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Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc 2018; 26:846-853. [PMID: 26410099 DOI: 10.1007/s00167-015-3795-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/15/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair. METHODS A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included. RESULTS One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment. CONCLUSION Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician. LEVEL OF EVIDENCE II.
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152
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Munegato D, Gridavilla G, Guerrasio S, Turati M, Cazzaniga C, Zanchi N, Zatti G, Bigoni M. Mini open versus open repair techniques in Achilles tendon rupture: clinical and isokinetic evaluation. Muscles Ligaments Tendons J 2018; 7:554-561. [PMID: 29387651 DOI: 10.11138/mltj/2017.7.3.554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The aim of the study was to compare the mini-open to the classic open repair techniques for Achilles tendon ruptures. Methods We retrospectively evaluated at a minimum of 2 years follow-up 32 subcutaneous Achilles tendon ruptures; 17 underwent mini-open surgery (Group A) and 15 the open technique (Group B). Results No difference in Achilles Tendon Total Rupture Score and in modified Leppillahti score was observed. With respect to the contralateral side the width of the operated Achilles tendon was 4.07 mm thicker in Group A and 7.67 mm in Group B (p<.05); the calf circumference reduction was respectively 10 mm and 23.75 mm (p<.05). Iso-kinetic peak force measurement of the calf muscle strength showed a loss of 8.21% in Group A versus 17.25% in Group B (p <.05). The mean Patient Satisfaction Score was 96.76 in Group A and 88.67 in Group B (p<.01); respectively 82.3% vs 66.7% of patients were able to return to previous levels of sporting activity. There were two post-operative complications in Group B and one in Group A. Conclusion Mini-open technique minimizes the risk of complications, leads to an improved tendon healing process and functional recovery with higher patient satisfaction. Level of evidence IV.
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Affiliation(s)
- Daniele Munegato
- Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Giulia Gridavilla
- Department of Orthopedic Surgery and Traumatology, Manzoni General Hospital, Lecco, Italy
| | - Stefano Guerrasio
- Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Marco Turati
- Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,Department of Paediatric Orthopedic Surgery, Hopital Couple Enfants, Grenoble Alpes University, Grenoble, France
| | - Carlo Cazzaniga
- Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Nicolò Zanchi
- Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Giovanni Zatti
- Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marco Bigoni
- Orthopedic Department, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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153
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Brorsson A, Grävare Silbernagel K, Olsson N, Nilsson Helander K. Calf Muscle Performance Deficits Remain 7 Years After an Achilles Tendon Rupture. Am J Sports Med 2018; 46:470-477. [PMID: 29068725 DOI: 10.1177/0363546517737055] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Nicklas Olsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Mölndal, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Department of Orthopaedics, Kungsbacka Hospital, Kungsbacka, Sweden
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154
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Zellers JA, Cortes DH, Corrigan P, Pontiggia L, Silbernagel KG. Side-to-side differences in Achilles tendon geometry and mechanical properties following achilles tendon rupture. Muscles Ligaments Tendons J 2018; 7:541-547. [PMID: 29387649 DOI: 10.11138/mltj/2017.7.3.541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Recovery of tendon structure has been suggested to play a role in clinical success following Achilles tendon rupture. The purpose of this study was to identify side-to-side differences in tendon geometry and mechanical properties following Achilles tendon rupture and investigate the relationship of tendon structure with clinical outcomes. Methods Participants within 1 year post complete rupture were included. Tendon geometry and mechanical properties were quantified using B-mode ultrasound imaging and continuous shear wave elastography (cSWE). Clinical outcomes included the heel-rise test. Participant self-reported function was measured using the Achilles tendon Total Rupture Score, Foot and Ankle Outcome Score - quality of life subscale, and the Physical Activity Scale. Results Twenty participants [mean (SD) age: 42.7(13.6) years, 13 managed surgically] were included. Tendon thickness was greater on the ruptured side (p <0.001) [median (IQR) rupture: 1.38(1.21-1.56) cm, non-rupture: 0.49(0.40-0.52)]. Tendon length to the gastrocnemius was longer (p <0.001) on ruptured [22.8 (21.71-24.31) cm] than non-ruptured [21.66(20.74-23.62) cm] sides. Viscosity was lower on the ruptured side (p <0.001) [median (IQR) rupture: 37.7(30.6-43.3) Pa*s, non-rupture: 53.5(48.4-59.6) Pa*s]. Shear modulus was not different between sides. Tendon thickness (rho = 0.675, p = 0.002) and shear modulus (rho = -0.791, p = 0.001) related to total work on the heel-rise test. Conclusion Ultrasound imaging, including cSWE, can be used to detect side-to-side differences in tendon structure in individuals with Achilles tendon rupture and tendon structure relates to clinical performance. Level of evidence III b.
