The influence of gap distance on clinical outcome in acute tendo Achilles rupture treated with accelerated functional rehabilitation

A. Qureshi, A. Gulati, A. Shah, J. Mangwani

Aim: To determine the influence of tendo achilles (TA) rupture gap distance and location on clinical outcome managed with accelerated functional rehabilitation.

Methods: Twenty six patients with acute complete TA ruptures underwent ultrasound (US) within a week of injury. Measurements included the distance of the rupture from the enthesis and the gap distance between the tendon edges in three positions - (1) foot plantigrade, (2) maximum equinus and (3) maximum equinus with 90^o knee flexion. All patients were managed non-operatively in functional weightbearing orthoses. Nineteen patients were followed up at a mean of 6.1 years (range 5.8-6.5). Outcomes included ultrasound confirmation of healing, Achilles Tendon Rupture Score (ATRS) and Modified Lepilahti score (MLS).

Results: The mean distance of the rupture from the enthesis was 52mm (range: 40-76mm). The mean gap distance with the foot plantigrade was 11.4mm (95%CI: 9.9, 12.9) which reduced to 4.8mm (95%CI: 3.3, 6.4) in equinus and 1.5mm (95% CI: 0.8, 2.2) with 90° knee flexion. At follow up, no re-ruptures had occurred. US demonstrated continuity in all healed tendons. Mean ATRS was 86 (95%CI: 78.8, 93.9). There was a significant correlation between the distance of the rupture with the MLS (p =0.015) and the ATRS domains of strength (p=0.037) and fatigue (p=0.017). There was no significant correlation between the measured gap distance in the three positions with respect to the MTLS, ATRS or individual ATRS domain scores. There was no significant difference when comparing outcomes between left and right TAs or comparing gaps less than 1cm with those greater than 1 cm.

Discussion: The distance of the gap from the enthesis may be more predictive of mid term clinical outcome in patients with TA rupture managed with accelerated functional rehabilitation compared with the magnitude of the gap and extent of closure with equinus and knee flexion.