85

C OPYRIGHT  2016

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

A commentary by Patrick B. Ebeling, MD, is

linked to the online version of this article at
jbjs.org.

Augmented Compared with Nonaugmented

Surgical Repair After Total Achilles Rupture
Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up
Juuso Heikkinen, MD, Iikka Lantto, MD, Tapio Flinkkila, MD, PhD, Pasi Ohtonen, MSc,
Ari Pajala, MD, PhD, Pertti Siira, PhT, and Juhana Leppilahti, MD, PhD
Investigation performed at the Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland

Background: This prospective randomized trial with a mean fourteen-year follow-up compared simple end-to-end repair
with fascial ap-augmented repair for acute Achilles tendon ruptures.
Methods: From 1998 to 2001, sixty patients with acute Achilles tendon rupture were randomized to receive simple endto-end repair or augmented repair; both groups were treated with postoperative bracing allowing free active plantar exion.
After a follow-up of thirteen years or more, fty-ve patients (twenty-eight in the nonaugmented-repair group and twentyseven in the augmented-repair group) were reexamined. Outcome measures included the Leppilahti Achilles tendon score,
isokinetic plantar exion strength (peak torque and the work-displacement decit at 10
intervals over the ankle range of
motion), tendon elongation, and the RAND 36-item health survey.
Results: After a mean of fourteen years of follow-up, the mean Leppilahti score was 87.1 points for the nonaugmented repairs
and 91.5 points for the augmented repairs, with a mean difference of 4.3 points (95% condence interval [CI], 20.1 to 8.8
points). The surgical technique did not have an impact on strength parameters, with a mean peak torque of 112.6 Nm after the
nonaugmented repairs and 107.3 Nm after the augmented repairs (mean difference, 5.3 Nm [95% CI, 222.2 to 11.6 Nm]) and
a median work-displacement decit of 6.7% to 20.3% after the nonaugmented repairs and 12.8% to 18.0% after the augmented repairs (p = 0.9). Strength did not signicantly change between the twelve-month and fourteen-year follow-up examinations. At a mean of fourteen years, the injured side showed a 12.2% to 18.0% median work-displacement decit compared
with the unaffected side (p < 0.001). RAND-36 scores indicated no between-group difference in health domains.
Conclusions: Augmented repair of total Achilles tendon ruptures provided no advantage over simple end-to-end repair.
Achilles tendon ruptures result in a permanent calf muscle strength decit, but its clinical relevance remains unclear.
Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Peer review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed
by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a nal review by the Editor-in-Chief prior to publication.
Final corrections and clarications occurred during one or more exchanges between the author(s) and copyeditors.

ecent mid-term to long-term studies of surgical repair

of acute Achilles tendon ruptures have generally shown
good or excellent clinical results1-5. However, despite intensive rehabilitation, patients may not recover normal calf mus-

cle strength even after several years3,5-7. Predisposing factors for a

strength decit reportedly include tendon elongation, advanced
age, and rerupture8-13. Although there has been a shift toward
more conservative treatment methods, surgery remains the most

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. None of the authors, or their institution(s), have had any nancial relationship, in the thirty-six months prior to submission of this work,
with any entity in the biomedical arena that could be perceived to inuence or have the potential to inuence what is written in this work. Also, no author has
had any other relationships, or has engaged in any other activities, that could be perceived to inuence or have the potential to inuence what is written in this
work. The complete Disclosures of Potential Conicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2016;98:85-92

http://dx.doi.org/10.2106/JBJS.O.00496

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efcient way to restore normal tendon length and tension and to

thus obtain optimal function4,14-17.
In the 1990s, it was common to augment tendon suture with
either one (Silfverskiold) or two (Lindholm) fascial aps, or with
plantaris tendon (Lynn technique). The aim of these methods was
to promote healing of the degenerated tendon, reduce rerupture
risk, and prevent tendon elongation during rehabilitation.
However, few studies have investigated whether such fascial
augmentation provides clinical benets. Our and other previous short-term studies showed no advantage of augmentation
compared with simple stable suturing in terms of clinical scores,
reruptures, or calf muscle strength2,4,5,18. We are not aware of any
published long-term studies addressing the relevance of fascial
augmentation.
Regardless of the treatment method, tendon healing has
been thought to require long-duration calf muscle immobiliza-

