ACHILLES TENDON RUPTURE CASE SUMMARY NAME: N.G.H R/N : 847992 Madam N.G.

H, 46 years old Chinese lady, resen!ed !o !he A""iden! and Emer#en"y de ar!men! a$!er she had a $all $rom a s!air"ase $o%r ho%rs rior !o admission. &he !'is!ed her le$! an(le and "om lained o$ ain and ina)ili!y !o 'al(. E*amina!ion o$ !he le$! lo'er lim) re+ealed loss o$ "on!in%i!y o$ !he A"hilles !endon. &immond,s !es! 'as osi!i+e and she 'as %na)le !o !i !oe. -here 'as no )ony !enderness and !he an(le .oin! 'as normal. -here 'as no $ra"!%re de!e"!ed $rom !he radio#ra h.

&he #a+e no his!ory o$ s!eroid in.e"!ion, a%!oimm%ne or in$lamma!ory diseases !ha! may redis ose her $or !he a"%!e r% !%re. /ia#nosis o$ "om le!e A"hilles !endon r% !%re 'as !hen made and she %nder'en! o era!i+e re air o$ !he r% !%red !endon.

-he o era!i+e ro"ed%re 'as done %nder s inal anes!hesia 'i!h !he a!ien! lyin# in rone osi!ion. A lon#i!%dinal s(in in"ision 'as made o+er !he os!erola!eral as e"! o$ !he an(le. -he ara!enon 'as o ened and !he !endon 'as $o%nd !o )e 90 er"en! r% !%red. -he !endon 'as "ore1s%!%red +ia 2%nnel !e"hni3%e )y %sin# non1a)sor)a)le 4rolene/0. -he ara!enon 'as "losed 'i!h /e*on 5/0 and !he s(in "losed 'i!h a)sor)a)le s%!%re, 6i"ry 5/0. 7la+in dressin# 'as a lied !o !he 'o%nd.

An a)o+e (nee "as! 'as a lied 'i!h !he $oo! in lan!ar $le*ion.

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&he 'as dis"har#ed !'o days la!er and !he "as! 'as (e ! $or 6 'ee(s 'i!h 2 'ee(ly "han#es ro#ressi+ely !o'ard dorsi$le*ion. 9a!es! $ollo' % a! 2 mo!hs os!1o era!i+ely sho'ed !he 'o%nd 'as healed and only minimal limi!a!ion o$ dorsi$le*ion 'hi"h "an )e im ro+ed 'i!h hysio!hera y.

DISCUSSION Introduction: R% !%res o$ !he A"hilles !endon are rela!i+ely "ommon al!ho%#h i! is !he s!ron#es! and !hi"(es! !endon in !he h%man )ody. -his !endon deri+ed i!s name $rom a Gree( 'arrior named :A"hilles; 'ho died in a 'ar a$!er a oisoned arro' hi! his le$! A"hilles !endon. -rea!men! $or !his in.%ry has )een re or!ed as early as Hi o"ra!es era and sin"e !hen se+eral a%!hors had s%##es!ed +ario%s !y es o$ !rea!men!. < era!i+e re air o$ r% !%red A"hilles !endon 'as ad+o"a!ed in 8888 )y a 7ren"hman, G%s!a+e 4olaillon al!ho%#h an Ara)ian hysi"ian er$ormed s%"h ro"ed%res as early as !he !en!h "en!%ry A./. -he !r%e na!%re o$ e!iolo#y and !he )es! me!hod o$ !rea!men! s!ill remain %n"lear sin"e some hysi"ians ad+o"a!e o era!i+e re air 'hils! o!hers insis! !ha! an o era!ion is %nne"essary and oses an %na""e !a)le ris(.

Anatomy: -he A"hilles !endon "onsis!s o$ #as!ro"nemi%s and sole%s !endons !ha! )lend in!o one !endon. -he $i)res s iral !hro%#h 90 de#rees d%rin# i!s des"en! )e$ore inser!in# on !he s% erior "al"aneal !%)erosi!y. -his ro!a!ion 'ill "a%se !he $i)ers, 'hi"h is on !he medial side ro*imally, !o )e"ome os!erior dis!ally and in !his 'ay elon#a!ion and elas!i" re"oil

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'i!hin !he !endon are ossi)le. -he !endon is "o+ered )y a ara!enon 'i!h +is"eral and arie!al layers, allo'in# a)o%! 8.= "m o$ !he !endon !o #lide. -he A"hilles !endon does no! ossess a !r%e syno+ial shea!h (1 .

