Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures

Comparison of channel-assisted minimally invasive repair and 3 common Achilles tendon restoration techniques

The present study aimed to investigate the biomechanical comparison of channel-assisted minimally invasive restoration and three common Achilles tendon restoration techniques in an in vitro model via a progressive rehabilitation program. The 42 porcine tendons were randomly assigned to the following six groups of tendons (n=7/group): Achillon, percutaneous Achilles repair system (PARS), Krackow, channel-assisted minimally invasive repair (CAMIR), CAMIR augmentation (CAMIR⁺), CAMIR-5 (repair with No. 5 Ethibond suture). There was no significant difference in elongation among groups following the first 10 loading cycles, which consisted of 20-100 N at 1 Hz. The elongation of the CAMIR group (7.51±1.77 mm) was significantly longer than the Achillon group (3.19±0.57 mm) and PARS group (3.73±0.66 mm; P<0.05) following 1,000 cycles. However, the CAMIR group exhibited no significant difference vs. the Krackow (7.32±1.09 mm) and CAMIR⁺ groups (7.11±1.50 mm) following 1,000 cycles. Following 2,000 cycles, there was no significant difference between the CAMIR-5 (7.99±1.68 mm) group, and the Achillon (3.19±0.57 mm) and PARS groups (3.73±0.66 mm). At the point of restoration construct failure, the total cycles of the CAMIR group (median, 1,000; range, 1,000-1,000) were significantly less than the Achillon group (median, 2,000; range, 2,000-2,013) and PARS group (median, 2,000; range, 2,000-2,010; P<0.05), but had no significant difference compared with the Krackow group (median, 1,000; range, 1,000-1,000) and CAMIR⁺ group 1,000 (median, 1,000; range, 1,000-1,004). There was also no significant difference between the CAMIR-5 group (median, 2,000; range, 2,000-2,000), and the Achillon group (median, 2,000; range, 2,000-2,013) and PARS group (median, 2,000; range, 2,000-2,010). Restricted by the strength of suture, the one-suture CAMIR restoration technique was weaker than the three-suture Achillon and PARS restoration techniques, but there was no significant difference with the open Krackow restoration technique, which provides a reliable mechanical strength for repairing. CAMIR has an advantage of reducing the risk of suture reactivity.

Older Age Predicts Worse Function 1 Year After an Acute Achilles Tendon Rupture: A Prognostic Multicenter Study on 391 Patients

Background

There is limited evidence regarding the patient-related factors that influence treatment outcomes after an acute Achilles tendon rupture.

Purpose/Hypothesis

The purpose of this study was to determine the predictors of functional and patient-reported outcomes 1 year after an acute Achilles tendon rupture using a multicenter cohort and to determine patient characteristics for reporting within the top and bottom 10% of the Achilles tendon Total Rupture Score (ATRS) and heel-rise height outcomes. The hypothesis was that older age, greater body mass index (BMI), and female sex would lead to inferior outcomes.

Study Design

Cohort study; Level of evidence, 2.

Methods

Patients were selected by combining 5 randomized controlled trials from 2 different centers in Sweden. Functional outcomes were assessed using validated heel-rise tests (height, number of repetitions, total work, and concentric power) for muscular endurance and strength, and the relationship between injured and uninjured legs was calculated as the limb symmetry index (LSI). Patient-reported outcomes were measured using the ATRS. All outcomes were collected at the 1-year follow-up. Independent predictors included were patient sex, smoking, BMI, age, and surgical versus nonsurgical treatment.

Results

Of the 391 included patients, 307 (79%) were treated surgically. The LSI of heel-rise height at the 1-year follow-up decreased by approximately 4% for every 10-year increment in age (beta, -3.94 [95% CI, -6.19 to -1.69]; P = .0006). In addition, every 10-year increment in age resulted in a 1.79-fold increase in the odds of being in the lowest 10% of the LSI of heel-rise height. Moreover, a nonsignificant superior LSI of heel-rise height was found in patients treated surgically compared with nonsurgical treatment (beta, -4.49 [95% CI, -9.14 to 0.16]; P = .058). No significant predictor was related to the ATRS. Smoking, patient sex, and BMI did not significantly affect the 1-year results for the LSI of the heel-rise tests.

Conclusion

Older age at the time of injury negatively affected heel-rise height 1 year after an Achilles tendon rupture. Irrespective of age, a nonsignificant relationship toward the superior recovery of heel-rise height was seen in patients treated surgically. None of the factors studied affected patient-reported outcomes.

Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis

OBJECTIVES

To compare re-rupture rate, complication rate, and functional outcome after operative versus nonoperative treatment of Achilles tendon ruptures; to compare re-rupture rate after early and late full weight bearing; to evaluate re-rupture rate after functional rehabilitation with early range of motion; and to compare effect estimates from randomised controlled trials and observational studies.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed/Medline, Embase, CENTRAL, and CINAHL databases were last searched on 25 April 2018 for studies comparing operative versus nonoperative treatment of Achilles tendon ruptures.

STUDY SELECTION CRITERIA

Randomised controlled trials and observational studies reporting on comparison of operative versus nonoperative treatment of acute Achilles tendon ruptures.

DATA EXTRACTION

Data extraction was performed independently in pairs, by four reviewers, with the use of a predefined data extraction file. Outcomes were pooled using random effects models and presented as risk difference, risk ratio, or mean difference, with 95% confidence interval.

RESULTS

29 studies were included-10 randomised controlled trials and 19 observational studies. The 10 trials included 944 (6%) patients, and the 19 observational studies included 14 918 (94%) patients. A significant reduction in re-ruptures was seen after operative treatment (2.3%) compared with nonoperative treatment (3.9%) (risk difference 1.6%; risk ratio 0.43, 95% confidence interval 0.31 to 0.60; P<0.001; I²=22%). Operative treatment resulted in a significantly higher complication rate than nonoperative treatment (4.9% v 1.6%; risk difference 3.3%; risk ratio 2.76, 1.84 to 4.13; P<0.001; I²=45%). The main difference in complication rate was attributable to the incidence of infection (2.8%) in the operative group. A similar reduction in re-rupture rate in favour of operative treatment was seen after both early and late full weight bearing. No significant difference in re-rupture rate was seen between operative and nonoperative treatment in studies that used accelerated functional rehabilitation with early range of motion (risk ratio 0.60, 0.26 to 1.37; P=0.23; I²=0%). No difference in effect estimates was seen between randomised controlled trials and observational studies.

CONCLUSIONS

This meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.

Management of acute Achilles tendon ruptures: A review

Objectives

The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits.

Methods

A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review.

Results

The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors.

Conclusion

The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development.

Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2.

Is open acute Achilles tendon rupture repair still justified? A single center experience and critical appraisal of the literature

INTRODUCTION

Acute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures.

METHODS

Between June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved.

RESULTS

We recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5-39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21-63) and 28 (IQR 15-28). Nevertheless, a difference of 10 points is considered clinically relevant.

CONCLUSION

The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed.

Outcomes of Limited Open Achilles Repair Using Modified Ring Forceps

Background

The optimal treatment of acute Achilles tendon ruptures remains controversial. When surgical repair is undertaken, the reported rate of infections and wound-healing complications ranges from 2% to 5%. Meta-analyses have demonstrated that minimally invasive approaches have equivalent rerupture rates, a significantly lower risk of superficial infections, and higher patient satisfaction rates compared with traditional open Achilles repair techniques.

Purpose

To review the clinical outcomes of acute, limited open Achilles tendon repair using modified ring forceps and to analyze functional results using foot and ankle-specific outcome measures.

Study Design

Case series; Level of evidence, 4.

Methods

The clinical records of 32 consecutive patients (mean age, 44 years) with 33 acute Achilles tendon ruptures were retrospectively reviewed. All patients underwent limited open repair with modified ring forceps through a 2- to 3-cm midline incision. Suture placement into the tendon stumps was guided using a pair of ring forceps bent 30°. Three No. 2 nonabsorbable sutures were placed in the proximal and distal segments, the tendon ends were reapproximated, and the sutures were tied to secure the tendon. Outcomes from a 10-cm visual analog scale (VAS), the Foot and Ankle Ability Measure (FAAM), and the Victorian Institute of Sport Assessment-Achilles (VISA-A) were assessed.

Results

At final follow-up (mean, 42.1 months [range, 6-90 months]), 31 of 32 patients (33 Achilles tendons) reported no pain in their Achilles, with a mean Achilles VAS score of 0.7 ± 4.2 of 100. The mean postoperative VISA-A score was 82.3 ± 19.5 of 100. The mean FAAM activities of daily living and sports subscores were 96.5% ± 5.2% and 85.1% ± 21.2%, respectively. Regarding current functional level, 19 of 33 tendons (57.6%) were rated as "normal," 10 (30.3%) as "nearly normal," and 4 (12.1%) as "abnormal"; none were rated as "severely abnormal." There was 1 case (3.0%) of a superficial infection; there were no cases of deep infections, sural neuritis, or reruptures. The cost of the modified ring forceps technique is 5.3 to 12.1 times less than commercially available devices.

Conclusion

Limited open Achilles repair with modified ring forceps provides an economical repair with excellent pain relief, favorable functional outcomes, and a very low complication rate at midterm follow-up.

Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis

Achilles tendon ruptures can be either surgically or conservatively treated with either early functional mobilization or cast immobilization. The purpose of the present study was to conduct a meta-analysis comparing the effect of early versus late weightbearing in conservatively treated adult patients, including only randomized controlled trials (RCTs). The primary endpoint was rerupture, and the secondary endpoints were strength, quality of life during treatment, range of motion, deep venous thrombosis, return to sports, and return to work. The search for studies was conducted using PubMed, EMBASE, and the Cochrane Central Register of Controlled trials. A search was performed, and 2 reviewers independently screened the studies by title, abstract, and, finally, by reading the full text. Four studies met the inclusion criteria. The reference lists of the included studies were scanned and 1 additional RCT study was included. The critical appraisal skills program checklist was applied for study appraisal. A statistician performed the data management and analysis. No statistically significant differences were found between the 2 treatment groups concerning rerupture (p = .796), return to sports (p = .455), or return to work (p = .888). One RCT found 1 case of deep venous thrombosis in the late weightbearing group. One RCT reported significant improvement in quality of life and one reported a significantly improved range of dorsiflexion in the early weightbearing group. No statistically significant difference was found between early and late weightbearing with conservative treatment regarding the rerupture rate. The results of the other outcomes were limited by the low number of studies included in the present meta-analysis. Larger randomized studies are needed to investigate these outcomes. From the results in the present study, we would recommend early weightbearing when an Achilles tendon rupture is treated conservatively.

Functional outcome and complication rate after percutaneous suture of fresh Achilles tendon ruptures with the Dresden instrument

Background

The aim of this study was to evaluate the outcome of patients with a rupture of the Achilles tendon (ATR) treated percutaneously with the Dresden instrument in the hands of surgeons others than its inventors.

Materials and methods

118 patients (FU rate: 77.1%) with an acute ATR treated with the Dresden instrument were retrospectively evaluated. The following data were evaluated: pain intensity, functional limitation, Hannover score, Achilles tendon total rupture score (ATRS), AOFAS ankle-hindfoot score, Tegner activity score, complications, maximum calf circumference (MCC) on both sides, and the Matles test for tendon lengthening. The effect of the time point of the surgery after trauma was examined.

Results

Hannover scores and ATRSs were good; AOFAS scores were excellent. Almost all patients returned to sporting activities postoperatively, and 66.1% were able to return to their previous level. The Tegner activity score revealed a slight posttraumatic decrease (p = 0.009) in the level of physical activity overall (pre-injury: 5.37 ± 0.15; postoperatively: 4.77 ± 0.15). The re-rupture rate was 2%. No sural nerve lesions and no infections were reported. Even after 3 years, there was still a difference in MCC that was correlated with inferior clinical score and AT lengthening. Patients treated within the first 2 days after ATR showed inferior clinical outcomes in terms of AOFAS score, ATRS, and functional limitations.

Conclusions

Percutaneous ATR suture with the Dresden instrument is a safe and reliable method. Low complication and re-rupture rates, good clinical results, and a high rate of return to play support this fact. The time point of the operation may influence the outcome.

Platelet-rich plasma in Achilles tendon healing 2 (PATH-2) trial: statistical analysis plan for a multicentre, double-blinded, parallel-group, placebo-controlled randomised clinical trial

Background

There has been a recent steep growth in platelet-rich plasma (PRP) use for musculoskeletal conditions, but findings from high quality clinical trial data are lacking in the literature. Here, we describe the statistical analysis plan (SAP) for the Platelet-rich plasma in Achilles Tendon Healing 2 (PATH-2) trial.

Methods

PATH-2 is a pragmatic, parallel-group, multi-centre, double-blinded, randomised, placebo-controlled, superiority trial. The study aims to evaluate the clinical efficacy of PRP in acute Achilles tendon rupture in terms of muscle-tendon function. Patients are identified in the orthopaedic/trauma outpatient clinic. The primary outcome is muscle-tendon work capacity from the Heel Rise Endurance Test result, expressed as the Limb Symmetry Index (work, in joules), at 24 weeks post randomisation. Multivariate linear regression adjusting for the stratification factors (centre and age) and additional prognostic factors will be used to investigate the adjusted effect of the intervention. The analysis will be by modified intention-to-treat. Sensitivity analysis will assess the internal validity of the trial results by performing a per-protocol analysis. Safety will be summarised by treatment arm for all patients who started treatment. Secondary patient-reported outcome measures will be analysed using linear mixed effects models to allow all data collected at all follow-up points to be considered. Missing data will be summarised and reported by treatment arm. Missing data imputation will be performed, if appropriate.

Discussion

The PATH-2 trial will be reported in accordance with the CONSORT statement. This SAP publication will avoid bias arising from prior knowledge of the study results. Any changes or deviations from the current SAP will be described and justified in the final report.

Trial registration

ISRCTN registry: ISRCTN54992179, assigned 12 January 2015. ClinicalTrials.gov: NCT02302664, received 18 November 2014. UK Clinical Research Network Study Portfolio Database: ID 17850.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2840-z) contains supplementary material, which is available to authorized users.

Ultrasonographic Evaluation of the Early Healing Process After Achilles Tendon Repair

Background:

Little is known about early healing of repaired Achilles tendons on imaging, particularly up to 6 months postoperatively, when patients generally return to participation in sports.

Purpose:

To examine changes in repaired Achilles tendon healing with ultrasonography for up to 12 months after surgery.

Study Design:

Case series; Level of evidence, 4.

Methods:

Ultrasonographic images of 26 ruptured Achilles tendons were analyzed at 1, 2, 3, 4, 6, and 12 months after primary repair. The cross-sectional areas (CSAs) and intratendinous morphology of the repaired tendons were evaluated using the authors’ own grading system (tendon repair scores), which assessed the anechoic tendon defect area, intratendinous hyperechoic area, continuity of intratendinous fibrillar appearance, and paratendinous edema.

Results:

The mean ratios (%) of the CSA for the affected versus unaffected side of repaired Achilles tendons gradually increased postoperatively, reached a maximum (632%) at 6 months, and then decreased at 12 months. The mean tendon repair scores increased over time and reached a plateau at 6 months.

Conclusion:

Ultrasonography is useful to observe the intratendinous morphology of repaired Achilles tendons and to provide useful information for patients who wish to return to sports. Clinical parameters such as strength, functional performance, and quality of healed repaired tendons should also be assessed before allowing patients to return to sports.

A new less invasive surgical technique in the management of acute Achilles tendon rupture through limited-open procedure combined with a single-anchor and "circuit" suture technique

Background

Traditional incision repair and minimally invasive repair for acute Achilles tendon repair have limitations. This study aimed to present our series of 23 patients with acute Achilles tendon rupture that was repaired using two small incisions to assist the anchor repair of the tear and a new “circuit” suture technique.

Methods

This was a retrospective study of 23 patients with acute Achilles tendon rupture treated with the new technique at Changhai Hospital between January 2015 and December 2016 and followed up for 14–33 months. Clinical outcome was assessed using the AOFAS, Leppilahti, and Arner-Lindholm scores. Complications, range of motion (ROM), and time to return to work and light sport activity were assessed.

Results

The AOFAS score was 85–96 at 3 months and 92–100 at 12 months. The 3-month ROM was 27°–37°, and the 12-month ROM was 36°–48°. The Leppilahti score was 85–95 at 3 months and 90–100 at 12 months. The recovery time of the patients was 10–18 weeks. The postoperative recovery time to exercise was 16–24 weeks. There was only one case of deep venous thrombosis. According to the Arner-Lindholm assessment criteria, patient outcomes were rated as excellent in 20 (87.0%) cases, good in three (13.0%) cases, and poor in 0 cases. The excellent-to-good rate was 100%.

Conclusion

The limited-open procedure combined with a single-anchor and “circuit” suture technique could be used to repair torn Achilles sites, with a low occurrence of complications. This new and minimally invasive technique could be an alternative in the management of acute Achilles tendon rupture.

The Ruptured Achilles Tendon Elongates for 6 Months After Surgical Repair Regardless of Early or Late Weightbearing in Combination With Ankle Mobilization: A Randomized Clinical Trial

BACKGROUND

Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim of this project was to examine whether tendon elongation, mechanical properties, and functional outcomes during rehabilitation of surgically repaired acute Achilles tendon ruptures were influenced by different rehabilitation regimens during the early postsurgical period.

HYPOTHESIS

Restricted early weightbearing that permits only limited motion about the ankle in the early phase of tendon healing limits tendon elongation and improves functional outcome.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

75 consecutive patients with an acute Achilles tendon rupture were included. They underwent surgical repair, and tantalum beads were placed in the distal and proximal parts of the tendon; thereafter, the patients were randomized into 3 groups. The first group was completely restricted from weightbearing until week 7. The second group was completely restricted from weightbearing until week 7 but performed ankle joint mobilization exercises. The first and second groups were allowed full weightbearing after week 8. The third group was allowed partial weightbearing from day 1 and full weightbearing from week 5. All patients received the same instructions in home exercise guidelines starting from week 9.