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tion, which leads to muscle atrophy. The immobilizationinduced strength decit decreases for up to a year, but it remains
uncertain whether there is continued improvement in other
aspects of function and symptoms. Olsson et al. found only
minor improvements in plantar exion strength of the ankle
between one and two-year follow-up examinations1. There are
few reports of long-term results of Achilles tendon rupture, and it
is unclear how to optimize treatment to avoid possible long-term
decits.
The aim of the present prospective, randomized, clinical
study was to compare the long-term results of augmented and
nonaugmented surgical repairs of total Achilles tendon ruptures in patients treated with identical postoperative rehabilitation protocols. Our secondary goal was to assess whether the
strength decit of the injured leg reported in our previous
study4 had resolved at the time of long-term follow-up.

Fig. 1

CONSORT (Consolidated Standards of Reporting Trials) ow diagram.

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TABLE I Demographic Data for Nonaugmented and Augmented-Repair Groups

Men/women (no.)
Mean age (SD) (yr)

Nonaugmented Repair (N = 28)

Augmented Repair (N = 27)

P Value

24/4

24/3

0.73

39 (9)

38 (7)

0.84

Activity level (no.)

0.9

Competitive athlete

Recreational athlete
Nonathlete

24
3

24
2

Mean BMI (SD) (kg/m2)

25 (2.6)

Materials and Methods

Study Design

his study was a long-term follow-up of a previously published, prospective, randomized, controlled trial comparing augmented with nonaugmented
4
surgical repair of Achilles tendon ruptures . The local research ethics committee
approved the original trial protocol and our reexamination of the patients. The study
was registered at ClinicalTrials.gov (NCT02018224). All patients received oral and
written information about the trial and provided informed consent to participate.
The inclusion criterion was a complete acute Achilles tendon tear in a patient
eighteen to sixty-ve years of age. The exclusion criteria were a delay of more than
one week between the rupture and treatment, local corticosteroid injection(s)
around the Achilles tendon within six months before the rupture, previous Achilles
tendon rupture on the contralateral side, open Achilles tendon rupture, skin
problems over the Achilles tendon area, living outside Finland, and diabetes mellitus.
Between October 1998 and January 2001, eighty-three patients were
screened for trial eligibility at a university teaching hospital (Fig. 1). Twenty-one
patients were excluded, and two eligible patients declined to participate. The primary study group comprised sixty patients, including fty-three men and seven
women, with a mean age of thirty-eight years (range, twenty-two to fty-six years).
4
Table I in our original study presents the participants mean age at the time of
injury, body mass index (BMI), activity level (competitive athlete, recreational
athlete, or nonathletic), smoking habits, and previous Achilles tendon symptoms.
The sixty patients were randomized preoperatively to receive end-to-end
repair with use of the Krackow locking loop surgical technique alone (nonaugmented repair group; thirty-two patients) or the same repair augmented with a
down-turned gastrocnemius fascia ap according to the method described by
Silfverskiold (augmented repair group; twenty-eight patients). The surgeon who
operated on all of the patients performed the randomization by drawing randomly
mixed, numbered, and sealed opaque envelopes before the operation was started.
Both groups received postoperative treatment with an early mobilization brace. The short-term (twelve-month) results of this randomized con4
trolled study have been previously published .

Operative Techniques
All operations were performed by the same surgeon. In the nonaugmented group
(thirty-two patients), the tendon was repaired using the Krackow technique with two
0-gauge polydioxanone absorbable sutures (PDS; Ethicon) and smaller 2-0 apposition
19
sutures with polyglactin (Vicryl; Ethicon) . The augmented procedure (twenty-eight
patients) started with end-to-end repair identical to the nonaugmented procedure.
Then the repair was augmented with a 10-mm-wide central gastrocnemius aponeurosis ap turned down over the suture line and stitched to the Achilles tendon with
20
2-0 Vicryl . The ankle was placed in a neutral position, and the skin was closed with
4-0 nylon sutures (Ethilon; Ethicon). Postoperatively, a temporary below-the-knee
rigid plaster splint was applied with the ankle in a neutral position in all cases.

Postoperative Management
Postoperative treatment was identical in both groups. On the rst postoperative
day, all patients received an individual below-the-knee dorsal brace made of Soft

27 (2.6)

0.01

Cast material (3M), which they wore for three weeks; the brace allowed active free
4
plantar exion of the ankle and restricted dorsiexion to neutral . The patients
were allowed 20 kg of weight-bearing for three weeks, half weight-bearing for
three to six weeks, and full weight-bearing thereafter. They were instructed to
4
perform exercises according to a standard rehabilitation program .