-he A"hilles !endon re"ei+es !heir )lood s%

ly $rom !hree so%r"es> $rom lon#i!%dinal

+essels in !he m%s"%lo!endino%s .%n"!ion, anas!omoses 'i!h +essels in !he erios!e%m a! !he osseo!endino%s .%n"!ion and ara!enon +essels mainly )y )ran"hes o$ os!erior !i)ial ar!ery (! . -he )lood $lo' o$ !he A"hilles !endon de ends on a#e, 'i!h a hi#her $lo' in yo%n#er indi+id%als. -here is a dis %!e "on"ernin# dis!ri)%!ion o$ )lood +essels in !he !endon. ?n.e"!ion s!%dies in "ada+ers ha+e sho'n !ha! !he ara!enon +essels are s"ar"e a! !he le+el 2 !o 6 "m ro*imal !o !he osseo%s inser!ion. -he in!ra!endino%s +essel rea"hes a nadir 4 "m ro*imal !o !he "al"ane%m (" . <!hers ha+e sho'n !ha! !he !endon is #enerally oor in )lood s% ly and do no! in #eneral +ary si#ni$i"an!ly alon# i!s len#!h (! . -he

area o$ A"hilles !endon rone !o r% !%re is rela!i+ely a+as"%lar "om ared 'i!h !he res! o$ !he !endon (# .

E$id%mio&o'y: 9e+i re or!ed !he ann%al in"iden"e !o )e 85.4 er 800 000 o %la!ion in Co enha#en (( . 9e ila!hi e! al es!ima!ed !ha! !he in"iden"e o$ !he A"hilles !endon r% !%re in !he "i!y o$ <%l%, 7inland, 8994 'as a ro*ima!ely 88 er 800 000 () . 2o!h s!%dies also sho'ed !ha! mos! r% !%res o""%r d%rin# s or! a"!i+i!ies @88A $rom 9e ilah!i> 86A $rom 9e+iB es e"ially )admin!on. A r% !%re o$ !he A"hilles !endon is more "ommon in males, 'i!h a male1!o1$emale ra!io ran#in# $rom 8.7:8 !o 82:8. -his ossi)ly re$le"!s !he #rea!er

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re+alen"e o$ males !han $emales 'ho are in+ol+ed in s or!s al!ho%#h !here may )e o!her %nre"o#niCed $a"!ors. -he le$! !endon is r% !%red more $re3%en!ly !han !he ri#h!. -y i"ally !his a"%!e r% !%re o""%rs in men in !he !hird !o $o%r!h de"ades o$ li$e 'ho lay s or! o""asionally (# .

Etio&o'y: & on!aneo%s r% !%re o$ !he A"hilles !endon has )een asso"ia!ed 'i!h a m%l!i!%de o$ disorders, s%"h as in$lamma!ory and a%!oimm%ne diseases> #ene!i"ally de!ermine "olla#en a)normali!ies, in$e"!io%s diseases and ne%rolo#i"al "ondi!ions. & or!s in addi!ion !o daily a"!i+i!y la"es addi!ional s!ress on !he A"hilles !endon, leadin# !o a""%m%la!ion o$ !ra%ma, 'hi"h al!ho%#h )elo' !he !hreshold $or $ran( r% !%re, "o%ld lead !o se"ondary in!ra!endino%s de#enera!i+e "han#es. Ho'e+er, !here is li!!le a#reemen! 'i!h re#ards !o i!s e!iolo#y (# .

?! is also s!ill no! ossi)le !o in oin! !he e!iolo#i"al role o$ s!eroid in redis osin# !endon !o r% !%re, al!ho%#h i! is 'ell (no'n 'ri!!en in many li!era!%res. Ho'e+er, rolon#ed oral adminis!ra!ion and re ea!ed eri!endino%s in.e"!ion o$ "or!i"os!eroids ro)a)ly sho%ld )e a+oided (# . Re"en!ly, $lo%ro3%inolones an!i)io!i" s%"h as "i ro$lo*a"in, ha+e )een im li"a!ed in !he e!iolo#y o$ A"hilles !endon r% !%re. ?n 7ran"e )e!'een 898= and 8992, 800 a!ien!s 'ho 'ere )ein# mana#ed 'i!h $lo%ro3%inolones had !endon disorder, 'hi"h in"l%ded 58 r% !%res (* .