RESULTS

The rehabilitation regimen in the initial 8 weeks did not significantly influence any of the measured outcomes including tendon elongation. Achilles tendon elongation and tendon compliance continued for up to 6 months after surgery, and muscle strength, muscle endurance, and patient-reported functional scores did not reach normal values at 12 months.

CONCLUSION

Differences in rehabilitation loading pattern in the initial 8 weeks after the repair of an Achilles tendon rupture did not measurably alter the outcome. The time to recover full function after an Achilles tendon rupture is at least 12 months. Registration: NCT02422004 ( ClinicalTrials.gov identifier).

Treatment of acute Achilles tendon rupture with a standardised protocol

INTRODUCTION

A treatment protocol favouring non-operative treatment and based on early weight-bearing and early range-of-motion exercises was implemented in standard clinical care of a level I trauma clinic.

MATERIALS AND METHODS

All patients treated due to acute Achilles tendon rupture between 2008 and 2014 were included in the study (n = 411). The patient records were retrospectively evaluated.

RESULTS

The mean age of patients was 47 (range 17-88) years. In total, 213 (52%) acute Achilles tendon ruptures were treated operatively and 198 (48%) non-operatively. The annual proportion of operatively treated patients declined from 70 to 21% during the study period. The traumatic re-rupture rate was similar between the operative (4%) and the non-operative (6%) treatment groups (p = 0.385), even though the patients in the non-operative group were significantly older and had more co-morbidities than the operatively treated patients. Of the operatively treated patients, 10% (n = 21) had wound healing problems. In 6/198 patients, the non-operative treatment had to be converted to surgical treatment in the early phase. Unsatisfactory functional outcome after the treatment was reported in 7/213 patients in the operative and 10/198 in the non-operative group (p = 0.234).

CONCLUSIONS

Our study showed that it is possible to implement a standardised treatment protocol to guide the decision-making and treatment and of an acute Achilles tendon rupture as a part of the daily care in a large standard trauma hospital. The clinical outcome and the rate of complications were fully comparable to the good clinical results achieved in RCT-study settings despite the heterogeneity of the treated patients and non-specialisation of the medical staff, showing that the protocol could find the most reasonable treatment for each patient and reduced dramatically the rate of operative treatment.

LEVEL OF EVIDENCE

Level III, comparative series.

Predictors of functional outcome in non-operatively managed Achilles tendon ruptures

BACKGROUND

Acute Achilles tendon (AT) rupture management remains debatable but non-operative functional regimes are beginning to gain popularity. The aim of this study was to identify predictors of functional outcome in patients with AT ruptures treated non-operatively with an immediate weight bearing functional regime in an orthosis.

METHODS

Analysis of prospectively gathered data from a local database of all patients treated non-operatively at our institution with an AT rupture was performed. For inclusion in the study patients required a completed Achilles Tendon Rupture Score (ATRS) at a minimum of 6 months post injury. The ATRS score was correlated against age, gender, time following rupture, duration (8 or 11 weeks) of treatment in a functional orthoses and complications were recorded.

RESULTS

236 patients of average age 49.5 years were included. The mean ATRS on completion of rehabilitation was 74 points. The mean ATRS was significantly lower in the 37 females (65.8) as compared to the 199 males (75.6) (p=0.013). Age inversely affected ATRS with a Pearsons correlation of -0.2. There was no significant difference in the ATRS score when comparing the two different treatment regime durations. There were 12 episodes of VTE and 4 episodes of re-rupture. The ATRS does not change significantly after 6 months following rupture treatment completion.

CONCLUSION

Patients with AT ruptures treated non-operatively with a functional rehabilitation regime demonstrate comparable function to other non-surgical regimes with low re-rupture rates. Increasing age and female gender demonstrate inferior functional outcomes.

CLINICAL RELEVANCE

Females and increasing age predict poorer functional outcome in acute Achilles tendon ruptures managed in a dynamic full-weight bearing treatment regime.

Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Acute Achilles tendon ruptures can be treated with surgical and nonsurgical treatment. However, the optimal intervention for acute Achilles tendon rupture remains controversial. The aim of the present study was to compare the clinical outcomes of surgical treatment versus conservative management for acute Achilles tendon rupture. Eight randomized controlled studies involving 762 patients were included in the meta-analysis. In general, re-rupture occurred in 14 of 381 surgically treated patients (3.7%) and 37 of 377 nonsurgically treated patients (9.8%). Pooled results showed that the total re-rupture rate was significantly lower in surgical group than that in the nonsurgical group (risk ratio 0.38, 95% confidence interval 0.21 to 0.68; p = .001). No significant differences were found between the 2 treatment groups in the incidence of deep venous thrombosis, the number who returned to sport, ankle range of motion (dorsiflexion, plantarflexion), Achilles tendon total rupture score, or physical activity scale. Surgical treatment can effectively reduce the re-rupture rate and might be a better choice for the treatment of acute Achilles tendon rupture. Multicenter, double-blind randomized controlled trials with stratification and long-term follow-up are needed to obtain a higher level of evidence and to guide clinical practice, especially in the comparison and selection of different treatments.

Ultrasound measurements of Achilles tendon length using skin markings are more reliable than extended-field-of-view imaging

PURPOSE

Elongation of the Achilles tendon has been associated with poorer function in patients treated for ruptures. This has led to the development of various ultrasound-based measurements, and the purpose of the present study was to compare the reliability of three ultrasound-based measuring procedures.

METHODS

Twenty healthy individuals (40 tendons) were assessed by two testers at two occasions, 12 weeks apart. The tendon length was measured from the calcaneal insertion to the mid-sagittal muscle tendon junction (MTJ) using skin markings or extended-field-of-view (EFOV) imaging, or from the calcaneal insertion to the distal medial MTJ using skin markings. Test-retest and inter-tester reliability as well as side-to-side length differences were assessed for all three procedures.

RESULTS

Test-retest intraclass correlation coefficients (ICCs) for measurements from the mid-sagittal MTJ using EFOV imaging and skin markings, and from the distal medial MTJ using skin markings were 0.83, 0.90 and 0.96 for tester 1 and 0.87, 0.91 and 0.96 for tester 2, respectively. The corresponding inter-tester ICCs were 0.85, 0.91 and 0.96. Side-to-side lengths were significantly different for measurements from the mid-sagittal MTJ and the distal medial MTJ using skin markings, with mean differences of 0.3 and 0.4 cm, respectively.

CONCLUSIONS

Test-retest and inter-tester ICCs were excellent for all three measuring procedures, however, the use of skin markings provided consistently better agreement and reliability compared to EFOV images. The best agreement and highest ICCs were achieved for measurements from the distal medial MTJ, but side-to-side length differences warrant caution when contralateral measurements are used to evaluate tendon elongation.

LEVEL OF EVIDENCE

III.

Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus?

Conservative "functional" management of acute Achilles tendon ruptures has become increasingly popular. Critical to this is the use of the walking orthosis, which positions the ankle in equinus to allow for early weightbearing. Our aim was to test whether 2 common orthoses achieved a satisfactory equinus position. A total of 11 sequentially treated Achilles tendon ruptures were assigned to either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus-corrected brace (EEB). The lateral radiographs of the cast immobilized tendons showed a mean tibiotalar angle (TTA) of 56° (range 54° to 57°) and a mean tibio-first metatarsal angle (1MTA) of 74° (range 62° to 85°). The FAWW resulted in a mean TTA of 28° (range 15° to 35°) and 1MTA of 37° (range 30° to 45°). The EEB resulted in a TTA of 48° (range 43° to 45°) and 1MTA of 54° (range 47° to 57°). Ankle equinus was significantly greater with the EEB than with the FAWW (p < .05) and similar to that with an equinus cast. The use of wedges produced an equinus appearance through the midfoot but not at the ankle. We express caution in the use of the FAWW because it is unlikely to achieve sufficient ankle equinus to shorten the Achilles tendon.

Risk Factors for Failed Nonoperative Treatment and Rerupture in Acute Achilles Tendon Rupture

BACKGROUND

Nonoperative treatment is feasible in most patients with acute Achilles tendon rupture. Risk factors associated with failed nonoperative treatment are poorly understood. We investigated risk factors associated with rerupture after nonoperative treatment and otherwise failed nonoperative treatment of Achilles tendon rupture.

METHODS

All patients diagnosed with acute Achilles tendon rupture between January 2009 and June 2016 and who underwent 8 weeks of nonoperative treatment with functional rehabilitation were included in the study. Patients with rerupture or otherwise failed nonoperative treatment were identified retrospectively. Time to rerupture and association of age, sex, time from injury, diabetes, and visits to the physiotherapist for cases of reruptures and otherwise failed nonoperative treatment were investigated. A total of 210 patients were included in the study.

RESULTS

Fifteen patients sustained a rerupture. Rerupture incidence was 7.1%. Incidence of late reruptures, those occurring after return to daily activities at 12 weeks, was 1.9%. Six patients had otherwise failed nonoperative treatment. Median time to rerupture was 23 days (6 to 61) after the end of the treatment. The incidence of all-cause failure was 10.0%. Male gender was associated with reruptures ( P = .013) and failed nonoperative treatment for any reason ( P = .029).