Outcome Measures
We were able to contact fty-seven of the sixty patients from the original study after
thirteen years or more of follow-up. Two others were lost to follow-up (one was
living abroad and the other declined to participate), leaving fty-ve patients
(twenty-eight treated with nonaugmented repair and twenty-seven treated with
augmented repair) (Fig. 1). These patients were reexamined between December
2013 and March 2014, after an average of fourteen years of follow-up (standard
deviation [SD], 0.5 year). Patients visited the outpatient clinic at three months,
twelve months, and an average of fourteen years after surgery. The clinical observers were blinded to the treatment group. The primary outcome measure was
8
the Leppilahti score at the fourteen-year follow-up examination . Secondary outcomes included calf muscle isokinetic strength and health-related quality of life
21
measured with the RAND 36-item health survey . Complications and the need for
a reoperation were also recorded.

Leppilahti Score
The Leppilahti score, which includes subjective factors (pain, stiffness, muscle
weakness, footwear restriction, and subjective outcome) and objective factors
(active range of ankle motion and isokinetic calf muscle strength), was assessed
at three months, twelve months, and an average of fourteen years. The score for
isokinetic muscle strength is calculated from plantar and dorsiexion peak
8
torques at three different ankle test speeds as described by Leppilahti et al. . The
maximum Leppilahti score is 100 points, with 90 points considered excellent;
8
75 to 89 points, good; 60 to 74 points, fair; and <60 points, poor . Patients
completed the subjective part of the Leppilahti score independently.

Strength Measurements
The isokinetic strength of both ankles was assessed three months, twelve months,
and an average of fourteen years after surgery. At the three and twelve-month
follow-up visits, a physiotherapist performed strength measurements using a Lido
Multi-Joint II computer-based isokinetic dynamometer (Loredan Biomedical). At
the fourteen-year follow-up visit, the same physiotherapist and an exercise physiologist performed strength measurements using a CON-TREX biomechanical test
and training system computer-based isokinetic dynamometer (CMV). Before
testing, patients were informed of the measurement procedure. They performed
ergometer cycling for a ten-minute warm-up period and a few submaximal and
maximal repetitions of ankle exion and extension movements at the isokinetic test
velocity. During testing, the patient was in the supine position with the knee
supported in extension. The extent of ankle motion was from 10
of dorsiexion to
30
of plantar exion. The isokinetic plantar exion strengths of both ankles were
measured at speeds of 60
/s, 120
/s, and 180
/s. Five maximal voluntary muscular
torque contractions were required.

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TABLE II RAND 36-Item Health Survey Scores at Fourteen-Year Follow-up Examination*

Mean (SD)

Mean (SD)

Nonaugmented
Repair

Augmented
Repair

P Value

Entire Study Group

General health

73 (20)

77 (13)

>0.9

75 (17)

58 (7)

Physical functioning

89 (17)

92 (8)

89 (16)

81 (7)

0.001

Mental health

84 (13)

89 (7)

>0.9

86 (11)

74 (3)

<0.0001

Social functioning

93 (13)

98 (5)

>0.9

95 (10)

80 (5)

<0.0001

Vitality

72 (19)

81 (11)

0.6

76 (17)

64 (5)

<0.0001

Domain

0.21

Finnish Reference
21
Population

P Value
<0.0001

Bodily pain

76 (26)

72 (19)

0.08

73 (24)

71 (6)

0.62

Role functioning/physical

91 (24)

88 (29)

0.08

88 (28)

69 (11)

<0.0001

Role functioning/emotional

95 (20)

99 (7)

0.7

96 (15)

74 (6)

<0.0001

*See the Appendix for the values adjusted for BMI. For the difference between the nonaugmented and augmented groups as determined with the
Student t test. For the difference between the entire study group and the Finnish reference population as determined with the Student t test.

From the best repetition, peak plantar exion torque at the angular
velocity of 60
/s was recorded for each leg, and work-displacement curves
(from 210
to 30
of plantar exion) were calculated for both calves to assess
work-displacement decits for each 10
interval over the ankle joints range of
motion. The relative decit in peak torque and work-displacement relationships was calculated as: ([unaffected 2 affected side]/unaffected side) 100%.
The injured and uninjured sides were compared using absolute values of peak
torque and the work-displacement relationship.

