Rupture of the Achilles and patellar tendons

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Epidemiology

The Achilles tendon is strongest tendon in the body, closely followed by the patellar tendon. Many possible etiological factors have been involved in its rupture, and these can broadly be divided into high-energy disruptions, degenerative changes, and mechanical imbalance. Injuries acquired from participation in sports account for the majority of ruptures [2]. Acute injuries result from rapid force shifts to the lower limb in sports like football, basketball, track and field, volleyball,

Basic science

Tendons were regarded as relatively inert tissue. The cellular elements in a tendon are very active, however, and allow for transmission of high tensile forces, elastic recoil, and longitudinal movement. In the response to physiological strain, microtears can form in the tendon substance, with new collagen being formed simultaneously, thus allowing for tendon remodeling [26]. Due to the helical arrangement of the tendon fibrils and the actin and myosin content, tendons can stretch up to 4%

Achilles tendon

Tensile force normalized to subject weight can be from 2.6 kN when walking to 9 kN when running [30], and the tendon can withstand approximately 50 to 100 N/mm. The mechanism of rupture has been classified into three main categories [31]: (1) 53% arising from weight-bearing, forefoot pushoff with knee in extension (eg, sprinting, jumping sports); (2) 17% occurring following sudden unexpected dorsiflexion of the ankle, such as slipping into a hole or falling downstairs; and (3) 10% arising

Clinical presentation

A detailed history and comprehensive physical examination are essential and often provide enough information for the diagnosis of lower limb tendon rupture.

Investigations

The diagnosis of Achilles and patellar rupture is formulated on a clinical basis. When the diagnosis is dubious, however, various investigations can clarify the diagnosis.

Management

There exists an extensive variety of methods for the management of Achilles tendon ruptures, ranging from those that are managed in an equinus cast to those that an external fixation device are applied to. This reflects the controversy over the best means of treatment [48]. Patellar tendon rupture is best managed by operative reconstruction of the extensor apparatus. The method of choice depends upon timing of repair and operator preference.

Acute Achilles tendon repair

Our method of choice for repairing acute Achilles tendon ruptures is based on the procedure described by Webb and Bannister [17], [66]. This involves a three-incision percutaneous repair under local anesthesia. After infiltration of local anesthesia around the Achilles tendon, the patient is placed prone, and a pillow is placed beneath the anterior aspect of the ankles to allow the feet to hang free. The operating table is angled 20° cranially to reduce venous pooling in the feet and ankles.

Summary

Certain similarities can clearly be appreciated between Achilles and patellar tendon ruptures. Both are strong tendons that transmit force bridging at least one joint of the lower limb. When healthy, both require massive forces to be disrupted, and both can be weakened through certain systemic disease processes, steroids, and fluoroquinones. Both allow for a variety of innovative management possibilities that ultimately lend themselves to individual surgical preference. We feel that, although

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