***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Despite the controversy regarding the best treatment for an acute Achilles tendon rupture , percutaneous and minimally invasive techniques seem to offer good results in terms of low risks of rerupture and complications with satisfactory clinical and functional outcomes . A comparison between a percutaneous surgical technique and a minimally invasive one has not been reported in the literature . We consecutively evaluated 12 patients who had a modified Ma and Griffith percutaneous Achilles tendon repair and 12 patients who had a minimally invasive technique .  The same semifunctional rehabilitation protocol was used after surgery in both groups . At a minimum followup of 24 months ( mean , 33 months ; range , 24 - 42 months ) , we observed no reruptures or major complications in either group . Both groups had similarly high values for the American Orthopaedic Foot and Ankle Society score . The two techniques allowed equivalent time for return to work and sports . In the group of patients treated with the modified Ma and Griffith suture only , the mean loss of calf circumference in the injured leg was greater , compared with the contralateral leg . The two groups were isokinetically similar . In this study , the percutaneous and minimally invasive techniques of repair of the Achilles tendon yielded essentially identical clinical and functional outcomes .Level of Evidence : Level III , therapeutic study . See the Guidelines for Authors for a complete description of levels of evidence In a prospect i ve , r and omised , multicentre study , 112 patients with Achilles tendon rupture ( ATR ) were allocated to surgical treatment  ( n=59 ) , followed by early functional rehabilitation using a brace , and non-surgical treatment ( n=53 ) , i.e. eight weeks of plaster treatment . In this study , the results of the isokinetic muscle strength evaluation are presented for contractions in both the concentric and the eccentric mode , plantar flexion and dorsiflexion , two angular velocities and three different positions of the subject . The heel-raise test for endurance , maximum calf circumference and tendon width were also evaluated . The re-rupture rate was 20.8 % in the non-surgically-treated group and 1.7 % in the surgically-treated group . No significant differences were found between the treatment groups in terms of the isokinetic strength measurements and the endurance test among the patients who did not sustain a re-rupture . If a re-rupture is avoided , both surgical and non-surgical treatment for ATR produce good functional outcome ; however , the muscle function was not restored after two years in either group Background Surgical repair of acute Achilles tendon ruptures is considered superior to nonoperative treatment , but complications other than rerupture range up to 34 % . Nonoperative treatment by functional bracing seems a promising alternative . Hypothesis Nonoperative treatment of acute Achilles tendon rupture with functional bracing reduces the number of complications compared with surgical treatment with a minimally invasive technique . Study Design R and omized controlled clinical trial ; Level of evidence , 2 . Method Using concealed r and om allocation , 83 patients with acute Achilles tendon rupture were assigned to nonoperative treatment by functional bracing or minimally invasive surgical treatment followed by tape b and age . Patients were allowed full weightbearing , and follow-up was 1 year . Results Complications risk other than rerupture by intention-to-treat basis was 9 in 42 patients ( 21 % ) for surgical treatment and 15 in 41 patients ( 36 % ) for nonoperative treatment ( risk ratio , 0.59 ; 95 % confidence interval , 0.29 - 1.19 ) . Reruptures risk was 5 in 41 patients after nonoperative treatment and 3 in 42 patients for surgical treatment ( risk ratio , 0.59 ; 95 % confidence interval , 0.15 - 2.29 ) . The mean time to work was 59 days ( SD , 82 ) after surgical treatment and 108 days ( SD , 115 ) after nonoperative treatment ( difference , 49 days ; 95 % confidence interval , 4 - 94 ; P < .05 ) . The difference between treatments for return to sports ( risk ratio , 0.55 ; 95 % confidence interval , 0.23 - 1.29 ) , pain , and treatment satisfaction did not reach statistical significance . Conclusion There appears to be a clinical ly important difference in the risk of complications between minimally invasive surgical treatment and nonoperative treatment for acute Achilles tendon ruptures , but this was not statistically significant Background We present the design of an open r and omized multi-centre study on surgical versus conservative treatment of acute Achilles tendon ruptures . The study is design ed to evaluate the effectiveness of conservative treatment in reducing complications when treating acute Achilles tendon rupture . Methods / Design At least 72 patients with acute Achilles tendon rupture will be r and omized to minimally invasive surgical repair followed by functional rehabilitation using tape b and age or conservative treatment followed by functional rehabilitation with use of a functional