Tendon Elongation
For the elongation measurements, radiographic markers were placed on both
4
sides of the rupture as previously described , and standardized radiographs
were made at one day, twelve months, and an average of fourteen years postoperatively. For each group, the Achilles tendon elongation measurements were
analyzed and correlated with clinical results.

Results
aseline patient parameters are shown in Table I.

Leppilahti Score
At the fourteen-year follow-up examination, the mean Leppilahti score was 87.1 points for the patients who had undergone
nonaugmented repair and 91.5 points for those treated with
augmented repair; the mean difference was 4.3 points (95%
condence interval [CI], 20.1 to 8.8 points), and the adjusted
mean difference was 3.9 points (95% CI, 20.7 to 8.5 points). In
the nonaugmented-repair group, the score was excellent for
thirteen patients (46%), good for thirteen (46%), and fair for
two (7%). In the augmented-repair group, the score was

RAND 36-Item Health Survey

At an average of fourteen years postoperatively, the RAND 36-item health
survey was independently completed by the patients. The RAND-36 scores were
compared between the study groups and with age-matched (in ve-year in21
tervals) and sex-matched reference values from the Finnish population .

Statistical Methods
Data were analyzed using an intention-to-treat principle. Simple between-group
comparisons were analyzed using the Student t test for continuous variables and
chi-square or Fisher exact test for categorical variables. Repeated-measures data
were analyzed using a linear mixed model with subjects set as random effects.
Between-measurement correlations were accounted for by testing different covariance patterns, the best of which was chosen using the Akaike information
criterion. Linear mixed-model analyses produced the p values for the overall
change over time (ptime), the average between-groups difference (pgroup), and the
interaction between time and group (ptime group). The original study showed
4
signicant baseline imbalance in BMI between the groups . This difference was
handled with adjusted analyses in a linear mixed model, and by using linear
regression for the Leppilahti score, strength measurements, tendon elongation,
and RAND-36 scores when comparing study groups. The results of both primary
and adjusted analyses are presented. Analyses were performed using IBM SPSS
Statistics for Windows (version 21.0) and SAS software (version 9.3; SAS Institute). Two-tailed p values are presented. A p value of <0.05 was considered
signicant. According to original power calculations, the present study had 90%
4
power to show a difference of 5.0 units in the Leppilahti score .

Fig. 2

Box plot comparing the Leppilahti scores between the study groups during the
follow-up period. The thick horizontal lines represent the medians, the boxes
represent the 25th and 75th percentiles, and the whiskers indicate the minimum
and maximum values. The p values were derived with BMI-adjusted analysis.

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Fig. 3

Intergroup comparison of the median work-displacement decits in plantar

exion measured at 10
intervals over the ankle range of motion at the
fourteen-year follow-up examination. The error bars represent the
25th and 75th percentiles. According to the BMI-adjusted analysis,
pdsplmnt = 0.10, pgroup = 0.30, and pdsplmnt group = 0.002.

excellent for twenty-one patients (78%) and good for six

(22%). The groups did not differ in terms of pain, stiffness,
subjective calf muscle weakness, footwear restrictions, ankle
joint range of motion, or the subjective result. In both
groups, the median Leppilahti score decreased slightly from
the twelve-month to the fourteen-year follow-up time point: by
10 points in the nonaugmented group and 5.0 points in the
augmented group (Fig. 2).

Fig. 4

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Isokinetic Calf Muscle Strength

At the fourteen-year follow-up examination, the mean peak
torque for the operatively treated leg did not differ between
groups (112.6 Nm in the nonaugmented group and 107.3 Nm
in the augmented group; mean difference, 25.3 Nm [95% CI,
222.2 to 11.6 Nm]; adjusted mean difference, 8.4 Nm [95% CI,
29.6 to 26.5 Nm]). The shapes of the work-displacement
decit curves in the two groups were similar (Figs. 3 and 4).
The median plantar exion work-displacement decit measured at the 10
intervals ranged from 6.7% to 20.3% in the
nonaugmented group and from 12.8% to 18.0% in the augmented group (p = 0.9).
At the fourteen-year follow-up examination, the mean
peak torque of the injured leg (110.0 Nm) remained lower
compared with that of the uninjured leg (119.3 Nm), with a
mean difference of 9.3 Nm (95% CI, 4.1 to 14.4 Nm). The
work-displacement curve showed similar differences, with the
median decit at the 10
intervals ranging from 12.2% to
18.0% on the injured side (p < 0.001) (Fig. 5).
In both groups, the median peak torque decit did not
substantially change between twelve months and fourteen
years, with a change from 9.2% to 11.0% in the nonaugmented
group (p = 0.8) and from 6.6% to 13.4% in the augmented
group (p = 0.66). Work-displacement decits for the injured
leg also did not substantially change, at any work-displacement
interval, from twelve months to fourteen years (p > 0.2 for all)
(Fig. 5).
Tendon Elongation
At the fourteen-year follow-up examination, the mean elongation
was 12.7 mm after the nonaugmented repairs and 14.5 mm after
the augmented repairs, with a mean difference of 21.8 mm