CONCLUSION

It is important to highlight the increased risk of rerupture in male patients during the first month after the end of the nonoperative treatment. Age alone, even in male patients, was a poor indication for operative treatment since it did not predict early failure. Further studies will hopefully clarify the influence of activity level on the risk of rerupture.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The improved oval forceps suture-guiding method for minimally invasive Achilles tendon repair

OBJECTIVE

To discuss the effect and advantage of the improved oval forceps suture-guiding method combined with anchor nail in the treatment of acute Achilles tendon rupture.

METHODS

A retrospective research was performed on 35 cases of acute Achilles tendon rupture treated with the improved oval forceps suture-guiding method from January 2013 to October 2016. Instead of the Achillon device, we perform the Achillon technique with the use of simple oval forceps, combined with absorbable anchor nail, percutaneously to repair the acute Achilles tendon rupture.

RESULTS

All patients were followed up for at least 12 months (range, 12-19 months), and all the patients underwent successful repair of their acute Achilles tendon rupture using the improved oval forceps suture-guiding method without any major intra- or postoperative complications. All the patients returned to work with pre-injury levels of activity at a mean of 12.51 ± 0.76 weeks. Mean AOFAS ankle-hindfoot scores improved from 63.95 (range, 51-78) preoperatively to 98.59 (range, 91-100) at last follow-up. This was statistically significant difference (P < 0.001). Mean Achilles Tendon Total Rupture Score (ATRS) at final follow-up was 94.87 (range, 90-100).

CONCLUSION

The improved oval forceps suture-guiding method could make the advantage of minimally invasive repair with less complications, reduced surgical time and similar functional outcomes compared with the traditional open surgery. In addition, our new technique could save the cost of surgery with the compare of the Achillon device. At the same time for the cases which the remote broken tendon ends were within 2 cm from the calcaneal nodules, because of the less tendon tissue was left in the remote side, traditional percutaneous methods are incapable to ensure the reconstruction strength. By using the anchor nail, the improved technique has better repair capacity and expands the operation indication of oval forceps method.

A simple suture-guiding device for minimally invasive Achilles tendon repair

BACKGROUND

Our hypothesis is to utilize a simple suture-guiding device for minimally invasive repair of Achilles tendon without any extra cost with a minimal risk of rerupture. The purpose of this study is to investigate the results of our minimally invasive technique for Achilles tendon repair using a simple ovarian clamp for suture guiding.

MATERIALS AND METHODS

Twenty patients with acute Achilles tendon rupture were treated with minimally invasive repair by an expert orthopaedic surgeon. Instead of an Achillon device, an ovarian clamp was directed to the proximal and distal parts of the Achilles tendon. All data relating to daily activities, walking, climbing stairs, sports activity, American Orthopaedic Foot and Ankle Society (AOFAS) and Thermannscores were recorded. Sural nerve was evaluated with physical examination for paraesthesia, hyperaesthesia, lateralis cruris and foot pain in all patient controls.

RESULTS

The average AOFAS score was 97.06 (76-100). All patients had intact Achilles tendon at last control. No rerupture was observed. Average time taken to return to work was 30.8 days (28-60 days). After 6 months, all patients returned to their previous sports activities.

CONCLUSION

For Achilles tendon ruptures, minimally invasive repair techniques have shown successful results with low complication rates. Besides their success, some suture-guiding devices bring extra costs for patients or health insurance. Minimally invasive techniques may be performed with devices without any extra cost. Our new suture-guiding device provides knot placement under paratenon like Achillon device to improve outcomes, provides early return to work and minimizes the complications. Finally, our suture-guiding device has no extra cost.

Severe Functional Debilitations After Complications Associated With Acute Achilles Tendon Rupture With 9 Years of Follow-Up

The purpose of the present study was to investigate the long-term effect of deep infection, sural nerve injury, and repeat rupture in the treatment of acute Achilles tendon rupture. A total of 324 patients had made a claim to the Danish Patient Insurance Association from 1992 to 2010 for a complication after acute Achilles tendon rupture. Of the 324 patients, 119 (36.7%) (77 [64.7%] males and 42 [35.3%] females) returned the Achilles tendon total rupture score and the 36-item short-form survey questionnaires. Patients with deep infection (n = 10), sural nerve injury (n = 10), and repeat rupture (n = 16) participated in a follow-up investigation. The mean follow-up period was 8.9 (range 3 to 21) years. The mean Achilles tendon total rupture score was 49 ± 27. The summary scores of the physical component and mental components scales of the 36-item Short Form Survey were 43 ± 11 and 52 ± 11, respectively. No significant differences were found among the subpopulations with deep infection, injury to the sural nerve, or repeat rupture. The physical evaluation investigating tendon length and heel rise work revealed a statistically significant difference between the affected and unaffected limb after repeat rupture (p < .01) but not after injury to the sural nerve (p > .05) or deep infection (p > .05). In conclusion, patients with from a complication after acute Achilles tendon rupture had a remarkable reduction of the Achilles tendon total rupture score and physical component scale score at mean follow-up point of 9 years. Patients with repeat rupture had a significant elongation of the tendon and reduction of strength in the affected limb.

Calf Muscle Performance Deficits Remain 7 Years After an Achilles Tendon Rupture

BACKGROUND

Optimizing calf muscle performance seems to play an important role in minimizing impairments and symptoms after an Achilles tendon rupture (ATR). The literature lacks long-term follow-up studies after ATR that describe calf muscle performance over time.

PURPOSE

The primary aim was to evaluate calf muscle performance and patient-reported outcomes at a mean of 7 years after ATR in patients included in a prospective, randomized controlled trial. A secondary aim was to evaluate whether improvement in calf muscle performance continued after the 2-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Sixty-six subjects (13 women, 53 men) with a mean age of 50 years (SD, 8.5 years) were evaluated at a mean of 7 years (SD, 1 year) years after their ATR. Thirty-four subjects had surgical treatment and 32 had nonsurgical treatment. Patient-reported outcomes were evaluated with Achilles tendon Total Rupture Score (ATRS) and Physical Activity Scale (PAS). Calf muscle performance was evaluated with single-leg standing heel-rise test, concentric strength power heel-rise test, and single-legged hop for distance. Limb Symmetry Index (LSI = injured side/healthy side × 100) was calculated for side-to-side differences.

RESULTS

Seven years after ATR, the injured side showed decreased values in all calf muscle performance tests ( P < .001-.012). Significant improvement in calf muscle performance did not continue after the 2-year follow-up. Heel-rise height increased significantly ( P = .002) between the 1-year (10.8 cm) and the 7-year (11.5 cm) follow-up assessments. The median ATRS was 96 (of a possible score of 100) and the median PAS was 4 (of a possible score of 6), indicating minor patient-reported symptoms and fairly high physical activity. No significant differences were found in calf muscle performance or patient-reported outcomes between the treatment groups except for the LSI for heel-rise repetitions.

CONCLUSION

Continued deficits in calf muscle endurance and strength remained 7 years after ATR. No continued improvement in calf muscle performance occurred after the 2-year follow-up except for heel-rise height.

Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures

PURPOSE

The aim of this study was to perform a long-term follow-up of patients treated for an Achilles tendon re-rupture, using established outcome measurements for tendon structure, lower extremity function and symptoms, and to compare the results with those for the uninjured side. A secondary aim was to compare the outcome with that of patients treated for primary ruptures. The hypotheses were that patients with a re-rupture recover well, and have similar long-term outcome as primary ruptures.

METHODS

Twenty patients (4 females) with a mean (SD) age of 44 (10.9) years, ranging from 24 to 64, were included. The patients were identified by reviewing the medical records of all Achilles tendon ruptures at Sahlgrenska University Hospital and Kungsbacka Hospital, Sweden, between 2006 and 2016. All patients received standardised surgical treatment and rehabilitation. The mean (SD) follow-up was 51 (38.1) months. A test battery of validated clinical and functional tests, patient-reported outcome measurements and measurements of tendon elongation were performed at the final follow-up. This cohort was then compared with the 2-year follow-up results from a previous randomised controlled trial of patients treated for primary Achilles tendon rupture.

RESULTS

There were deficits on the injured side compared with the healthy side in terms of heel-rise height (11.9 versus 12.5 cm, p = 0.008), repetitions (28.5 versus 31.7, p = 0.004) and drop-jump height (13.2 versus 15.1 cm, p = 0.04).  There was a significant difference in calf circumference (37.1 versus 38.4 cm, p =< 0.001) and ankle dorsiflexion on the injured side compared with the healthy side (35.3° versus 40.8°, p = 0.003). However, no significant differences were found in terms of tendon length 22.5 (2.5) cm on the injured side and 21.8 (2.8) cm on the healthy side. Compared with primary ruptures, the re-rupture cohort obtained significantly worse results for the Achilles tendon total rupture score, with a mean of 78 (21.2) versus 89.5 (14.6) points, (p = 0.007). The re-ruptures showed a higher mean LSI heel-rise height, 94.7% (9.3%) versus 83.5% (11.7%) (p = < 0.0001), and superior mean LSI eccentric-concentic power, 110.4% (49.8%) versus 79.3% (21%) (p = 0.001), than the primary ruptures.