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Affiliation(s)
| | - Daniel H Cortes
- Department of Mechanical and Nuclear Engineering, Penn State University, State College, PA, USA
| | - Patrick Corrigan
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Laura Pontiggia
- Department of Mathematics, Physics, and Statistics, University of the Sciences, Philadelphia, PA, USA
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Westin O, Nilsson Helander K, Grävare Silbernagel K, Samuelsson K, Brorsson A, Karlsson J. Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures. Knee Surg Sports Traumatol Arthrosc 2018; 26:3063-3072. [PMID: 29691618 PMCID: PMC6154022 DOI: 10.1007/s00167-018-4952-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 04/16/2018] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Katarina Nilsson Helander
- 0000 0000 9919 9582grid.8761.8Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,000000009445082Xgrid.1649.aDepartment of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden ,grid.415546.7Hallands Sjukhus, Kungsbacka, Sweden
| | - Karin Grävare Silbernagel
- 0000 0000 9919 9582grid.8761.8Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,0000 0001 0454 4791grid.33489.35Department of Physical Therapy, University of Delaware, Newark, DE USA
| | - Kristian Samuelsson
- 0000 0000 9919 9582grid.8761.8Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,000000009445082Xgrid.1649.aDepartment of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Annelie Brorsson
- 0000 0000 9919 9582grid.8761.8Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,IFK Kliniken Rehab, Gothenburg, Sweden
| | - Jón Karlsson
- 0000 0000 9919 9582grid.8761.8Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,000000009445082Xgrid.1649.aDepartment of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Individuals Post Achilles Tendon Rupture Exhibit Asymmetrical Knee and Ankle Kinetics and Loading Rates During a Drop Countermovement Jump. J Orthop Sports Phys Ther 2018; 48:34-43. [PMID: 29073841 DOI: 10.2519/jospt.2018.7684] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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157
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Westin O, Svensson M, Nilsson Helander K, Samuelsson K, Grävare Silbernagel K, Olsson N, Karlsson J, Hansson Olofsson E. Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2018; 26:3074-3082. [PMID: 29696317 PMCID: PMC6154020 DOI: 10.1007/s00167-018-4953-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/16/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Mikael Svensson
- Health Metrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Nicklas Olsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital, Mölndal, Sweden
| | - Elisabeth Hansson Olofsson
- Department of Orthopaedics, Institute of Clinical Science at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg, Sweden
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158
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Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal S. Practice patterns in the care of acute Achilles tendon ruptures : is there an association with level I evidence? Bone Joint J 2017; 99-B:1629-1636. [PMID: 29212686 DOI: 10.1302/0301-620x.99b12.bjj-2017-0465.r1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/17/2017] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- U Sheth
- University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G 1V7, Canada
| | - D Wasserstein
- University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room MG323, Toronto, Ontario, M4N 3M5, Canada
| | - R Jenkinson
- University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room MG323, Toronto, Ontario, M4N 3M5, Canada
| | - R Moineddin
- University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G 1V7, Canada
| | - H Kreder
- University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room MG323, Toronto, Ontario, M4N 3M5, Canada
| | - S Jaglal
- University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G 1V7, Canada
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159
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Lim CS, Lees D, Gwynne-Jones DP. Functional Outcome of Acute Achilles Tendon Rupture With and Without Operative Treatment Using Identical Functional Bracing Protocol. Foot Ankle Int 2017; 38:1331-1336. [PMID: 28891323 DOI: 10.1177/1071100717728687] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Che Siu Lim
- 1 Whangarei Hospital, Orthopaedic Outpatients, Whangarei, New Zealand
| | - David Lees
- 2 Waikato District Health Board, Hamilton, New Zealand
| | - David P Gwynne-Jones
- 3 Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,4 Department of Orthopaedic Surgery, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand
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Brorsson A, Willy RW, Tranberg R, Grävare Silbernagel K. Heel-Rise Height Deficit 1 Year After Achilles Tendon Rupture Relates to Changes in Ankle Biomechanics 6 Years After Injury. Am J Sports Med 2017; 45:3060-3068. [PMID: 28783473 DOI: 10.1177/0363546517717698] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Richard W Willy
- Department of Physical Therapy, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina, USA
| | - Roy Tranberg
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