8=

Me"hani"al !heory as s!a!ed )y 2ar$red "on"l%ded !ha! !he ris( o$ r% !%re 'o%ld )e #rea!es! 'hen !he !endon 'as o)li3%ely loaded, 'hen !he m%s"le 'as in !he ma*im%m "on!ra"!ion and 'hen !he ini!ial !endon len#!h 'as shor! (+ . All !hese $a"!ors are ro)a)ly resen! in mo+emen!s o""%rrin# in many s or!s !ha! re3%ire ra id %sh1o$$. 4os!a""hini D 4%dd% "on"l%ded !ha! in"om le!e syner#ism o$ a#onis! m%s"le "on!ra"!ions, dis"re an"y in !he !hi"(ness 3%o!ien! )e!'een m%s"le and !endon and ine$$i"ien! a"!ion o$ !he lan!aris m%s"le a"!in# as a !ensor o$ !he A"hilles !endon

redis ose !he !endon !o r% !%re in yo%n# heal!hy a!ien!s (, .

Arner D 9indholm "lassi$ied !he !ra%ma res%l!in# in !he r% !%re in nine!y1!'o a!ien!s in!o !hree "a!e#ories (1- . -he $irs! "a!e#ory 'as %shin# o$$ 'i!h !he 'ei#h!1)earin# $ore$oo! 'hile e*!endin# !he (nee. -his mo+emen! is seen in s rin! s!ar!s and in .%m in# s or!s s%"h as )as(e!)all. -his me"hanism a""o%n!ed $or =5A o$ !he r% !%res in !heir series. -he se"ond "a!e#ory 'as s%dden, %ne* e"!ed dorsi$le*ion o$ !he an(le, s%"h as !ha! o""%rrin# 'hen !he $oo! sli s in!o a hole or !he indi+id%al $alls do'n s!airs and !his a""o%n!ed 87A o$ !he r% !%res. -he !hird "a!e#ory 'as +iolen! dorsi$le*ion o$ !he lan!ar $le*ed $oo!> s%"h as may o""%r a$!er $all $rom hei#h! and !his "on!ri)%!es 80A o$ !he r% !%res.

Dia'no.i.: ?n #eneral, "lini"al e*amina!ion is s%$$i"ien! $or a dia#nosis o$ a"%!e r% !%re o$ !he A"hilles !endon. 4a!ien!s are o$!en %na)le !o )ear 'ei#h! and "om lain o$ ain in !he a$$e"!ed le# 'i!h 'ea(ness or s!i$$ness o$ !he a$$e"!ed an(le. E*amina!ion may re+eal

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s'ellin# and al a)le #a may )e $el! alon# !he "o%rse o$ !he !endon, !y i"ally !'o !o si* "en!ime!ers ro*imal !o i!s inser!ion. -here are se+eral !es!s, 'hi"h "an )e %sed !o $a"ili!a!e !he dia#nosis o$ r% !%re A"hilles !endon:

1. Cal$1s3%eeCe !es! also (no'n as -hom son !es! or &immond,s !es!> done )y s3%eeCin# !he $leshy ar! o$ !he "al$ 'hile a!ien! lyin# rone on !he e*aminin# !a)le and !he an(les "lear o$$ !he !a)le. -he $oo! 'ill #o !o lan!ar $le* i$ !he A"hilles !endon is s!ill in!a"!. 2. Enee $le*ion !es!> a!ien! is as(ed !o a"!i+ely $le* !he (nees !o 90 de#rees 'hile lyin# rone. /%rin# !his mo+emen!, i$ !he $oo! on !he a$$e"!ed side $alls in!o ne%!ral or dorsi$le*ion, a r% !%re o$ A"hilles !endon "an )e dia#nosed. 3. Needle !es!> hy odermi" needle is inser!ed .%s! medial !o !he midline and !en "en!ime!ers ro*imal !o !he inser!ion o$ !he !endon, in!o !he !endon s%)s!an"e i!sel$. ?$, in an(le dorsi$le*ion, !he needle oin!s ro*imally, !here is res%med !o )e a loss o$

