To The Editor:
I enjoyed "Current Concepts Review. Rupture of the Achilles Tendon"
(81-A: 1019-1036, July 1999) by Nicola Maffulli. I was worried by
the complications of conservative treatment of tendo Achillis rupture,
and, in 1976, the technique was changed. Patients presenting within
twenty-four hours after injury are placed in a below-the-knee, non-weight-bearing,
gravity equinus plaster cast. At ten days, the cast is removed and
the tendon is examined with the patient lying prone. The swelling
will have disappeared, and it will be easy to feel if the tendon
is in continuity. If there is no palpable gap, the foot can be gently dorsiflexed.
If healing is progressing satisfactorily, the foot will plantar
flex slightly when the calf is squeezed. If there is a palpable
defect, or if the calf-squeeze test is abnormal, the tendon should
be repaired. If healing is satisfactory, a further below-the-knee,
weight-bearing, equinus cast is used.
A review of the literature revealed that the average rupture
rate after conservative treatment is approximately 17 percent. I
think re-rupture is a misnomer because I suspect that, in most cases, the
tendon has not united. When we reviewed 120 cases, seventeen were
thought to be abnormal at ten days and proceeded to surgery. None of
these had any wound complications or later problems. Two cases that
were judged to be satisfactory at ten days presented with later
ruptures after cast removal. During this series, thirty-three other
cases had a primary repair because they presented more than one
day after injury or participated in high-level sporting activities.
We feel that inspection at ten days substantially reduces the rate
of late rupture. If surgery is necessary, the ten-day delay seems
to diminish the problems with wound-healing associated with acute
surgery. The percentage of cases explored at ten to fourteen days
approximates the quoted prevalence of "re-rupture," and I think
that most of the cases that will not heal because of fibrous "nonhealing"
of the ruptured tendo Achillis can be selected then.
Chris J. Bossley M.B.Ch.B., F.R.C.S.(London), F.R.A.C.S.
Hutt Valley Health Corporation
High Street, Private Bag 31907
Lower Hutt, New Zealand
To The Editor:
I have read the historical introduction of "Current Concepts
Review. Rupture of the Achilles Tendon" (81-A: 1019-1036, July 1999)
by Nicola Maffulli, and I completely disagree with his statements.
Nowadays, a widespread inaccuracy still exists concerning the
relation between the heel - and the strongest tendon in the human
body - and the name of the demigod Achilles, the hero of Homer's
Iliad.
The demigod Achilles, born of Peleus, king of the Myrmidons,
was dipped three times in the river Styx by his mother, the Nereid
Thetis, who wanted to immortalize him; only the heel by which she
held him was left vulnerable.
Achilles was indeed killed by an arrow fired by Paris who, guided
by Apollo, struck Achilles' heel. Therefore, the connection between
the heel and the name of Achilles is justified, as is the common
expression that associates the Achilles heel with vulnerability.
On the other hand, the meaning of Achilles tendon is rather different;
it characterized not the Greek hero, but an action that he performed
after the death of Hector. The corpse of the Trojan hero was secured,
through the strongest tendon in his body, to Achilles' chariot and
then dragged around the city walls:
he pierced the sinews
at the back of both his feet, from heel to ankle,
and passed the thongs of ox-hide through
the slits he had made:
thus he made the body fast to his chariot,
letting the head trail upon the ground.3
It is thus obvious that the Achilles tendon and the Achilles
heel are two different things that should not be mixed up; unfortunately,
this confusion is rather frequent even in the medical community.
Bruno Martinelli, Prof.
Department of Orthopaedic Surgery
Ospedale Maggiore, Trieste, Italy
N. Maffulli replies:
Like Professor Martinelli, I have read the Iliad. It does not
clearly transpire whether the expression "Achilles tendon" is to
be ascribed to the tendon of Achilles or to the tendon of Hector that
was used by Achilles to secure Hector's body. As in many areas of
orthopaedics, even this is not immune to multiple interpretations!
Mr. Bossley may be right. However, in the absence of controlled
trials, one has to rely on the diagnosis of re-rupture formulated
by the authors of the various papers. In his letter, it is not clear
what Mr. Bossley considers to be abnormal at ten days, but I suspect
that he refers to the presence of an unfilled gap. Indeed, should
this happen, this is an indication for surgery, and I fully agree
with Mr. Bossley's management at that stage.
Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth)
Department of Orthopaedic Surgery
University of Aberdeen Medical School
Polwarth Building, Foresterhill
Aberdeen AB25 2ZD, Scotland
To The Editor:
The excellent "Current Concepts Review. Rupture of the Achilles
Tendon" (81-A: 1019-1036, July 1999), by Nicola Maffulli, omits,
in my opinion, a very useful and complication-free technique for
repairing very late neglected ruptures. The following is a method
for late repair that utilizes rather than sacrifices scar tissue.
In most symptomatic cases of neglected spontaneous Achilles tendon
rupture, a hiatus develops. This hiatus lies between the distal
tendinous stub on the calcaneus and the retracted proximal aponeurotic
portion. The gap is usually filled by a callus-like fibrous mass
of scar. This scar functionally reattaches the two ends, but it
does so with elongation. Many complicated methods of overcoming
this elongation have been devised, beginning with excision of all
scar tissue. A method is then needed to overcome the wide void that
is surgically created. A very bulky repair mass usually results,
which is extremely difficult to close over and keep covered. Complications
and failures ensue. The following technique avoids most problems.
It is applicable to injuries that have been neglected for several weeks
or years.
A serpentiform skin incision is made on the medial side of the
damaged tendon. The tendon and contiguous scar are dissected directly
upon their surface, avoiding all other layer separation. The full
and undisturbed thickness of the skin and subcutaneous tissue are
carefully preserved. At the junction of the "callus" and the distal
calcaneal stub of good tendon, a clean, sharp, transverse cut is
made. The nearly normal distal part of the tendon with a clean,
flat face is revealed. The proximal muscular end is grasped and pulled
distally with sufficient force to stretch it to its maximum. Overlapping
proximal tissue is cut off cleanly and transversely at the level
of the calcaneal stub and is discarded. This maneuver establishes
the proper length and leaves two clean, flat faces of "tendon" for
an easy cabinetmaker's fit. It is important that the repair knot
or knots be distal to the repair to facilitate snug drawing down
and approximation of the two ends. In my experience, the "callus"
tissue is strong when mature, will hold sutures, and will heal well.
Moreover, it will be as strong as or stronger than the various grafts
that must ultimately also depend upon scar. Careful, simple wound
closure in a more or less single layer is followed by a long leg
cast flexed at the knee and extended at the ankle for eight weeks.
Rehabilitation includes a gradually diminishing heel-lift.
Clifford C. Raisbeck, M.D.
1199 Bush Street, Suite 240
San Francisco, California 94109
N. Maffulli replies:
Dr. Raisbeck is right: I did not report the technique that he
describes in his letter, and I am sure that I did not cite tens
of other established or innovative techniques to repair fresh or
neglected Achilles tendon ruptures. This was not out of ignorance
or maliciousness; whenever writing a Current Concepts Review, one
is faced with a vast number of references. The need to be comprehensive
and exhaustive clashes with the necessity to cover the subject in
a preciously limited space. Hence, authors have to hope that they
have tickled the curiosity of critical readers such as Dr. Raisbeck
enough for them to go deeper in the subject.
For example, I have not dwelled on V-Y gastrocnemius advancement1, alone or combined with excision
of the fibroadipose defect and end-to-end anastomosis4,7. For those readers who are particularly
interested in the topic of neglected Achilles tendon rupture, may
I suggest the excellent review by Gabel and Manoli2.
To return to Dr. Raisbeck's preferred method, which is simple
and elegant, given the present evidence I would immobilize the limb
in a below-the-knee cast, with the foot plantigrade, and allow weight-bearing
as tolerated as soon as possible, keeping the plaster on for six
weeks. If the appropriate length of the musculotendinous unit has
been restored, the cyclical tension afforded by walking and weight-bearing
will allow better maintenance of the muscle mass of the gastrocsoleus
and faster regaining of dorsiflexion of the ankle once the plaster
has been removed5,6.
Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth)
Department of Orthopaedic Surgery
University of Aberdeen Medical School
Polwarth Building, Foresterhill
Aberdeen AB25 2ZD, Scotland