bracing system . Both treatment arms use a 7 weeks post-rupture rehabilitation protocol . Four hospitals in the Netherl and s will participate . Primary end-point will be reduction in complications other than re-rupture . Secondary end-point will be re-rupturing , time off work , sporting activity post rupture , functional outcome by Leppilahti score and patient satisfaction . Patient follow-up will be 12 month . Discussion By making this design study we wish to contribute to more profound research on AT rupture treatment and prevent publication bias for this open-labelled r and omized trial . Trial registration IS RCT Adequate reporting of r and omized , controlled trials ( RCTs ) is necessary to allow accurate critical appraisal of the validity and applicability of the results . The CONSORT ( Consoli date d St and ards of Reporting Trials ) Statement , a 22-item checklist and flow diagram , is intended to address this problem by improving the reporting of RCTs . However , some specific issues that apply to trials of nonpharmacologic treatments ( for example , surgery , technical interventions , devices , rehabilitation , psychotherapy , and behavioral intervention ) are not specifically addressed in the CONSORT Statement . Furthermore , considerable evidence suggests that the reporting of nonpharmacologic trials still needs improvement . Therefore , the CONSORT group developed an extension of the CONSORT Statement for trials assessing nonpharmacologic treatments . A consensus meeting of 33 experts was organized in Paris , France , in February 2006 , to develop an extension of the CONSORT Statement for trials of nonpharmacologic treatments . The participants extended 11 items from the CONSORT Statement , added 1 item , and developed a modified flow diagram . To allow adequate underst and ing and implementation of the CONSORT extension , the CONSORT group developed this elaboration and explanation document from a review of the literature to provide examples of adequate reporting . This extension , in conjunction with the main CONSORT Statement and other CONSORT extensions , should help to improve the reporting of RCTs performed in this field In a prospect i ve , r and omised , multicentre study , 112 patients ( 99 men and 13 women , aged between 21 and 63 years ) with acute , complete rupture of tendo Achillis were allocated either to surgical treatment followed by early functional rehabilitation , using a brace , or to non-surgical treatment , with plaster splintage for eight weeks . The period of follow-up was for two years . Evaluation was undertaken by independent observers and comprised interviews , clinical measurements , isokinetic muscle performance tests , heel-raise tests and an overall outcome score . The rate of rerupture was 20.8 % after non-surgical and 1.7 % after surgical treatment ( p < 0.001 ) . Surgical and non-surgical treatment produced equally good functional results if complications were avoided . However , the rate of rerupture after non-surgical treatment was unacceptably high Ultrasonography and MRI are highly reliable and reproducible methods of determining the separation of a ruptured Achilles tendon and the degree of tendon repair in the course of healing . While MRI is expensive , it can be restricted to research and special indications . In a r and omized trial a operative treatment and a conservative/functional treatment with a newly developed boot were compared in 50 patients ( 22 of whom underwent operative treatment and 28 , conservative treatment ) . In this trial there were no significant differences either in the functional results or in the course of healing . Functional treatment in both groups allowed shorter periods of rehabilitation , and acceptance of the boot was particularly high in all patients Hexcelite(R ) and plaster of Paris below-knee walking casts were compared in a controlled clinical trial , involving 82 patients .  Fewer b and age complications , problems and better comfort was found with Hexcelite compared to plaster of Paris ( P<0.05 ) . If all costs relating to material s , transportation , complications and extra visits due to these , were taken into account , plaster of Paris was found more expensive than Hexcelite ® . Based on the above an increased use of Hexcelite ® is recommended This prospect i ve , r and omized trial compared healing characteristics of the Achilles tendon after surgical and nonsurgical treatment for complete rupture of the Achilles tendon . Fifty-eight patients were examined by ultrasonography after 6 , 12 , and 24 months and by magnetic resonance imaging after 12 months . A st and ardized protocol was used , and the outcome was correlated with clinical findings . Common findings 1 year after the injury were tendon thickening and moderate heterogeneity of the tendon . Peritendinous reactions , edema , and defects were present only in a minority of patients . There were no significant differences between the treatment groups in any of the evaluated parameters apart from the gliding function of the tendon , which was significantly less in the surgically treated group than in the nonsurgically treated group . No correlations were found between the radiological findings and the clinical parameters , such as muscle strength , endurance , and range of motion . We conclude that the roles of ultrasonography and magnetic resonance imaging during the healing process after Achilles tendon rupture are limited , due to a weak correlation with clinical findings Fifteen operatively and eight  non-operatively  treated subcutaneous achilles tendon ruptures were r and omly selected from 120 surgically and 35 non-surgically treated patients . Their calf muscle function was studied three to five years after treatment . Non-operatively treated patients were found to have a significantly impaired dynamic muscle function of the calf muscles when tested in a specially constructed heel-raise test device . Operatively treated patients did not show any significant impairment of their muscle function . Measurement of muscle area with CT-scanning showed a significant reduction of the calf muscle in the non-operatively treated patient while no such difference could be found in the operatively treated patients . Isokinetic muscle torque did not differ in the two groups of patients , thus Cybex- measurements do not seem to be a discriminating method in study ing muscle function after achilles ruptures . On the basis of our findings we recommend that all athletes with achilles tendon ruptures be treated surgically . In non-athletes and older patients non-operative treatment might be considered Background : Controversy persists regarding the ideal surgical technique for repair of a ruptured Achilles tendon . We propose a limited open procedure with use of an instrument that provides the advantage of an open repair but avoids the soft-tissue problems with which open repair has been associated . Methods : We first performed a cadaver study in order to develop an instrument and a technique for a limited open repair and then , using this procedure in conjunction with an early functional rehabilitation protocol , we began a prospect i ve multicenter study . We are reporting on the first eighty‐seven patients consecutively treated with the new instrument and followed for an average of twenty‐six months ( range , eighteen to forty‐two months ) . All patients were assessed clinical ly and with an enhanced American Orthopaedic Foot and Ankle Society ( AOFAS ) rating score . In addition , all fifty patients who had been followed for at least twenty-four months were further evaluated with isokinetic dynamometry . Results : Four patients were lost to follow‐up and one patient died , which left eighty‐two patients for evaluation . There were no problems with wound-healing , and there were no infections . No patient noted a sensory disturbance in the sural nerve distribution . All patients returned to their previous professional or sporting activities . The mean AOFAS score was 96 points ( range , 85 to 100 points ) . Isokinetic dynamometry showed no significant difference in strength between the injured and uninjured limbs of the fifty patients who were tested . Complications occurred in three patients . Two of them were noncompliant and removed the orthosis , so that the repair was disrupted by a new injury within the first three weeks postoperatively . One patient fell twelve weeks after the surgery and sustained a rerupture . All three new injuries were repaired with an open surgical procedure . Conclusions : This new procedure allows the surgeon to precisely visualize and control the tendon ends while avoiding excessive dissection and disturbance of local vascularity and minimizing nerve and wound-healing problems . Such a technique , along with an early functional rehabilitation program , allowed us to achieve a high rate of successful results with minimal morbidity The purpose of the study was to examine the recovery of some motor performance aspects of the lower extremity after Achilles tendon ( AT ) rupture repair by early functional postoperative treatment and early postoperative immobilization of the AT in tension in the early phase of recovery . The measured motor performance aspects were reaction time , speed of movement , foot tapping speed and coordination . The study population comprised 30 patients operated on for an acute , complete , closed AT rupture . The surgical technique was Kessler sutures plus one aponeurosis flap in all cases , and postoperatively the subjects were r and omly divided to have immobilization with a plaster cast or an active brace . Measurements were made 12 and 24 weeks after the operation . There were no statistically significant differences in the results between the operated and contralateral nonoperated lower extremities 12 and 24 weeks 
    Output:
    
Functional status including sporting activity was variably and often incompletely reported , including frequent use of non st and ardised outcome measures , and the results were inconclusive .
Open surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with non-surgical treatment , but produces significantly higher risks of other complications , including wound infection .
The latter may be reduced by performing surgery percutaneously