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Braunstein M, Baumbach SF, Herterich V, Böcker W, Polzer H. Die akute Achillessehnenruptur. Unfallchirurg 2017; 120:1007-1014. [DOI: 10.1007/s00113-017-0420-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Temporal Healing of Achilles Tendons After Injury in Rodents Depends on Surgical Treatment and Activity. J Am Acad Orthop Surg 2017; 25:635-647. [PMID: 28837456 PMCID: PMC5603242 DOI: 10.5435/jaaos-d-16-00620] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Achilles tendon ruptures affect 15 of 100,000 women and 55 of 100,000 men each year. Controversy continues to exist regarding optimal treatment and rehabilitation protocols. The objective of this study was to investigate the temporal effects of surgical repair and immobilization or activity on Achilles tendon healing and limb function after complete transection in rodents. METHODS Injured tendons were repaired (n = 64) or left nonrepaired (n = 64). The animals in both cohorts were further randomized into groups immobilized in plantar flexion for 1, 3, or 6 weeks that later resumed cage and treadmill activity for 5, 3, or 0 weeks, respectively (n = 36 for each regimen), which were euthanized at 6 weeks after injury, or into groups immobilized for 1 week and then euthanized (n = 20). RESULTS At 6 weeks after injury, the groups that had 1 week of immobilization and 5 weeks of activity had increased range of motion and decreased ankle joint toe stiffness compared with the groups that had 3 weeks of immobilization and 3 weeks of activity. The groups with 6 weeks of immobilization and no activity period had decreased tendon cross-sectional area but increased tendon echogenicity and collagen alignment. Surgical treatment dramatically decreased fatigue cycles to failure in repaired tendons from groups with 1 week of immobilization and 5 weeks of activity. Normalized comparisons between 1-week and 6-week postinjury data demonstrated that changes in tendon healing properties (area, alignment, and echogenicity) were maximized by 1 week of immobilization and 5 weeks of activity, compared with 6 weeks of immobilization and no activity period. DISCUSSION This study builds on an earlier study of Achilles tendon fatigue mechanics and functional outcomes during early healing by examining the temporal effects of different immobilization and/or activity regimens after initial postinjury immobilization. CONCLUSION This study demonstrates how the temporal postinjury healing response of rodent Achilles tendons depends on both surgical treatment and the timing of immobilization/activity timing. The different pattern of healing and qualities of repaired and nonrepaired tendons suggest that two very different healing processes may occur, depending on the chosen immobilization/activity regimen.
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Carmont MR, Zellers JA, Brorsson A, Olsson N, Nilsson-Helander K, Karlsson J, Silbernagel KG. Functional Outcomes of Achilles Tendon Minimally Invasive Repair Using 4- and 6-Strand Nonabsorbable Suture: A Cohort Comparison Study. Orthop J Sports Med 2017; 5:2325967117723347. [PMID: 28856168 PMCID: PMC5571770 DOI: 10.1177/2325967117723347] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The aim of management of Achilles tendon rupture is to reduce tendon lengthening and maximize function while reducing the rerupture rate and minimizing other complications. Purpose: To determine changes in Achilles tendon resting angle (ATRA), heel-rise height, patient-reported outcomes, return to play, and occurrence of complications after minimally invasive repair of Achilles tendon ruptures using nonabsorbable sutures. Study Design: Cohort study; Level of evidence, 3. Methods: Between March 2013 and August 2015, a total of 70 patients (58 males, 12 females) with a mean age of 42 ± 8 years were included and evaluated at 6 weeks and 3, 6, 9, and 12 months after repair of an Achilles tendon rupture. Surgical repair was performed using either 4-strand or 6-strand nonabsorbable sutures. After surgery, patients were mobilized, fully weightbearing using a functional brace. Early active movement was permitted starting at 2 weeks. Results: There were no significant differences in the ATRA, Achilles Tendon Total Rupture Score (ATRS), and Heel-Rise Height Index (HRHI) between the 4- and 6-strand repairs. The mean (SD) relative ATRA was –13.1° (6.6°) (dorsiflexion) following injury; this was reduced to 7.6° (4.8°) (plantar flexion) directly after surgery. During initial rehabilitation at 6 weeks, the relative ATRA was 0.6° (7.4°) (neutral) and –7.0° (5.3°) (dorsiflexion) at 3 months, after which ATRA improved significantly with time to 12 months (P = .005). At 12 months, the median ATRS was 93 (range, 35-100), and the mean (SD) HRHI and Heel-Rise Repetition Index were 81% (0.22%) and 82.9% (0.17%), respectively. The relative ATRA at 3 and 12 months correlated with HRHI (r = 0.617, P < .001 and r = 0.535, P < .001, respectively). Conclusion: Increasing the number of suture strands from 4 to 6 does not alter the ATRA or HRHI after minimally invasive Achilles tendon repair. The use of a nonabsorbable suture during minimally invasive repair when used together with accelerated rehabilitation did not prevent the development of an increased relative ATRA. The ATRA at 3 months after surgery correlated with heel-rise height at 12 months.
