After Achilles Repair, Musculotendinous Strength Remains a Big Challenge
Amid ongoing uncertainty regarding the optimum management of Achilles tendon ruptures, recent controlled trials seem to have moved the pendulum back toward nonsurgical treatment. Still, there are many people walking around on surgically repaired Achilles tendons, and in the September 20, 2017 issue of The Journal, Heikkinen et al. report on the 13+-year outcomes of operative repair followed by early functional postoperative management in 52 patients.
All orthopaedic surgeons who have treated patients with this tendon injury have noted the postoperative calf atrophy. Using carefully analyzed MRI studies, these authors found that the mean volumes of the soleus, medial gastrocnemius, and lateral gastrocnemius muscles were 13%, 13%, and 11% lower, respectively, in the affected legs than in the uninjured legs. The mean 6% elongation of the repaired tendon that Heikkinen et al. also found at this long-term follow-up makes sense, because we are repairing tendinous tissue whose inherent collagen bundle structure has been “overstretched” prior to total failure. It also makes sense that surgeons are often hesitant to shorten the ends of the tendon aggressively for fear of placing too great a tensile strain on the suture repair.
What is most impressive to me is the degree of calf-muscle atrophy revealed in these results. Whether the findings from future trials tilt us further toward nonoperative or back toward operative care, we need to solve the muscle atrophy issue. The solution will most likely come from even more aggressive rehabilitation. To date, many of us have erred on the side of not pushing these patients too far during rehab, out of concern for failure of repair or reinjury.
With solid surgical and nonsurgical treatments for fractures, we have solved many issues to achieve optimum bone healing with good anatomic and strength outcomes. However, we have not really begun to make gains on limiting muscle, ligament, and tendon atrophy in lower extremity injuries. This should be high on the agenda for the trauma research community during the next 2 to 3 decades.
Marc Swiontkowski, MD