"on!in%i!y )e!'een !he needle and !he si!e o$ !he inser!ion o$ !he !endon (11 . 4. & hy#momanome!er !es!> a "%$$ is 'ra ed aro%nd mid ar! o$ !he "al$ 'hile !he a!ien! is rone. -he "%$$ !hen in$la!ed !o 800 mm mer"%ry 'i!h !he $oo! in

lan!ar$le*ion. -he $oo! is !hen dorsi$le*ed and !he ress%re sho%ld rise !o a ro*ima!ely 840 mm mer"%ry in !he in!a"! !endon )%! remains aro%nd 800mm mer"%ry i$ r% !%re o""%rred (1! . 7%r!her ima#in# s!%dies s%"h as radio#ra h, %l!raso%nd and ma#ne!i" resonan"e ima#in# @MR?B are %s%ally no! needed in !he dia#nosis o$ a"%!e !endon r% !%re.

87

Tr%atm%nt: -here are many !e"hni3%es and ro"ed%res des"ri)ed $or !he !rea!men! o$ an a"%!ely r% !%red A"hilles !endon. -hey "an )e #ro% ed %nder !hree headin#s: o en o era!i+e, er"%!aneo%s o era!i+e and non1o era!i+e.

A) Open operative: -here are also many o era!i+e !e"hni3%es %sed !o re air r% !%re A"hilles !endon ran#in# $rom sim le end1!o1end s%!%rin# 'i!h 2%nnel or Eessler1!y e s%!%res, !o more "om le* re airs 'i!h !he %se o$ $as"ial rein$or"emen! or !endon #ra$!s. Modi$ied end1!o1end s%!%re )y !he %se o$ ma!erials s%"h as /a"ron +as"%lar #ra$! also has )een ro osed, )%! !he la"( o$ !ension on !he re air si!e may no! )e ad+an!a#eo%s (1" . &e+eral a%!hors ha+e ro osed rimary a%#men!a!ion o$ !he re air 'i!h !he lan!aris !endon, !he erone%s !endon, a sin#le "en!ral #as!ro"nemi%s $as"ial !%rndo'n or !'o s%"h $la s. Ho'e+er, !here is no e+iden"e !ha! rimary a%#men!a!ion re air o$ an a"%!e r% !%re is doin# any )e!!er !han non1a%#men!ed one, )%! some s%r#eons re$er !o %se a%#men!a!ion in delayed re airs and re1r% !%re "ases (# .

B) Percutaneous repair Ma and Gri$$i!h de+elo ed a me!hod o$ er"%!aneo%s re air as a "om romised )e!'een o era!i+e and non1o era!i+e !rea!men! and sho'ed a #ood res%l! 'i!h minor s(in "om li"a!ions and no re1r% !%re (1# . Ho'e+er, mos! s!%dies ha+e demons!ra!ed !ha! !he ra!e o$ re ea! r% !%re a$!er er"%!aneo%s re air is hi#her !han a$!er o en o era!i+e re air. Moreo+er, er"%!aneo%s re air ro+ides only a ro*ima!ely =0 er"en! o$ !he ini!ial

88

s!ren#!h a$$orded )y o en re air and la"es !he s%ral ner+e a! ris( o$ )ein# !rans$i*ed d%rin# ro"ed%re (# .

C) Non-operative treatment -he mos! "ommonly %sed $orm o$ non1o era!i+e !rea!men! is immo)iliCa!ion in a las!er "as!, %s%ally $or a eriod o$ si* !o ei#h! 'ee(s and !he "as! sho%ld )e "han#ed re#%larly @e# $or!ni#h!lyB, de"reasin# !he an#le o$ lan!ar$le*ion as m%"h as ossi)le ea"h !ime (# . Ano!her o !ion is !o immo)iliCe in a "as! $or !hree 'ee(s $ollo'ed )y "on!rolled early mo)iliCa!ion in a &he$$ield s lin! @an(le1$oo! or!hosis !ha! holds !he an(le in 8= de#rees $le*ion )%! allo's some mo+emen! a! me!a!arso halan#eal .oin!sB (1" . -he ran#e o$ dorsi$le*ion o$ !he an(le im ro+ed more ra idly a$!er !rea!men! 'i!h !he s lin!, and a!ien!s 'ere a)le !o re!%rn !o normal a"!i+i!ies sooner. <n !he o!her hand, lan!ar$le*ion o'er 'as similar and !he ra!es o$ re1r% !%re are similar $or )o!h #ro% s.

