Achilles tendon, the largest and strongest tendon in the human body, is most commonly injured in sports, and therefore, there has been an increasing incidence of injuries of the tendon over the past decade, particularly in the more developed countries.

To avoid confusing terminology referring to Achille tendon injuries, the clinical syndrome in and around the tendon characterized by pain, swelling and impaired ability to perform certain movements or activities has been generically called Achilles tendinopathy (55-65% of injury cases).

Specialists have identified two main sources of tendinopathies: loading-induced degeneration, caused by overuse (strenuous physical activities, running, jumping) and systemic, predisposing diseases, such as rheumatoid arthritis (only 2% of cases).

Among the factors that predispose a person to these problems, there are a few intrinsic risk factors ? ?lower extremity malalignments, leg length discrepancy, muscle weakness and imbalance, decreased flexibility, and overweight � (Jarvinen et al.) and several extrinsic factors, such as excessive loading of the body and training errors.

There are many treatment options for tendinopathies described in the literature, mostly nonoperative; initial phases can be corrected with the help of orthotics, to correct malalignments, complete rest of the ankle joint, nonsteroidal anti-inflammatory drugs, corticosteroid injections around the Achilles tendon (used with precaution) and specific exercise protocols. Most patients with tendinopathies have responded favourably to conservative treatment, and only a clear failure of such treatment indicates that surgery is necessary.

Ruptures are spontaneous, complete tears of the Achille tendon. Generally, no symptoms are present before the rupture; however, histopathologic studies have shown tissue degeneration at and around the rupture site. It was concluded that sedentary lifestyle, leading to poor local blood circulation and sudden or repetitive movements (usually occurring in sports) lead to Achille tendon ruptures.

There are three main types of treatment of Achille tendon ruptures: the open operative method, the percutaneous operative method and nonoperative options. Operative treatments are preferred for young people and for patients whose initial treatment has been delayed and whose symptoms persist. Nonoperative options were the primary method used before the 20th century, usually carried out nowadays by immobilization with a plaster cast or in a functional brace/orthosis (for 6-8 weeks). Indisputably, the history of complications and reruptures is less considerable in the case of operative treatment as compared to nonoperative treatment.

The percutaneous repair method was first described by Ma and Griffith in 1977. Unlike open repair, it only involves making six small incisions along the medial and lateral borders of the tendon. Sutures are passed through the tendon using these incisions. No significant complications were noted after the repair, though isokinetic testing revealed 13% loss of power. However, a high rate of reruptures was later associated with the percutaneous repair.

A more recent study by Young et al. (1998) analyzed the possibility of repair using mesenchymal stem cell-seeded implants; stem cells are primary cells capable of becoming any other of the various types of cells in the body, under the appropriate conditions. Using the autologous implantation technique, the research team suspended the cultured, autologous, marrow-derived mesenchymal stem cells in a collagen gel delivery vehicle, then contracted this cell-gel composite onto a pretentioned suture, to implant the resulting tissue prosthesis into a gap defect of rabbit Achille tendon. The delivery of stem cell, contracted collagen implants to tendon defects proved to bring important structural and functional improvements in the tendon. ?The collagen appeared to have a greater cross-sectional area and better alignment than in controls � (Schepsis et al.).



References:

Järvinen Tero A.H. MD, Kannus Pekka MD, Paavola Mika MD, Järvinen Teppo L. N. MD, Józsa László MD and Järvinen Markku MD: Achilles tendon injuries. Current Opinion in Rheumatology, 13:150 ?155, 2001

Ma G.W., Griffith T.G.: Percutaneous repair of acute closed ruptured Achilles
tendon: A new technique. Clin Orthop 128: 247 ?255, 1977

Schepsis Anthony A. MD, Jones Hugh MD, Haas Andrew L., MD: Achilles Tendon Disorders in Athletes, The American Journal Of Sports Medicine, Vol. 30, No. 2, 2002

Young RG, Butler DL, Weber W, et al: Use of mesenchymal stem cells
in a collagen matrix for Achilles tendon repair. J Orthop Res 16: 406 ?413, 1998