|dc.contributor.author||Nilsson Helander, Katarina||
|dc.description.abstract||The overall purpose of this thesis was to evaluate the treatment of patients with an acute Achilles tendon rupture with regard to complications, function and patient-reported outcome. Moreover, the purpose was to develop and evaluate new outcome measurements.
Introduction: Controversy still remains about whether surgical or non-surgical treatment is
the best option to treat patients with Achilles tendon ruptures. There are only a few randomised,
controlled studies that compare surgical and non-surgical treatment, when both groups receive early
mobilisation. Many outcome measurements found in the current literature are non-validated and
based on a mixture of assessments and there is a need for patient-reported instruments. In patients
with a chronic rupture or a re-rupture of the Achilles tendon, the recommended treatment is surgical.
Various surgical techniques have been reported in the literature; however, the outcome is rarely
evaluated with a sufficiently long follow-up, using appropriate end-points. Venous thromboembolism
(VTE) is a major complication and a high incidence of VTE has been reported in previous studies
of patients treated for an Achilles tendon rupture. The majority of patients with an Achilles tendon
rupture have strength deficits and it is therefore desirable to evaluate function with valid, reliable
methods, which are sensitive enough to detect possible differences between treatment groups.
Ma terial and Methods: In Study I, a new patient-reported instrument, the Achilles tendon
Total Rupture Score (ATRS), was developed for measuring outcome, related to symptoms and physical
activity after treatment in patients with a total Achilles tendon rupture. In Study II, 97 patients
with an acute Achilles tendon rupture were followed for one year. Surgical and non-surgical treatments
were compared; both groups were treated with early mobilisation. The primary end-point was
re-rupture. The patients were evaluated using the ATRS, functional tests and clinical examinations.
In Study III, 28 patients were evaluated 29 (12-117) months after surgery. A new surgical method to
treat a chronic rupture and re-rupture of the Achilles tendon was used and evaluated. The surgical
technique involved a single incision, with a free gastrocnemius aponeurosis flap to cover the tendon
gap after an end-to-end suture. The patients were evaluated as described in Study II. In Study IV,
a new heel-rise work test was evaluated in 78 patients. In Study V, 95 patients from Study II were
screened for deep venous thrombosis using Colour Doppler Sonography (CDS).
Results: The ATRS was found to be a valid and reliable patient-reported instrument with good
responsiveness to measure outcome in terms of symptoms and physical activity in patients with an
Achilles tendon rupture. The re-rupture rate was 2 (4%) and 6 (12%) respectively in the surgical
and non-surgical group. There were no significant differences when comparing surgically and nonsurgically
treated Achilles tendon ruptures, in terms of re-ruptures and patient-reported outcome.
Functional tests indicate a difference between the two groups when evaluated 6 months after initial
treatment, with better results in the surgically treated group. This was not, however, seen at 12
months, except in the heel-rise work test. The use of a free gastrocnemius aponeurosis flap to treat
a chronic rupture and a re-rupture of the Achilles tendon rendered a good overall subjective and
objective outcome in the majority of patients. A heel-rise test that measures both the height of each
repetition and the number of repetitions had good validity and a greater ability to detect differences
between the injured and uninjured sides than a test that measures only the number of heel-rise repetitions.
The incidence of asymptomatic and symptomatic deep venous thrombosis was high (34%),
however, without any difference between the two groups.
Conclusion: We found no strong evidence to suggest that surgical treatment is preferable to
non-surgical treatment with regard to re-rupture rate and patient-reported scores in patients with
an acute Achilles tendon rupture. However, significant differences in favour of surgery were found
in muscle function at 6 months. Both groups improved significantly over time and, at the 12-month
evaluation, the results were similar except in the heel-rise work test. The functional tests showed
that muscle function deficits remained between the injured and uninjured sides after 12 months,
regardless of surgical or non-surgical treatment. The use of a free gastrocnemius aponeurosis flap
appears to be a useful alternative when treating a chronic rupture and a re-rupture of the Achilles
tendon. The new heel-rise work test has good validity and greater ability to detect differences that
measuring the number of heel-rises. There was a high incidence of DVT after Achilles tendon rupture
and there is a need to evaluate the benefit of thromboprophylactic treatment in the future.
Key words: Achilles tendon rupture, chronic rupture, free flap, augmentation, deep venous
thrombosis, movable brace, re-rupture, ATRS, heel-rise work test||en
|dc.relation.haspart||I. The Achilles tendon Total Rupture Score (ATRS): development and validation. Nilsson-Helander K, Thomeé R, Grävare-Silbernagel K, Thomeé P, Faxén E, Eriksson BI, Karlsson J.
Am J Sports Med. 2007;35:421-426. ::pmid::17158277||en
|dc.relation.haspart||II. Acute Achilles Tendon Rupture: A Randomized, Controlled Study Comparing Surgical and Non-surgical Treatments Using Validated Outcome Measures. Nilsson-Helander K, Grävare Silbernagel K, Faxén E, Thomeé R, Olsson N, Eriksson BI, Karlsson J.
|dc.relation.haspart||III. A new surgical method to treat chronic ruptures and re-ruptures of the Achilles tendon. Nilsson-Helander K, Swärd L, Grävare Silbernagel K, Thomeé R, Eriksson BI,
Karlsson J. Knee Surg Sports Traumatol Arthrosc. 2008:16:614-620. ::pmid::18273601||en
|dc.relation.haspart||IV. A new measurement of heel-rise endurance with the ability to detect functional deficits in patients with Achilles tendon rupture. Grävare Silbernagel K, Nilsson-Helander K, Thomeé R, Eriksson BI, Karlsson J.
|dc.relation.haspart||V. High incidence of deep venous thrombosis after Achilles tendon rupture – a prospective study. Nilsson-Helander K, Thurin A, Karlsson J, Eriksson BI. Knee Surg Sports Traumatol Arthrosc: 2009 Feb 24 (Epub ahead of print) ::pmid::19238360||en
|dc.subject||achilles tendon rupture||en
|dc.subject||deep venous thrombosis||en
|dc.subject||heel-rise work test||en
|dc.title||Acute achilles tendon rupture. Evaluation of treatment and complications||en
|dc.type.degree||Doctor of Philosophy (Medicine)||en
|dc.gup.origin||University of Gothenburg. Sahlgrenska Academy||en
|dc.gup.department||Institute of Clincial Sciences. Department of Orthopaedics||en
|dc.gup.defenceplace||Fredagen den 8 maj 2009, kl. 9.00, Aulan, Sahlgrenska Universitetssjukhuset/Sahlgrenska, Göteborg||en