Fig. 5

Fig. 4 Intergroup comparison of the absolute median work-displacement values in plantar exion for the operatively treated legs measured at 10
intervals
over the ankle range of motion at the fourteen-year follow-up examination. The error bars represent the 25th and 75th percentiles. According to the
BMI-adjusted analysis, pdsplmnt < 0.001, pgroup = 0.20, and pdsplmnt group = 0.33. Fig. 5 Comparison of the three-month, twelve-month, and fourteen-year
median work-displacement decits in plantar exion of the operatively treated leg, as compared with the control (healthy) leg, measured at 10
intervals
over the ankle range of motion. The error bars represent the 25th and 75th percentiles.

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(95% CI, 28.7 to 5.0 mm) and an adjusted mean difference of

1.8 mm (95% CI, 24.9 to 8.6 mm). From twelve months to
fourteen years, the mean elongation was 3.0 mm (SD, 2.8 mm)
in the nonaugmented group and 2.2 mm (SD, 2.5 mm) in the
augmented group, with a mean difference of 0.8 mm (95% CI,
20.8 to 2.5 mm). Achilles tendon elongation did not correlate
with any isokinetic strength parameter or clinical result at the
fourteen-year follow-up examination.
RAND 36-Item Health Survey
The results on the RAND 36-item health survey indicated no
between-group differences in any health domain. Compared with
age and sex-matched reference values from the Finnish population21, the study patients with Achilles tendon rupture achieved
better results in all but the bodily pain domain (Table II, with the
values adjusted for BMI shown in the Appendix).
Complications
In each group, three reruptures occurred at a mean of two months
(range, two to 112 days) postoperatively. Four supercial infections
occurred in the nonaugmented group and two deep infections, in
the augmented group4. No additional complications occurred after
twelve months postoperatively. Two patients in the nonaugmented
group and one in the augmented group had a contralateral Achilles
tendon rupture at sixteen months, seven years, and four years after
the index injury, respectively. All contralateral ruptures were
treated operatively with end-to-end repair followed by six weeks
of postoperative cast immobilization.
Discussion
he present fourteen-year follow-up study showed that augmented and nonaugmented surgical repair of Achilles tendon rupture produced similar clinical results, isokinetic strength,
tendon elongation, complications, and rerupture rates. Clinical
scores and isokinetic strength did not substantially change between twelve months and fourteen years postoperatively. The
median plantar exion strength decit for the entire range of
motion ranged from 12.2% to 18.0% compared with that on the
uninjured side, evidence of the permanence of strength decits
measured at one year. Achilles tendon rupture did not worsen
the patients long-term health-related quality of life compared
with that for a reference population.
Several augmentation techniques for Achilles tendon repair
have been reported11,20,22-30. In cadaver studies, both ap and
cross-stitch-suture augmentation increased gap resistance by as
much 29% compared with that observed with simple sutures for
Achilles tendon repair11,28. Additionally, the increased collagen
obtained by augmentation can strengthen the Achilles tendon,
lower rerupture rates, and enable earlier weight-bearing5,31-33.
However, these theoretical advantages of augmentation were not
conrmed by our present results or in previous short-to-mid-term
clinical studies. Augmentation may also have potential disadvantages, especially delayed wound-healing due to increased
tendon diameter24,33,34.
We are aware of only two randomized clinical studies
comparing augmentation and nonaugmentation operative tech-

