Treatment of acute rupture of the Achilles tendon is the frequent subject of investigation and innovation. The orthopaedic literature is replete with evaluations and reports of novel suture techniques, new surgical approaches, implants for both placing and holding suture, and various rehabilitation protocols. Dr. Leppilahti and his group have delivered an interesting and useful paper that stands out in this crowded field of study.

In 2009, this same group reported the results of a prospective, randomized trial comparing a group of nonaugmented surgical repairs of Achilles tendon ruptures with a group of repairs augmented using a gastrocnemius fascial flap. After one year of follow-up, they detected no advantage of the augmented repair. They now present an evaluation of fifty-five of the original sixty patients in the earlier cohort after an average duration of follow-up of fourteen years. Even though the overall number of patients is relatively small, the duration of follow-up and level of patient retention are remarkable.

Patient outcomes were evaluated with multiple criteria, including tendon elongation, a nonvalidated clinical score, and strength measurements, all of which were consistent across the time points. After fourteen years of follow-up, the augmented repair again offered no clear advantage. Interestingly, there was no significant change, for either group, in the strength measurements between the twelve-month and fourteen-year follow-up evaluations, leading the authors to conclude that Achilles tendon rupture and subsequent repair result in a permanent strength deficit in the injured leg that is static by approximately one year after surgery.

The weaknesses of this study are important but not fatal. The number of subjects is small, and it is possible that a larger cohort would show a difference between treatment groups. In addition, the thirteen-year interval between evaluations provided an opportunity for confounding variables, such as additional injury, courses of physical therapy, or exposure to medications, to occur and not be reported. The clinical score and strength measurements have not been validated for this injury, but they were used at both time points and the uninjured extremity was used as a control. Finally, only one specific type of augmented repair was studied and only one postoperative rehabilitation protocol was used. Therefore, it is not clear that the results are transferable to other methods of augmentation or that they would not have been affected by a change in the postoperative protocol.