CONCLUSION

The results of this study indicate that patients with an Achilles tendon re-rupture had continued symptoms and functional deficits on the injured side, after a long-term follow-up. Patients with an Achilles tendon re-rupture had worse patient-reported outcomes but similar or superior functional results compared with patients with primary ruptures.

LEVEL OF EVIDENCE

Case series, Level IV.

Achilles tendon rupture healing is enhanced by intermittent pneumatic compression upregulating collagen type I synthesis

PURPOSE AND HYPOTHESIS

Adjuvant intermittent pneumatic compression (IPC) during leg immobilization following Achilles tendon rupture (ATR) has been shown to reduce the risk of deep venous thrombosis. The purpose of this study was to investigate whether IPC can also promote tendon healing.

METHODS

One hundred and fifty patients with surgical repair of acute ATR were post-operatively leg immobilized and prospectively randomized. Patients were allocated for 2 weeks of either adjuvant IPC treatment (n = 74) or treatment-as-usual (n = 74) in a plaster cast without IPC. The IPC group received 6 h daily bilateral calf IPC applied under an orthosis on the injured side. At 2 weeks post-operatively, tendon healing was assessed using microdialysis followed by enzymatic quantification of tendon callus production, procollagen type I (PINP) and type III (PIIINP) N-terminal propeptide, and total protein content. 14 IPC and 19 cast patients (control group) consented to undergo microdialysis. During weeks 3-6, all subjects were leg-immobilized in an orthosis without IPC. At 3 and 12 months, patient-reported outcome was assessed using reliable questionnaires (ATRS and EQ-5D). At 12 months, functional outcome was measured using the validated heel-rise test.

RESULTS

At 2 weeks post-rupture, the IPC-treated patients exhibited 69% higher levels of PINP in the ruptured Achilles tendon (AT) compared to the control group (p = 0.001). Interestingly, the IPC-treated contralateral, intact AT also demonstrated 49% higher concentrations of PINP compared to the non-treated intact AT of the plaster cast group (p = 0.002). There were no adverse events observed associated with IPC. At 3 and 12 months, no significant (n.s.) differences between the two treatments were observed using patient-reported and functional outcome measures.

CONCLUSIONS

Adjuvant IPC during limb immobilization in patients with ATR seems to effectively enhance the early healing response by upregulation of collagen type I synthesis, without any adverse effects. Whether prolonged IPC application during the whole immobilization period can also lead to improved long-term clinical healing response should be further investigated. The healing process during leg immobilization in patients with Achilles tendon rupture can be improved through adjuvant IPC therapy, which additionally prevents deep venous thrombosis.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

Longer duration of operative time enhances healing metabolites and improves patient outcome after Achilles tendon rupture surgery

PURPOSE

The relationship between the duration of operative time (DOT), healing response and patient outcome has not been previously investigated. An enhanced healing response related to DOT may potentiate repair processes, especially in hypovascular and sparsely metabolized musculoskeletal tissues such as tendons. This study aimed to investigate the association between DOT and the metabolic healing response, patient-reported outcome and the rate of post-operative complications after acute Achilles tendon injury.

METHODS

Observational cohort, cross-sectional study with observers blinded to patient grouping. A total of two-hundred and fifty-six prospectively randomized patients (210 men, 46 women; mean age 41 years) with an acute total Achilles tendon rupture all operated on with uniform anaesthetic and surgical technique were retrospectively assessed. At 2 weeks post-operatively, six metabolites were quantified using microdialysis. At 3, 6 and 12 months, patient-reported pain, walking ability and physical activity were examined using self-reported questionnaires, Achilles tendon total rupture score, foot and ankle outcome score and physical activity scale. At 12 months, functional outcome was assessed using the heel-rise test. Complications, such as deep venous thrombosis, infections and re-operations, were recorded throughout the study.

RESULTS

Patients who underwent longer DOT exhibited higher levels of glutamate (p = 0.026) and glycerol (p = 0.023) at 2 weeks. At the 1-year follow-up, longer DOT was associated with significantly less loss in physical activity (p = 0.003), less pain (p = 0.009), less walking limitations (p = 0.022) and better functional outcome (p = 0.014). DOT did not significantly correlate with the rate of adverse events, such as deep venous thrombosis, infections or re-ruptures. Higher glutamate levels were associated with less loss in physical activity (p = 0.017). All correlations were confirmed by multiple linear regressions taking confounding factors into consideration.

CONCLUSION

The results from this study suggest a previously unknown mechanism, increased metabolic response associated with longer DOT, which may improve patient outcome after Achilles tendon rupture surgery. Allowing for a higher amount of traumatized tissue, as reflected by up-regulation of glycerol in patients with longer DOT, may prove to be an important surgical tip for stimulation of repair of hypometabolic soft tissue injuries, such as Achilles tendon ruptures.

LEVEL OF EVIDENCE

II.

Individuals Post Achilles Tendon Rupture Exhibit Asymmetrical Knee and Ankle Kinetics and Loading Rates During a Drop Countermovement Jump

Study Design Cross-sectional laboratory study. Background Asymmetrical knee loading during jogging and hopping has been reported in individuals who have ruptured their Achilles tendon. No studies have examined knee loads in individuals post Achilles tendon rupture during high-demand tasks, such as single-limb landings. Objectives We sought to determine whether individuals post Achilles tendon rupture demonstrated asymmetrical knee loads and impact forces during drop countermovement jumps (CMJs). Methods Achilles tendon length and the single-leg heel-rise test for endurance were assessed in 34 individuals (31 male) 6.1 ± 2.0 years post Achilles tendon rupture. Movement patterns were assessed during a drop CMJ. Data were analyzed via repeated-measures analyses of variance, with comparisons between limbs and prior treatment history (surgery versus nonsurgery). Results An 8.6% longer Achilles tendon (P<.001) was found in the involved limb. During the single-leg heel-rise test, the involved limb demonstrated 22.4% less endurance and 14.6% lower heel-rise height (all, P<.001). During the landing phase of the drop CMJ, the involved limb exhibited 39.6% greater loading rate (P<.001), 16.8% greater eccentric knee power (P = .048), but 21.6% lower eccentric ankle power (P<.001). During the take-off phase, the involved limb exhibited 12.1% lower jump height and 19.9% lower concentric ankle power (both, P<.001). Conclusion Elevated eccentric knee joint power and higher loading rates during a drop CMJ in individuals who experienced Achilles tendon rupture several years earlier may be a compensation pattern for reduced plantar flexor function. This movement pattern may place individuals who have had an Achilles tendon rupture at greater risk for knee injuries. J Orthop Sports Phys Ther 2018;48(1):34-43. Epub 26 Oct 2017. doi:10.2519/jospt.2018.7684.

Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures

PURPOSE

An Achilles tendon rupture is a common injury that typically affects people in the middle of their working lives. The injury has a negative impact in terms of both morbidity for the individual and the risk of substantial sick leave. The aim of this study was to investigate the cost-effectiveness of surgical compared with non-surgical management in patients with an acute Achilles tendon rupture.

METHODS

One hundred patients (86 men, 14 women; mean age, 40 years) with an acute Achilles tendon rupture were randomised (1:1) to either surgical treatment or non-surgical treatment, both with an accelerated rehabilitation protocol (surgical n = 49, non-surgical n = 51). One of the surgical patients was excluded due to a partial re-rupture and five surgical patients were lost to the 1-year economic follow-up. One patient was excluded due to incorrect inclusion and one was lost to the 1-year follow-up in the non-surgical group. The cost was divided into direct and indirect costs. The direct cost is the actual cost of health care, whereas the indirect cost is the production loss related to the impact of the patient's injury in terms of lost ability to work. The health benefits were assessed using quality-adjusted life years (QALYs). Sampling uncertainty was assessed by means of non-parametric boot-strapping.

RESULTS

Pre-injury, the groups were comparable in terms of demographic data and health-related quality of life (HRQoL). The mean cost of surgical management was €7332 compared with €6008 for non-surgical management (p = 0.024). The mean number of QALYs during the 1-year time period was 0.89 and 0.86 in the surgical and non-surgical groups respectively. The (incremental) cost-effectiveness ratio was €45,855. Based on bootstrapping, the cost-effectiveness acceptability curve shows that the surgical treatment is 57% likely to be cost-effective at a threshold value of €50,000 per QALY.

CONCLUSIONS

Surgical treatment was more expensive compared with non-surgical management. The cost-effectiveness results give a weak support (57% likelihood) for the surgical treatment to be cost-effective at a willingness to pay per QALY threshold of €50,000. This is support for surgical treatment; however, additionally cost-effectiveness studies alongside RCTs are important to clarify which treatment option is preferred from a cost-effectiveness perspective.

LEVEL OF EVIDENCE

I.

[Preliminary effectiveness of laminated bevel suturing technique for treating acute closed Achilles tendon rupture]

Objective

To introduce a modified technique for treating acute closed Achilles tendon rupture and evaluate the preliminary effectiveness.