Operative Compared with Nonoperative Treatment Eellam D H%n!er er$ormed a re+ie' o$ !he li!era!%re and iden!i$ied 609 a!ien!s 'ho had )een mana#ed o era!i+ely and 208 'ho had )een mana#ed non1o era!i+ely (1# . -he ra!e o$ re ea! r% !%re 'as 8 er"en! $or a!ien!s 'ho had o era!ion "om ared 'i!h 88 er"en! $or !he a!ien!s 'ho had non1o era!i+e mana#emen!. Also, 85 er"en! o$ !he a!ien!s mana#ed o era!i+ely and 69 er"en! o$ !hose mana#ed 'i!h immo)iliCa!ion in "as! re!%rn !o !he re1in.%ry le+el a"!i+i!y. ?n addi!ion, 95 er"en! o$ a!ien!s mana#ed o era!i+ely and 66 er"en! o$ !hose mana#ed non1o era!i+ely 'ere sa!is$ied 'i!h !he res%l! o$ !he !rea!men!.

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?n ano!her randomiCed s!%dy done )y Nis!or in 80= a!ien!s @4= in o era!i+e #ro% and 60 in non1o era!i+e #ro% B, !he ra!e o$ re ea! r% !%re in !he #ro% mana#ed o era!i+ely 'as 4 er"en! "om ared !o 8 er"en! in !he non1o era!i+e #ro% (1( . Ho'e+er !here 'ere a lar#e n%m)er o$ se"ondary "om li"a!ions in !he #ro% 'ho had an o era!ion. -he a!ien! 'ho 'ere mana#ed non1o era!i+ely 'ere $o%nd !o ha+e less a)sen"e $rom 'or(, less an(le s!i$$ness and similar s!ren#!h "om ared 'i!h !he o era!i+e #ro% . &imilar $indin#s 'ere re or!ed )y 9oo D Eir(ley 'here !he ra!e o$ re1r% !%re is hi#her in !he non1 o era!i+e #ro% and se"ondary "om li"a!ions 'ere hi#her in !he o era!i+e #ro% (1) .

Ano!her iss%e in !rea!in# A"hilles !endon r% !%re is !he os! o era!i+e mana#emen!. ?n mos! "ases !he a$$e"!ed lim) 'ill )e in a $%ll len#!h "as! $or a eriod o$ si* 'ee(s. ?$ !he "as! has )een a lied 'i!h an(le in !he e3%in%s osi!ion, !he "as! is "han#ed a! !'o 'ee(ly in!er+als 'hen !he an(le is la"ed in #rad%ally in"reasin# dorsi$le*ion %n!il a lan!i#rade osi!ion is rea"hed. Re"en! li!era!%re has re or!ed more a##ressi+e os!

o era!i+e mana#emen!, 'hi"h allo's early an(le mo!ion. -he reason )ehind !hese "han#es is !ha! early mo)iliCa!ion 'ill enhan"e !he healin# ro"ess in !he !endon and orien!a!ion o$ !he "olla#en $i)ers and !he s!ren#!h o$ !he "al$ m%s"les is im ro+ed i$ !he !endon e* erien"es !ension d%rin# healin# (# . ?n !he la!es! a er )y Mor!ensen e! al 'ho had done randomiCed ros e"!i+e s!%dies "om arin# early mo!ion and !radi!ional 8 'ee(s o$ immo)iliCa!ion in "as! $or os! o era!i+e mana#emen! o$ r% !%re o$ A"hilles !endon re air, !heir res%l!s sho'ed no "om li"a!ion rela!ed !o early mo!ion and i! shor!ened !he reha)ili!a!ion eriod (1* .

