Dear Sir,

It has been a pleasure to read the article by Westin et al. [6] on Achilles tendon re-ruptures. Though uncommon, we are encountering re-ruptures of the tendo Achillis with increasing frequency, and it is a welcome adjunct to the literature that such clinical entity has raised the interest of this research team.

We would like to highlight a few issues:

  1. 1.

    It appears that the authors have not identified in their literature search our own publication on this topic [3]. Our investigation reports on 21 patients enrolled in a prospective fashion, and followed up for a mean of 39 (range 27–61) months (albeit, we acknowledge, we did not have a control group of patients with a primary rupture: for this, we congratulate Westin et al. for their foresight). Westin et al. make a point that their article reports on the largest cohort to date. We respectfully point out that our own study investigated a marginally larger number of patients

  2. 2.

    Westin et al. state that previous studies had used non-validated outcome measurements. In our own, the Achilles tendon rupture score (ATRS) was used as a patient-reported outcome measure, together with isometric strength of the gastro-soleus complex. In addition, the function of the reconstructed tendon was assessed with the single-leg heel lift test, and the maximum number of single-leg heel lifts on the affected leg was also recorded

  3. 3.

    Our philosophy of surgical management is slightly different from what described by Westin et al. Instead of a free gastrocnemius aponeurosis flap, we undertook a reconstruction using either an ipsilateral free semitendinous tendon transfer [4], or a peroneus brevis transfer [5]. Turn down flaps, V–Y lengthening, tendon transfers, tendon grafts, and synthetic materials have all been used for the purposes of reconstituting the continuity of the Achilles tendon. These procedures can be effective, but they do have some flaws and drawbacks, both related to their invasiveness and to the used graft for managing the gap. For example, a local free gastrocnemius aponeurosis flap requires a wide exposure of both the Achilles tendon and gastro-soleus complex, and may alter permanently the ratio between the tendon and muscle length

  4. 4.

    As in the study by Westin et al., we evidenced a permanent loss of strength and function, but in our patients the overall outcome after surgery was excellent or good in 17 (81%) of 21 patients, fair in 3 (14%), and poor in 1 (5%). We reported a statistically significant improvement of the maximum calf circumference and isometric plantar flexion strength in the operated leg after surgery. However, there was no evidence of a statistically significant association between ATRS and maximum calf circumference, or ATRS and isometric strength. Moreover, the isometric plantarflexion strength of the gastrocsoleus complex was significantly lower than that of the opposite side, although all patients were able to stand and walk on tiptoes. Finally, all of our patients returned to their pre-injury occupation

  5. 5.

    We have in the past evidenced that the profound alterations in biochemical [1] and histological [2] characteristics of the Achilles tendon and the tissues connected to the tendon itself. This has led us to the use of new ‘fresh’ autologous tendinous tissue implanted in a minimally invasive fashion: in this respect, it is possible that the respect of the local biology, and the use of less invasive techniques may well contribute to optimal outcome.

In any case, we congratulate Dr. Westin and colleagues for having allowed further insight in this potentially invalidating condition, and we look forward to further contributions in this field from this research group.