Methods

Between March 2011 and September 2015, 8 cases (8 sides) with acute closed Achilles tendon rupture were repaired with the laminated bevel suturing technique. All of the patients were male with an average age of 39.3 years (range, 22-58 years), injured in nonprofessional sports. The diagnosis was confirmed by typical signs of positive heel-lift test and Thompson test; the complete rupture of Achilles tendon was determined by color Doppler ultrasound or MRI, and the distance between the stump and calcaneus was 2-5 cm (mean, 3.3 cm). The time from injury to operation was 2-12 days (mean, 4.1 days). With the patient in prone position, a posterior longitudinal incision medial to the tendon was made, the broken stumps of Achilles tendon were divided into 3 layers on the coronal plane, fibers made into strips. The strips were staggered and stacked, stitched side to side with absorbable suture. The ankle joint at the plantar flexion position was fixed with plaster, and early rehabilitation exercise was carried out.

Results

The operation time was 70-135 minutes (mean, 99 minutes); the intraoperative blood loss was 5-30 mL (mean, 15.6 mL). All the incisions healed by first intention without infection, except for 1 case who need dressing exchange because of partial delayed healing. All the patients were followed up 6-50 months (mean, 30.5 months). There was no complication of surgical site infection, sural nerve injury, or deep vein thrombosis. The patients could walk normally with powerful raising heels and return to previous sports, without complication of re-rupture. Compared with the contralateral side, the activity of ankle joint dorsiflexion reduced 0-6° (mean, 3°); plantar flexion reduced 1-5° (mean, 2°). At last follow-up, according to Arner-Lindholm score, the surgical results were excellent in 7 cases and good in 1 case, with an excellent and good rate of 100%.

Conclusion

Laminated bevel suturing technique is simple for repairing acute closed Achilles tendon rupture without the need of special surgical instruments. It provides enough tensile strength for early rehabilitation exercise to rapid and good recovery.

Practice patterns in the care of acute Achilles tendon ruptures : is there an association with level I evidence?

AIMS

To determine whether the findings from a landmark Canadian trial assessing the optimal management of acute rupture of the Achilles tendon influenced the practice patterns of orthopaedic surgeons in Ontario, Canada.

MATERIALS AND METHODS

Health administrative databases were used to identify Ontario residents ≥ 18 years of age with an Achilles tendon rupture from April 2002 to March 2014. The rate of surgical repair (per 100 cases) was calculated for each calendar quarter. A time-series analysis was used to determine whether changes in the rate were chronologically related to the dissemination of results from a landmark trial published in February 2009. Non-linear spline regression was then used independently to identify critical time-points of change in the surgical repair rate to confirm the findings.

RESULTS

A total of 29 531 patients sustained an Achilles tendon rupture during the study period. Consistently, around 21 out of every 100 cases underwent surgical repair up to the first quarter of 2010. However, by the first quarter of 2014, only 6.5 cases per 100 had surgery. A statistically significant decrease in the rate of surgical repair was observed within one year of the presentation of landmark trial results in 2009 (p < 0.001). July 2009 was independently identified as a critical time at which the surgical repair rate began to significantly decline (p < 0.001). The dissemination of trial results was associated with a significant drop in the rate of surgical repair at non-teaching hospitals (p = 0.001).

CONCLUSION

The current study demonstrates that large, well-designed randomised trials, have the potential to encourage significant changes in the practice patterns of orthopaedic surgeons. Cite this article: Bone Joint J 2017;99-B:1629-36.

Development and reliability of the Achilles Tendon Length Measure and comparison with the Achilles Tendon Resting Angle on patients with an Achilles tendon rupture

BACKGROUND

There is a need for a valid, reliable, and easily applicable clinical measure of the length of the Achilles tendon (AT) after rupture. This study examines the reliability of a new ruler based measurement, the Achilles Tendon Length Measure (ATLM) in comparison with the goniometer-based Achilles Tendon Resting Angle (ATRA).

METHODS

Measurements were performed by two independent physiotherapists eight weeks after AT rupture on 28 patients treated non-operatively.

RESULTS

The mean (SD) injured ATLM was 56.5 (2.3)cm, ICC_2.1 0.91(CI [0.72-0.97]), SEM 0.7cm (SEM% 1.2), MDC 1.9cm (MDC% 3.4). Corresponding data for the injured ATRA was mean 64.4° (3.9°), ICC_2.1 0.84 (CI [0.68-0-92]), SEM 1.5° (SEM% 2.4), MDC 4.3° (MDC% 6.6).

CONCLUSION

Both ATLM and ATRA showed excellent inter-rater reliability with low measurement error. Both measurements seem easy to use in clinical practice and potentially providing an indirect measure of the length of the AT after rupture.

Functional Outcome of Acute Achilles Tendon Rupture With and Without Operative Treatment Using Identical Functional Bracing Protocol

BACKGROUND

The purpose of this study was to compare the functional results of operative and nonoperative treatment of acute Achilles tendon rupture using an identical rehabilitation program of functional bracing.

METHODS

Over a 10-year period, 200 patients (99 operative, 101 nonoperative) aged between 18 and 65 years were treated at our institution's physiotherapy department after acute Achilles tendon rupture. There were 132 patients (62 operative, 70 nonoperative) available for a minimum 2-year follow-up (average 6.5 years; range, 2-13 years). Functional outcome was assessed using the Achilles tendon total rupture score (ATRS).

RESULTS

With the numbers available, no significant difference could be detected in ATRS between operative (mean 84.8, median 90) and nonoperative groups (mean 85.3, median 91; P = 0.55). No significant difference could be detected in ATRS between male and female patients however treated ( P = 0.30) or between patients younger and older than 40 years at time of injury ( P = 0.68). There was no correlation between ATRS score and age at injury in all patients (ρ = -0.0168, P = 0.85). In male patients, there was a weak trend with older patients at follow-up having better scores (ρ = 0.21, P = 0.069). However, among female patients, there was a significant negative correlation between ATRS scores and increasing age (ρ = -0.29, P = 0.03). Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS.

CONCLUSIONS

This study showed no significant difference detectable in ATRS between operative and nonoperative patients in the treatment of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Heel-Rise Height Deficit 1 Year After Achilles Tendon Rupture Relates to Changes in Ankle Biomechanics 6 Years After Injury

BACKGROUND

It is unknown whether the height of a heel-rise performed in the single-leg standing heel-rise test 1 year after an Achilles tendon rupture (ATR) correlates with ankle biomechanics during walking, jogging, and jumping in the long-term.

PURPOSE

To explore the differences in ankle biomechanics, tendon length, calf muscle recovery, and patient-reported outcomes at a mean of 6 years after ATR between 2 groups that, at 1-year follow-up, had less than 15% versus greater than 30% differences in heel-rise height.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Seventeen patients with less than 15% (<15% group) and 17 patients with greater than 30% (>30% group) side-to-side difference in heel-rise height at 1 year after ATR were evaluated at a mean (SD) 6.1 (2.0) years after their ATR. Ankle kinematics and kinetics were sampled via standard motion capture procedures during walking, jogging, and jumping. Patient-reported outcome was evaluated with Achilles tendon Total Rupture Score (ATRS), Physical Activity Scale (PAS), and Foot and Ankle Outcome Score (FAOS). Tendon length was evaluated by ultrasonography. The Limb Symmetry Index (LSI = [Injured Side ÷ Healthy Side] × 100) was calculated for side differences.

RESULTS

The >30% group had significantly more deficits in ankle kinetics during all activities compared with patients in the <15% group at a mean of 6 years after ATR (LSI, 70%-149% and 84%-106%, respectively; P = .010-.024). The >30% group, compared with the <15% group, also had significantly lower values in heel-rise height (LSI, 72% and 95%, respectively; P < .001) and heel-rise work (LSI, 58% and 91%, respectively; P < .001) and significantly larger side-to-side difference in tendon length (114% and 106%, respectively; P = .012). Achilles tendon length correlated with ankle kinematic variables ( r = 0.38-0.44; P = .015-.027) whereas heel-rise work correlated with kinetic variables ( r = -0.57 to 0.56; P = .001-.047). LSI tendon length correlated negatively with LSI heel-rise height ( r = -0.41; P = .018). No differences were found between groups in patient-reported outcome ( P = .143-.852).

CONCLUSION

Height obtained during the single-leg standing heel-rise test performed 1 year after ATR related to the long-term ability to regain normal ankle biomechanics. Minimizing tendon elongation and regaining heel-rise height may be important for the long-term recovery of ankle biomechanics, particularly during more demanding activities such as jumping.

Therapeutic Effects of Doxycycline on the Quality of Repaired and Unrepaired Achilles Tendons

BACKGROUND

Achilles tendon tears are devastating injuries, especially to athletes. Elevated matrix metalloproteinase (MMP) activity after a tendon injury has been associated with deterioration of the collagen network and can be inhibited with doxycycline (Doxy).

HYPOTHESIS

Daily oral administration of Doxy will enhance the histological, molecular, and biomechanical quality of transected Achilles tendons. Additionally, suture repair will further enhance the quality of repaired tendons.

STUDY DESIGN

Controlled laboratory study.

METHODS

Randomized unilateral Achilles tendon transection was performed in 288 adult male Sprague-Dawley rats. The injured tendons were either unrepaired (groups 1 and 2) or surgically repaired (groups 3 and 4). Animals from groups 2 and 4 received Doxy daily through oral gavage, and animals from groups 1 and 3 served as controls (no Doxy). Tendons were harvested at 1.5, 3, 6, and 9 weeks after the injury (n = 18 per group and time point). The quality of tendon repair was evaluated based on the histological grading score, collagen fiber orientation, gene expression, and biomechanical properties.