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niques4,5. Pajala et al.4 and Tezeren and Kuru5 reported no

differences between augmentation and nonaugmentation in
terms of Achilles tendon performance score or isokinetic
strengths after twelve to twenty-four months of follow-up.
However, Pajala et al. found more marked tendon elongation
in their nonaugmented group, and tendon elongation was
signicantly correlated with strength decits at twelve months
postoperatively. Moreover, one prospective and two retrospective studies demonstrated no differences between augmentation and nonaugmentation at the time of short-term
follow-up31,35,36.
Our present results showed persistent strength decits
even at the time of long-term follow-up and despite good clinical
outcomes. Similarly, Olsson et al. found good clinical outcomes
despite functional decits on the injured side two years after
Achilles tendon rupture, regardless of whether the patients had
been treated surgically or nonsurgically1. Increasing age, higher
BMI, and major complications (deep infection and rerupture)
are strong predictors of plantar exion strength decits and
symptoms after Achilles tendon rupture. A ten-year age increase
reduces the expected heel-rise height by ;8%, and a 5-unithigher BMI predicts an approximately 10-point reduction in the
Achilles tendon total rupture score8,37,38. Bostick et al. found
delayed recovery of calf endurance at one year among males,
patients with Achilles tendon pain at rest at three months
postinjury, and patients with lower physical functioning and
calf endurance at six months39. The etiology of strength decits
is multifactorial, with potential inuences by both anatomical
and neuromuscular factors40. Our results suggest that tendon
lengthening likely plays a minor role in long-term strength
decits.
Many exercise-science studies have shown that regular
physical activity leads to a better health-related quality of life41-45.
RAND-36 scores did not differ between our study groups, but the
patients scores were markedly better than those for an age and
sex-matched reference population. Our patients were very physically active and probably not representative of the general Finnish
population. Additionally, the RAND-36 likely cannot capture all
aspects of health-related quality of life of physically active persons,
and more sensitive outcome instruments should be used in this
population.
Strengths of the present study include its prospective
randomized design and homogeneous group of patients. The
clinical observers were blinded to the treatment groups. Few
patients were lost to follow-up, with 92% of patients attending
the latest check-up. The Leppilahti scoring system is widely
used in studies of Achilles tendon ruptures and its results are
congruent with the American Orthopaedic Foot & Ankle Society score2,4,8,10,17,46-51.
Our study was powered to show a 5-point difference in the
primary outcome score. The upper limit of the CI was 8.5,
leaving a small possibility of type-II error. Another weakness of
our study is the long period between follow-up visits. Patients
may not have accurately recalled later ankle injuries. Also, the
results may not be generalizable to other treatment methods.
The measurement of Achilles tendon elongation using radiographic

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markers was standardized, but it is uncertain how well markers

remain in their original positions over the long term. The isokinetic dynamometer changed during the follow-up period, but
this probably had minimal effect as we used the healthy side as a
reference.
Although extreme tendon lengthening has negative consequences, the impact of minor or moderate tendon lengthening
on functional outcome remains unclear. Additionally, further
research is needed to determine whether more rapid progression
of weight-bearing and more intensive rehabilitation under a
physiotherapists instruction during the rst three months would
prevent a strength decit and whether more intensive rehabilitation in the healing period could lead to increased tendon
elongation.
In conclusion, augmentation was not found to provide
any benet compared with simple suture repair of acute
Achilles tendon ruptures. Our patients recovered calf muscle
isokinetic strength during the rst year postinjury with only
minimal changes thereafter. At the fourteen-year follow-up
examination, a 12% to 18% plantar exion strength decit
persisted, but the clinical relevance of this decrease in strength
remains unknown.

A U G M E N T E D C O M PA R E D W I T H N O N AU G M E N T E D S U R G I C A L
R E PA I R A F T E R T O TA L A C H I L L E S R U P T U R E

Appendix
A table showing the values in Table II adjusted for BMI is
available with the online version of this article as a data
supplement at jbjs.org. n

Juuso Heikkinen, MD1

Iikka Lantto, MD1
Tapio Flinkkila, MD, PhD1
Pasi Ohtonen, MSc1
Ari Pajala, MD, PhD1
Pertti Siira, PhT1
Juhana Leppilahti, MD, PhD1
1Division of Orthopaedic and Trauma Surgery,
Department of Surgery (J.H., I.L.,
T.F., P.O., A.P., and J.L.), and
Department of Physical Medicine and Rehabilitation (P.S.),
Medical Research Center Oulu,
Oulu University Hospital,
University of Oulu, Finland

E-mail address for J. Leppilahti: juhana.leppilahti@oulu.

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