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Affiliation(s)
- Michael R Carmont
- Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom.,Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jennifer A Zellers
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nicklas Olsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Kungsbacka Hospital, Kungsbacka, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Carmont MR, Kuiper JH, Grävare Silbernagel K, Karlsson J, Nilsson-Helander K. Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures. J Exp Orthop 2017; 4:26. [PMID: 28733950 PMCID: PMC5520830 DOI: 10.1186/s40634-017-0101-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/14/2017] [Indexed: 12/28/2022] Open
Abstract
Background Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading. Methods Nineteen bovine Achilles tendons were repaired using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weight-bearing, before being loaded to failure. Results Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. Conclusion The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.
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Affiliation(s)
- Michael R Carmont
- Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital, Telford, UK. .,Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Jan Herman Kuiper
- Department of Biomechanical Engineering, The Robert Jones & Agnes Hunt District General Hospital, University of Keele, Keele, UK
| | | | - Jón Karlsson
- Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedic Surgery, Kungsbacka Hospital, Kungsbacka, Sweden
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Ho G, Tantigate D, Kirschenbaum J, Greisberg JK, Vosseller JT. Increasing age in Achilles rupture patients over time. Injury 2017; 48:1701-1709. [PMID: 28457569 DOI: 10.1016/j.injury.2017.04.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Gavin Ho
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Direk Tantigate
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Josh Kirschenbaum
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Justin K Greisberg
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - J Turner Vosseller
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States.
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Rensing N, Waterman BR, Frank RM, Heida KA, Orr JD. Low Risk for Local and Systemic Complications After Primary Repair of 1626 Achilles Tendon Ruptures. Foot Ankle Spec 2017; 10:216-226. [PMID: 27837039 DOI: 10.1177/1938640016676340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Historically, Achilles tendon repairs and other surgeries about the hindfoot have demonstrated a significantly higher rate of wound healing complications and surgical site morbidity. The purpose of this study was to evaluate the comprehensive complication profile and risk factors for adverse short-term, clinical outcomes after primary repair of Achilles tendon ruptures. METHODS Between the years 2005 and 2014, all cases of primary Achilles tendon repair (Current Procedural Terminology code 27650) entered into the National Surgical Quality Improvement Project (NSQIP) database were extracted for analysis. Primary outcomes of interest were rates of total complication, reoperation, and rerupture within 30 days of index surgery. Independent risk factors associated with these selected endpoints were assessed with chi-square and logistic regression analysis and odds ratios with 95% confidence intervals were used to express relative risk. RESULTS Of 1626 patients with an average age of 44 years (SD 13.3), the average ASA classification was 1.69 and hypertension (20.7%), morbid obesity (8.3%), and diabetes (4.9%) were among the most common medical comorbidities. A total of 28 (1.7%) patients sustained perioperative complications, including 1.3% with local complications (0.7% superficial wound infection, 0.4% wound disruption) and no cases of peripheral nerve injury or early repair failure. Systemic complications occurred in 0.4%, most commonly with deep venous thrombosis or nonfatal thromboembolism. Preoperative albumin was independently associated with an increased risk of local wound complications (odds ratio [OR] 28.67; 95% CI 1.42-579.40; P = .029). Chronic obstructive pulmonary disease (OR 22.33, 95% CI 2.49-199.81; P = .006) and bleeding disorder (OR 14.83, 95% CI 1.70-129.50; P = .015) were more likely to result in a systemic complication, and preoperative creatinine correlated with an increased risk of any complication (OR 6.11, 95% CI 1.15-32.34; P = .033). In total there were 5 (0.3%) readmissions with 2 (0.1%) unplanned reoperations attributed to local wound complications. CONCLUSION Among a broad-based demographic of the United States, the rate of local wound complications was exceedingly low in the short-term perioperative period, although this risk may be significantly magnified with subtle decreases in albumin levels. Preoperative risk stratifications should carefully scrutinize for subtle abnormalities in nutritional parameters and renal function prior to undergoing Achilles surgery. LEVELS OF EVIDENCE Therapeutic, Level II: Prospective, comparative trial.
