements, an outcome score, isokinetic calf muscle performance tests, and tendon elongation measurements.

Results: The mean operative time was twenty-five minutes longer and the incision was 7 cm longer in the augmented repair group as compared with the simple repair group (p < 0.001 for both). In the simple repair group, the overall ankle score was excellent for nineteen patients (63%) and good for eight patients (27%) and three patients (10%) had an early failure (all because of rerupture). In the augmented repair group, the ankle score was excellent for fourteen patients (56%) and good for six patients (24%) and five patients (20%) had a failure because of rerupture (three) or deep infection (two). The difference between the groups with regard to the overall result was not significant (p = 0.68). In the simple repair group the isokinetic calf muscle strength score was excellent for eleven patients (37%), good for fourteen patients (47%), and fair for two patients (7%), with three patients (10%) having a failure, whereas in the augmented repair group the score was excellent for nine patients (36%), good for seven patients (28%), fair for three patients (12%), and poor for one patient (4%), with five patients (20%) having an early failure. Achilles tendon elongation occurred in both groups, and elongation correlated significantly with isokinetic peak torque deficits ({rho} = 0.64, p = 0.001) and isometric strength deficits ({rho} = 0.48, p = 0.026) in the simple repair group. No significant differences were seen between the two groups at the three-month and twelve-month checkups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, overall outcome, isokinetic calf muscle strength, mean peak work-displacement relationships, or tendon elongation.

Conclusions: Augmented repair of a fresh total Achilles tendon rupture does not have any advantage over simple end-to-end repair.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.


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