20

SUMMARY

rimary #oal o$ !he !rea!men! o$ a r% !%re o$ !he A"hilles !endon is !o a+oid

len#!henin# o$ !he !endon, and !his "anno! )e a"hie+ed 'i!h non1o era!i+e !rea!men!. Ho'e+er, !rea!men! sho%ld )e indi+id%aliCed a""ordin# !o !he "on"erns and heal!h o$ !he a!ien!. 7%!%re de+elo men!s may in"l%de !he %se o$ adhesi+es in o era!i+e re air and an %nders!andin# o$ !he role !ha! "y!o(ines lay in !endon healin# also may lead !o ne' !rea!men!s, ossi)ly )ased on #ene !hera y.

RE/ERENCES: 8
0i&&iam. PL and 0ar1ic2 R3 Gray,s Ana!omy. New or!" Churchi## $ivin%stone 8980. Ed. 56, .608. 2 A4m%d IM5 La'o$ou&u. M5 McConn%&& P5 Soam%. R05 S%6ton 783 2lood s% A"hilles !endon. & Orthop 'es 8998> 86@=B: =921=96. ly !o !he

28

Sa&t9man C and :onar S3 -endon ro)lem o$ !he $oo! and an(le. <r!ho aedi" Eno'led#e F da!e. Am Acd Orth (ur% 8994> 2691282.

Ma6u&&i N3 C%rren! "on"e !s re+ie'. R% !%re o$ !he A"hilles !endon. & Bone &oint (ur% 8999> 881 A: 808918056.

= 6

L%;i N3 -he in"iden"e o$ A"hilles !endon r% !%re in Co enha#en. )n*ur+ 8997> 28: 5881585. L%$$i&a4ti <5 Puran%n <5 Ora;a S3 ?n"iden"e o$ A"hilles !endon r% !%re. Act Orthop (cand 8996> 67: 2771279.

Roy%r R<5 Pi%r6itt% C5 N%tt%r P3 7ea!%res o$ !endon disorders 'i!h $l%oro3%inolones. Therapie 8994> 49: 7=176.

:ar6r%d T3 Einesiolo#i"al "ommen!s on s%)"%!aneo%s r% !%res o$ !he A"hilles !endon. Act Orthop (can 8978> 42: 597140=.

Po.tacc4ini /5 Puddu 73 s%)"%!aneo%s r% !%re o$ !he A"hilles !endon. )nternat (ur% 8976> 4: 84=18=0.

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Arn%r O5 Lind4o&m A3 &%)"%!aneo%s r% !%re o$ !he A"hilles !endon. A s!%dy o$ 92 "ases. Act Chir, (can 89=9> &% l 259.

88

O=:ri%n T3 -he needle !es! $or "om le!e r% !%re o$ !he A"hilles !endon. & Bone &oint (ur% 8984> 66: 809918808.

82

Co$%&and SA3 R% !%re o$ !he A"hilles !endon: A ne' "lini"al !es!. Ann 'o+ Co## (ur% -n% 8990> 72: 2701278.

85

Sa&%4 M5 Mar.4a&& PD5 S%nior R5 Mac/ar&an%: -he &he$$ield s lin! $or "on!rolled early mo)iliCa!ion a$!er r% !%re o$ !he "al"aneal !endon. A ros e"!i+e, randomiCed "om arison 'i!h las!er !rea!men!. & Bone &oint (ur% 8992> 7412:2061209.

84

8%&&am </5 Hunt%r 7A5 McE&1ain <P3 Re+ie' o$ !he o era!i+e !rea!men! o$ !he A"hilles !endon r% !%re. C#in Orthop 898=> 208: 80185.

8=

Ni.tor L3 &%r#i"al and nons%r#i"al !rea!men! o$ A"hilles !endon r% !%re. A randomiCed s!%dy. & Bone &oint (ur% 8988> 651A: 5941599.

ros e"!i+e

86

Lo I85 8ir2&%y A5 Non1%i&%r :5 8um>4ar% DA3 < era!i+e +s nono era!i+e !rea!men! o$ a"%!e A"hilles !endon r% !%res: a 3%an!i!a!i+e re+ie'. C#in & (port .ed 8997> 7: 2071288.

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87

Mort%n.%n NHM5 S2o; O5 <%n.%n PE3 Early mo!ion o$ !he an(le a$!er o era!i+e !rea!men! o$ a r% !%re o$ !he A"hilles !endon. A ros e"!i+e, randomiCed "lini"al and radio#ra hi" s!%dy. & Bone &oint (ur% 8999> 881A: 9851980.

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