Achilles tendon rupture : comparison of two surgical techniques, evaluation of outcomes after complications and biochemical and histological analyses of collagen type I and III and tenascin-C expression in the Achilles tendon
1University of Oulu, Faculty of Medicine, Institute of Clinical Medicine, Department of Surgery, Division of Orthopaedic and Trauma Surgery
2University of Oulu, Faculty of Medicine, Institute of Diagnostics, Department of Clinical Chemistry
|Online Access:||PDF Full Text (PDF, 1.5 MB)|
|Persistent link:|| http://urn.fi/urn:isbn:9789514290923
|Publish Date:|| 2009-04-28
|Thesis type:||Doctoral Dissertation
|Defence Note:||Academic Dissertation to be presented with the assent of the Faculty of Medicine of the University of Oulu for public defence in Auditorium 1 of Oulu University Hospital, on 8 May 2009, at 12 noon
Docent Pekka Kannus
Docent Sakari Orava
The Achilles tendon is the largest tendon in the human body and is affected by many diseases and is vulnerable to many forms of damage due to the heavy loads it must bear. Rupture of the Achilles tendon has become more common in recent times, with an almost four-fold increase in prevalence from 1979–1990 to 1991–2000 and a peak incidence of 19 ruptures per 100 000 of population in 1999 in our epidemiological assessment. The incidences of major complications, re-rupture and deep infection, increased along with primary ruptures, peaking in 1999. The results after successful primary repair are good in over 90% of cases, as we have shown in a randomized study and in a review of the literature, and the result after re-rupture is still good in about 70% of cases, but achieving good performance after deep infection is a highly random matter. Our retrospective survey did not identify any good results, but the deep infection cases in our randomized study showed good performance due to prompt action taken for their treatment.
The best method for treating a ruptured Achilles tendon has been under debate for almost 100 years, with surgery and conservative methods advocated to equal extents. We have advocated surgical treatment as the primary choice and conservative treatment is given for selected high risk patients, for example patients with diabetes, skin problems, systemic use of corticosteroids or severe other illness. The type of surgery technique is not a straightforward choice, either, and various forms of open surgery and percutaneous techniques exist. We compared an end-to-end simple suture with the same suture augmented with one central gastrocnemius turn-over flap in a randomized series of 60 patients and found no differences with respect to subjective complaints, calf muscle strength or tendon elongation with time. The end-to-end technique is simpler and is therefore justified as the primary method of choice for the surgical repair of fresh complete Achilles tendon ruptures.
The tissue composition has been shown to alter not only with time but also after repeated tearing of the tendon collagen fibres. A normal tendon is mainly composed of type I collagen, but the rupture areas express more type III collagen, which is thinner and withstands loads less effectively. Type III collagen accumulates slowly in the tendon, since its production does not increase very much, a situation that is indicative of microtrauma. Crosslinking of the fibres is important for collagen matrix properties, and we found that there is a change in the quality of crosslinking with age and that this may have role in the observed changes in tendon stiffness, as also noted in other studies.
We also studied the appearance of tenascin-C at the rupture site in the Achilles tendon and at two other sites in the same tendon, but found no difference in its expression. It has been proposed that tenascin-C may take part in the tendon’s reaction to loading, but its exact function remains unknown.
Acta Universitatis Ouluensis. D, Medica
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