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TEXTBOOK : ACHILLES TENDON

ACHILLES TENDON

Edited by Andrej Čretnik .

154 pages .
Open Access .

Achilles tendon is beside a quadriceps one, the strongest tendon in human body. Its name arises from the ancient hero Achilles. His mother Thetis wanted to make him invulnerable by immersing him in the saint river Styx. As she had to hold him his heel remained unprotected and thus his weakest point. This was a cause of his death – he was hit in a heel by a poisoned Paris’ arrow (led by a God Apollo) in the siege of Troy (term “Achilles heel” is so commonly used to describe the weakest point of someone).
The name Achilles tendon comes from the story of the siege of Troy as well through the “barbarian” Achilles action when he attached the body of killed enemy Hector through “the strongest tendons in the body” to the chariot and drove him around the walls as a prove that he has beaten the greatest Troy’s warrior.
Despite of the fact that Achilles tendon rupture is not a very common injury, it has always attracted a great attention. Hippocrates is believed to be the first who wrote about its treatment, but the first description of the Achilles tendon rupture can be found in the works of Ambrois Pare in 1575. “Modern” concepts of conservative as well as operative treatment with many proposed methods can be found since 1929 in works of Quenu and Stojanović. These works still attract attention and many publications still arise every year.
As very high forces are acting in this region (6000 N “in-vivo” and almost 10000 N “invitro” testings), a lot of “troubles” in patients could be expected in the Achilles tendon region. Differential diagnoses and current knowledge about this problems can be read in Section and Chapters of Achilles tendon disorders. The most commonly used term for different inflammative, degenerative and non-degenerative, reversible and nonreversible processes in this area is term tendinopathy nowadays. Clinical signs and symptoms are swelling, pain and functional impairment. Etiology is not completely known, unfortunately but many factors including genetic as well as extrinsic and intrinsic factors are already discovered and intensively studied. Effective treatment is on the way although unfortunately problems are not completely solved. New technologies with growth factors are promising but further studies with long term results are needed in order to confirm early findings.
Achilles tendon rupture could be entitled as the “final stage” of Achilles tendon disorders, although it occurs with no previous troubles or any signs in many patients. Structure of Achilles tendon is already well known and various new imaging modalities enable us to visualize tendons and changes in them. This is beautifully described in the Section of Tendons and imaging. These could be of a great help in further investigation of the Achilles tendon disorders, particularly as the etiology of these problems remains incomprehensible. Crucial answer seems to hide in bindings (hydrogen and covalent) - what could be of a great importance in organization, structure and capacity of tendon to withstand burdening. Despite of a great knowledge and recognition of many important processes in human tendons, number, strength and maturity of bindings cannot be (yet) “measured or determined” and thus potentially problems cannot (yet) be predicted.
Once Achilles tendon rupture occurs, the most effective treatment is expected from the therapists. Despite of many different studies and meta-analyses, there is no universal agreement on the optimal management strategy of the acute total Achilles tendon rupture. Most authors prefer open surgical repair as it contributes to a low incidence of re-rupture, ranging from 1,4% to 2,8%. Strong repair with the restored length and optional augmentation offers the possibility of early functional treatment. As it is associated with significant number of complications (11,8% to 21,6%) as well as high costs, some authors advocate conservative treatment. High incidence of re-ruptures (12% to 17%), lengthened tendon and loss of strength are the main arguments for the opponents to criticize this method. Percutaneous repair seems to bridge the gap, combining the advantages of conservative and operative treatment, particularly if performed in an outpatient manner and under local anesthesia. As it has been criticized to be weaker than open repair with higher re-rupture rate, some new percutaneous techniques and one with biomechanically comparative strength and final functional results to open procedures are already in common use.
As the rupture most commonly occurs in “mid-aged” persons (in the most creative and productive part of life), the highest effort should be put in enabling patients to return to previous activities as soon as possible. There is universal agreement that functional treatment is the most effective way in this regardless of the used conservative or operative (open or percutaneous) method. There are more and more papers favoring functional conservative treatment, what (probably) yields to better results according to the lower re-rupture rate (but still higher in comparison to operative treatment) and better functional results. If percutaneous (or open) method is used as strong repair as possible (sensible) should be used as the repaired ends are better protected against gapping in functional postoperative treatment (what brings to better; final muscular strength.
Restoring the length and function (strength) is probably the toughest part of repairing neglected Achilles tendon ruptures. Despite of a very good and simple clinical (Simmonds-Thompson) test (no plantar movement of foot by squeezing sural muscles when kneeling over the edge of bench) Achilles tendon rupture could be overlooked in an up to 20% due to several reasons. In a final chapter of this book, we can read about successful restoration with the use of different other tendons or stripes. This brings our book to a good end. Hopefully this short overview will inspire you enough to open and read our book.

Prof. Andrej Čretnik, MD, Ph.D., 
Medical Councillor
University of Maribor, Faculty of Medicine, Maribor
University Clinical Centre Maribor, Maribor
Slovenia
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CONTENTS : 

Part 1 Tendons and Imaging .


 1 Imaging Studies of the Mechanical and Architectural Characteristics of the Human Achilles Tendon in Normal, Unloaded and Rehabilitating Conditions 3 Shantanu Sinha and Ryuta Kinugasa

Part 2 Achilles Tendon Disorders .


 2 Gene Variants that Predispose to Achilles Tendon Injuries: An Update on Recent Advances 25 Stuart M. Raleigh and Malcolm Collins

Part 3 Achilles Tendon Tendinopathies .


 3 Tendon Healing with Growth Factors 43 Sebastian Müller, Atanas Todorov, Patricia Heisterbach and Martin Majewski

 4 Noninsertional Achilles Tendinopathy – Treatment with Platelet Rich Plasma (PRP) 63 Marta Tarczyńska and Krzysztof Gawęda

 5 Current Strategy in the Treatment of Achilles Tendinopathy 75 Justin Paoloni

Part 4 Achilles Tendon Ruptures .


 6 ABO Blood Groups and Achilles Tendon Injury 99 Bisciotti Gian Nicola, Eirale Cristiano and Lello Pier Paolo

 7 Surgical Treatment of the Neglected Achilles Tendon Rupture 115 Jake Lee and John M. Schuberth .



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