RESULTS

In surgically repaired samples, Doxy enhanced the quality of tendon repair compared with no Doxy ( P = .0014). Doxy had a significant effect on collagen fiber dispersion, but not principal fiber angle. There was a significant effect of time on the gene expression of MMP-3, MMP-9 and TIMP1, and Doxy significantly decreased MMP-3 expression at 9 weeks. Doxy treatment with surgical repair increased the dynamic modulus at 6 weeks but not at 9 weeks after the injury ( P < .001). Doxy also increased the equilibrium modulus and decreased creep strain irrespective of the repair group. Doxy did not have a significant effect on the histology or biomechanics of unrepaired tendons.

CONCLUSION

The findings indicate that daily oral administration of Doxy accelerated matrix remodeling and the dynamic and equilibrium biomechanics of surgically repaired Achilles tendons, although such enhancements were most evident at the 3- to 6-week time points.

CLINICAL RELEVANCE

The inhibition of MMPs at the optimal stage of the repair process may accelerate Achilles tendon repair and improve biomechanical properties, especially when paired with surgical management.

Surgical Management of the Aging Athlete

Epidemiologic data show that the number of middle aged (>40 yr) and elderly (>65 yr) individuals continues to increase steadily, creating an expanding need for sports medicine care. Management of injuries in this subset of patients is expanding well beyond sustaining a patient's ability to perform activities of daily living. In fact, many older individuals increasingly expect to maintain reasonably high activity levels throughout their lifespan as well as after musculoskeletal injury. While a number of the emerging physiologic benefits of physical activity in older patients have been outlined, no recent review has outlined the current best surgical techniques, rehabilitation protocols, and return-to-sport recommendations for older athletes after soft-tissue repair or reconstruction as well as joint replacement. The goal of orthopaedic care in the elderly patient is shifting from simple pain relief toward return to athletic activity.

Intrarater reliability and agreement of linear encoder derived heel-rise endurance test outcome measures in healthy adults

A linear encoder measuring vertical displacement during the heel-rise endurance test (HRET) enables the assessment of work and maximum height in addition to the traditional repetitions measure. We aimed to compare the test-retest reliability and agreement of these three outcome measures. Thirty-eight healthy participants (20 females, 18 males) performed the HRET on two occasions separated by a minimum of seven days. Reliability was assessed by the intraclass correlation coefficient (ICC) and agreement by a range of measures including the standard error of measurement (SEM), coefficient of variation (CV), and 95% limits of agreement (LoA). Reliability for repetitions (ICC=0.77 (0.66, 0.85)) was equivalent to work (ICC=0.84 (95% CI 0.76, 0.89)) and maximum height (ICC=0.85 (0.77, 0.90)). Agreement for repetitions (SEM=6.7 (5.8, 7.9); CV=13.9% (11.9, 16.8%); LoA=-1.9±37.2%) was equivalent to work (SEM=419J (361, 499J); CV=13.1% (11.2, 15.8%); LoA=0.1±34.8%) with maximum height superior (SEM=0.8cm (0.6, 1.0cm); CV=6.6% (5.7, 7.9%); LoA=1.3±17.1%). Work and maximum height demonstrated acceptable reliability and agreement that was at least equivalent to the traditional repetitions measure.

Increasing age in Achilles rupture patients over time

BACKGROUND

The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time.

METHODS

Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies.

RESULTS

The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI.

CONCLUSION

Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years.

LEVEL OF EVIDENCE

Level III; Retrospective cohort study.

Conservative, minimally invasive and open surgical repair for management of acute ruptures of the Achilles tendon: a clinical and functional retrospective study

BACKGROUND

At present, it is unclear which is the best management for Achilles tendon rupture.

PURPOSE

We assess the clinical, functional and imaging outcomes of active patients undergoing 3 different types of management for acute subcutaneous rupture of the Achilles tendon, including conservative cast immobilization, traditional open surgery and percutaneous repair.

METHODS

26 active patients were managed for a rupture of the Achilles Tendon from January 2007 to March 2008. Anthropometric measurements, Functional assessment, Isometric strength, Ultrasonographic assessment, Patient satisfaction, Working life, Physical activity, Functional score and Complications were recorded retrospectively.

RESULTS

All 23 (21 men, 2 women) patients were reviewed at a minimum follow-up of 24 months (average 25.7, range 24 to 32 months, SD: 6.3) from the index injury. Thermann scores and patient satisfaction were significantly higher following surgery than conservative management with no significance between open and minimally invasive operated patients. Sensitive disturbances occur in up to 12% of open repairs and 1.8% of patients managed nonsurgically.

CONCLUSIONS

Clinical and functional outcomes following surgical repair, percutaneous and open, of the Achilles tendon are significantly improved than following conservative management.

LEVEL OF EVIDENCE

Level III.

Microcirculation after Achilles tendon rupture correlates with functional and patient-reported outcomes

Patients with acute Achilles tendon rupture (ATR) display an extended healing process with varying clinical outcome. Poor microcirculatory blood flow has been suggested to be a significant factor for the healing process. However, whether microcirculation may predict healing outcome has been mostly unknown. Therefore, we investigated whether blood flow in the Achilles tendon may be associated with patient-reported and functional outcomes after ATR. In vivo laser-Doppler flowmetry was used to assess microvascular blood flow bilateral in the Achilles tendons, during post-occlusive reactive hyperemia, of nine patients with acute total ATR at 2 weeks post-operatively. At 3 months post-operatively, patient-reported outcome was assessed using Achilles tendon Total Rupture Score (ATRS). At 1 year a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining validated, independent, patient-reported (ATRS), and functional outcome (heel-rise test) measures. An improved combined patient-reported and functional outcome, ACOS, at 1 year was significantly correlated with higher maximum blood flow (r=.777, P=.040) in the injured limb. Furthermore, enhanced patient-reported outcome, ATRS, at 3 months, was associated with an elevated ratio of maximum to resting blood flow (r=.809, P=.015) in the uninjured limb. Blood flow in early tendon healing is associated with long-term patient-reported and functional outcomes after ATR. The microcirculatory blood flow of both the healing and contralateral Achilles tendon seems to determine the healing potential after injury.

Return to competition after an Achilles tendon rupture using both on and off the field load monitoring as guidance: A case report of a top-level soccer player

OBJECTIVES

To describe the Return to competition after Achilles Tendon rupture (ATR) in an elite soccer player.

DESIGN

Case report.

SETTING

Return to sport (RTS) of a professional soccer player who suffered an ATR during a match. The RTS phase started 15 weeks after surgery and specific on-field activities were gradually introduced. Criteria used to monitor the transition through the different phases were strength and endurance of the calf muscle and ability to sustain specific on-field training loads (TL) monitored with Global Positioning System and heart-rate system. TLs were weekly compared to pre-injury values to evaluate recovery and to prescribe future sessions.

PARTICIPANT

A 39-year-old (height 178 cm, weight 75 kg) elite soccer defender player, playing in Italian Serie-A league.

RESULTS

Days of absence were lower compared to a cohort presented in UEFA study (119 versus 161 ± 65 days, respectively). External-TL and Internal-TL were organized to gradually increase during RTS and resulted in higher values prior to return to competition compared to pre-injury values. Concentric plantar flexion peak torque increased till 9th months after surgery.

CONCLUSIONS

Monitoring of the field activities allowed comparison with pre-injury values and provided a useful and functional criteria to pass return to team activity and competition.

Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?

Background:

Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications.

Methods:

A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted.

Results:

There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected ( P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified—a significantly lower complication rate than that reported in the literature ( P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature ( P < .0001; CI 0.067-1.94).

Conclusion:

In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients’ overall recovery, a significantly lower rate of complications existed compared to that reported in the literature.

Level of Evidence:

Level IV.

Acute Rupture Open Repair Techniques

Achilles tendon injuries can be serious injuries requiring either operative or nonoperative management. For appropriate surgical candidates, operative intervention may provide lower rerupture rates and adequate end-to-end tendon healing. Our preference is an open Achilles tendon repair, specifically a limited open technique using the PARS device (Arthrex, Naples, FL). Postoperatively, we use functional rehabilitation and early range of motion. Although the current literature remains controversial regarding operative versus nonoperative management, the authors have obtained satisfactory results in appropriately chosen surgical candidates.

Elevated Knee Joint Kinetics and Reduced Ankle Kinetics Are Present During Jogging and Hopping After Achilles Tendon Ruptures

BACKGROUND

Deficits in plantarflexor function are common after an Achilles tendon rupture. These deficits may result in an altered distribution of joint loads during lower extremity tasks.

HYPOTHESIS

We hypothesized that, regardless of treatment, the Achilles tendon-ruptured limb would exhibit deficits in ankle kinematics and joint power while exhibiting elevated knee joint power and patellofemoral joint loads during walking, jogging, and hopping. We further hypothesized that this loading pattern would be most evident during jogging and hopping.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty-four participants (17 participants treated surgically, 17 treated nonsurgically) were tested at a mean 6.1 ± 2.0 years after an Achilles tendon rupture. Lower extremity kinematics and kinetics were assessed while participants completed walking, jogging, and single-legged hopping trials. Patellofemoral joint stress was calculated via a musculoskeletal model. Data were analyzed via mixed-model repeated analyses of variance (α = .05) and the limb symmetry index (LSI).

RESULTS

No differences ( P ≥ .05) were found between the surgical and nonsurgical groups. In both groups, large side-to-side deficits in the plantarflexion angle at toeoff (LSI: 53.5%-73.9%) were noted during walking, jogging, and hopping in the involved limb. Side-to-side deficits in the angular velocity were only present during jogging (LSI: 93.5%) and hopping (LSI: 92.5%). This pattern was accompanied by large deficits in eccentric (LSI: 80.8%-94.7%) and concentric (LSI: 82.2%-84.7%) ankle joint powers in the involved limb during all tasks. Interestingly, only jogging and hopping demonstrated greater knee joint loads when compared with the uninvolved limb. Concentric knee power was greater during jogging (LSI: 117.2%) and hopping (LSI: 115.9%) compared with the uninvolved limb. Similarly, peak patellofemoral joint stress was greater in the involved limb during jogging (LSI: 107.5%) and hopping (LSI: 107.1%), while only hopping had a greater loading rate of patellofemoral joint stress (LSI: 110.9%).

CONCLUSION

Considerable side-to-side deficits in plantarflexor function were observed during walking, jogging, and hopping in patients after an Achilles tendon rupture. As a possible compensation, increased knee joint loads were present but only during jogging and hopping.

CLINICAL RELEVANCE

These data suggest that after an Achilles tendon rupture, patients may be susceptible to greater mechanical loading of the knee during sporting tasks, regardless of surgical or nonsurgical treatment.

Acute Achilles Rupture Percutaneous Repair: Approach, Materials, Techniques

Closed traumatic Achilles tendon rupture is a common injury, especially in the aging athlete. Traditionally open repair has been recognized to offer a lower rerupture rate compared with nonoperative methods but with a higher complication rate. Percutaneous repair has been described to offer the benefits of open repair while avoiding the complications. The sural nerve is potentially susceptible to injury, and specialized instrumentation has been developed to avoid this event. This article discusses several techniques of minimally invasive Achilles tendon repair. Many authors have evaluated these techniques and the results are discussed here.

Acute Achilles Tendon Rupture: Clinical Evaluation, Conservative Management, and Early Active Rehabilitation

The Achilles tendon (AT) is the strongest, largest, and most commonly ruptured tendon in the human body. Physical examination provides high sensitivity and specificity. Imaging studies are not recommended unless there are equivocal findings in the physical examination. Recent studies have shown that the risk of re-rupture is negated with implementation of functional rehabilitation protocols. Heterogeneity in study design makes conclusions on the specifics of functional rehabilitation protocols difficult; however, it is clear that early weight bearing and early controlled mobilization lead to better patient outcome and satisfaction in both surgically and conservatively treated populations.

Rehabilitation of Achilles tendon ruptures: is early functional rehabilitation daily routine?

INTRODUCTION

Ruptures of the Achilles tendon are the most common tendon injuries of the lower extremities. Besides the initial operative or non-operative treatment, rehabilitation of patients plays a crucial role for tendon healing and long-term outcome. As only limited evidence is available for optimized rehabilitation regimen and guidelines for the initial (e.g., first 6 weeks) rehabilitation are limited, this study investigated the current rehabilitation concepts after Achilles tendon rupture.

MATERIALS AND METHODS

We analyzed 213 written rehabilitation protocols that are provided by orthopedic and trauma surgery institutions throughout Germany in terms of recommendations for weight-bearing, range of motion (ROM), physiotherapy, and choice of orthosis. All protocols for operatively and non-operatively treated Achilles tendon ruptures were included. Descriptive analysis was carried out and statistical analysis applied where appropriate.

RESULTS

Of 213 institutions, 204 offered rehabilitation protocols for Achilles tendon rupture and, therefore, 243 protocols for operative and non-operative treatment could be analyzed. While the majority of protocols allowed increased weight-bearing over time, significant differences were found for durations of fixed plantar flexion between operative (o) and non-operative (n) treatments [fixed 30° (or 20)° to 15° (or 10)°: 3.6 weeks (±0.1; o) vs 4.7 weeks (±0.3; n) (p ≤ 0.0001) and fixed 15° (or 10)° to 0°: 5.8 weeks (±0.1; o) vs 6.6 weeks (±0.2; n) (p ≤ 0.001)]. The mean time of the recommended start of physiotherapy is at 2.9 weeks (±0.2; o) vs 3.3 weeks (±0.4; n), respectively.

CONCLUSION

Our study shows that a huge variability in rehabilitation after Achilles tendon rupture exists. This study shows different strategies in rehabilitation of Achilles tendon ruptures using a convertible vacuum brace system. To improve patient care, further clinical as well as biomechanical studies need to be conducted. This study might serve as basis for prospective randomized controlled trials to optimize rehabilitation for Achilles tendon ruptures.

Ageing, deep vein thrombosis and male gender predict poor outcome after acute Achilles tendon rupture

AIMS

Patients with an acute Achilles tendon rupture (ATR) take a long time to heal, have a high incidence of deep vein thrombosis (DVT) and widely variable functional outcomes. This variation in outcome may be explained by a lack of knowledge of adverse factors, and a subsequent shortage of appropriate interventions.

PATIENTS AND METHODS

A total of 111 patients (95 men, 16 women; mean age 40.3, standard deviation 8.4) with an acute total ATR were prospectively assessed. At one year post-operatively a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining three validated, independent, outcome measures: Achilles tendon Total Rupture Score, heel-rise height test, and limb symmetry heel-rise height. Predictors of ACOS included treatment; gender; age; smoking; body mass index; time to surgery; physical activity level pre- and post-injury; symptoms; quality of life and incidence of DVT.

RESULTS

There were three independent variables that correlated significantly with the dichotomised outcome score (ACOS), while there was no correlation with other factors. An age of less than 40 years old was the strongest independent predictor of a good outcome one year after ATR (odds ratio (OR) 0.20, 95% confidence interval (CI) 0.08 to 0.51), followed by female gender (OR) 4.18, 95% CI 1.01 to 17.24). Notably, patients who did not have a DVT while immobilised post-operatively had a better outcome (OR 0.31, 95% CI 0.12 to 0.80).

CONCLUSION

Over the age of 40 years, male gender and having a DVT while immobilised are independent negative predictors of outcome in patients with an acute ATR. Cite this article: Bone Joint J 2016;98-B:1635-41.

The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27 607 patients

AIMS

The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada.

PATIENTS AND METHODS

Patients ≥ 18 years of age who presented with an AATR to an emergency department in Ontario, Canada between 1 January 2003 and 31 December 2013 were identified using administrative databases. The overall and annual incidence density rate (IDR) of AATR were calculated for all demographic subgroups. The annual rate of surgical repair was also calculated and compared between demographic subgroups.

RESULTS

A total of 27 607 patients (median age, 44 years; interquartile range 26 to 62; 66.5% male) sustained an AATR. The annual IDR increased from 18.0 to 29.3 per 100 000 person-years between 2003 and 2013. The mean IDR was highest among men between the ages of 40 and 49 years (46.0/100 000 person-years). The annual rate of surgical repair dropped from 20.1 in 2003 to 9.2 per 100 AATRs in 2013. There was a noticeable decline after 2009.

CONCLUSION

The incidence of AATR is increasing in Ontario, while the annual rate of surgical repair is decreasing. A sharp decline in the rate of surgical repair was noted after 2009. This coincided with the publication of several high-quality RCTs which showed similar outcomes for the 'functional' non-operative management and surgical repair. Cite this article: Bone Joint J 2017;99-B:78-86.

Management of acute Achilles tendon rupture with tendon-bundle technique

Objective * These authors contributed equally to this work. To explore tendon-bundle technique for treating Achilles tendon rupture with no defects. Methods Patients with full unilateral Achilles tendon rupture with no defects were included. The Achilles tendon medial edge surgical repair approach was used, revealing horsetail-like rupture bundles. Tendon bundles were anatomically realigned and repaired end-to-end using 5-0 sutures. Patients were followed-up for 1 year, and assessed for differences between the repaired versus healthy limb. Results Out of 24 patients (18 male, 6 female; aged 19-56 years) at 1 year following surgery, mean American Orthopaedic Foot and Ankle Society score was 92.4 ± 5.9; mean differences between the surgically repaired versus contralateral side in dorsiflexion and plantarflexion angle were 3.5 ± 2.3° and 5.6 ± 3.2°, respectively; mean difference in calf circumference between the two sides was 0.9 ± 0.5 cm; and mean increase in Achilles tendon width versus the healthy side was 0.8 ± 0.2 cm. By 1 year post-surgery, there were no significant between-side differences in dorsiflexion and plantarflexion angle, or calf circumference. Conclusions Tendon-bundle surgery resulted in good ankle function restoration and low complication rates. Tendon-bundle surgery may reduce blood supply destruction and maximally preserve Achilles tendon length, and may be effective for treating Achilles tendon rupture with no defects.