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Affiliation(s)
- Nicholas Rensing
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
| | - Brian R Waterman
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
| | - Rachel M Frank
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
| | - Kenneth A Heida
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
| | - Justin D Orr
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas (NR, BRW, KAH, JDO).,Rush University Medical Center, Chicago, Illinois (RMF)
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Abstract
BACKGROUND Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture. METHODS We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury. RESULTS Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost. CONCLUSION From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management. LEVEL OF EVIDENCE III, Economic Decision Analysis.
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Heikkinen J, Lantto I, Flinkkila T, Ohtonen P, Niinimaki J, Siira P, Laine V, Leppilahti J. Soleus Atrophy Is Common After the Nonsurgical Treatment of Acute Achilles Tendon Ruptures: A Randomized Clinical Trial Comparing Surgical and Nonsurgical Functional Treatments. Am J Sports Med 2017; 45:1395-1404. [PMID: 28282504 DOI: 10.1177/0363546517694610] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It remains controversial whether nonsurgical or surgical treatment provides better calf muscle strength recovery after an acute Achilles tendon rupture (ATR). Recent evidence has suggested that surgery might surpass nonsurgical treatment in restoring strength after an ATR. PURPOSE To assess whether magnetic resonance imaging (MRI) findings could explain calf muscle strength deficits and the difference between nonsurgical and surgical treatments in restoring calf muscle strength. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS From 2009 to 2013, 60 patients with acute ATRs were randomized to surgery or nonsurgical treatment with an identical rehabilitation protocol. The primary outcome measure was the volume of calf muscles assessed using MRI at 3 and 18 months. The secondary outcome measures included fatty degeneration of the calf muscles and length of the affected Achilles tendon. Additionally, isokinetic plantarflexion strength was measured in both legs. RESULTS At 3 months, the study groups showed no differences in muscle volumes or fatty degeneration. However, at 18 months, the mean differences between affected and healthy soleus muscle volumes were 83.2 cm3 (17.7%) after surgery and 115.5 cm3 (24.8%) after nonsurgical treatment (difference between means, 33.1 cm3; 95% CI, 1.3-65.0; P = .042). The study groups were not substantially different in the volumes or fatty degeneration of other muscles. From 3 to 18 months, compensatory hypertrophy was detected in the flexor hallucis longus (FHL) and deep flexors in both groups. In the nonsurgical treatment group, the mean difference between affected and healthy FHL muscle volumes was -9.3 cm3 (12%) and in the surgical treatment group was -8.4 cm3 (10%) ( P ≤ .001). At 18 months, Achilles tendons were, on average, 19 mm longer in patients treated nonsurgically compared with patients treated surgically ( P < .001). At 18 months, surgically treated patients demonstrated 10% to 18% greater strength results ( P = .037). Calf muscle isokinetic strength deficits for the entire range of ankle motion correlated with soleus atrophy (ρ = 0.449-0.611; P < .001). CONCLUSION Treating ATRs nonsurgically with a functional rehabilitation protocol resulted in greater soleus muscle atrophy compared with surgical treatment. The mean Achilles tendon length was 19 mm longer after nonsurgical treatment than after the surgical treatment of ATRs. These structural changes partly explained the 10% to 18% greater calf muscle strength observed in patients treated with surgery compared with those treated nonsurgically. Registration: NCT02012803 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Tapio Flinkkila
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Jaakko Niinimaki
- Research Unit of Medical Imaging, Physics and Technology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Pertti Siira
- Department of Physical Medicine and Rehabilitation, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Vesa Laine
- Department of Physical Medicine and Rehabilitation, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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Willy RW, Brorsson A, Powell HC, Willson JD, Tranberg R, Grävare Silbernagel K. Elevated Knee Joint Kinetics and Reduced Ankle Kinetics Are Present During Jogging and Hopping After Achilles Tendon Ruptures. Am J Sports Med 2017; 45:1124-1133. [PMID: 28186834 DOI: 10.1177/0363546516685055] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Richard W Willy
- Department of Physical Therapy, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina, USA
| | - Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hayley C Powell
- Department of Physical Therapy, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina, USA
| | - John D Willson
- Department of Physical Therapy, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina, USA
| | - Roy Tranberg
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
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Rehabilitation of Achilles tendon ruptures: is early functional rehabilitation daily routine? Arch Orthop Trauma Surg 2017; 137:333-340. [PMID: 28097423 DOI: 10.1007/s00402-017-2627-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Indexed: 10/20/2022]
Abstract
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.
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171
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Park YH, Jeong SM, Choi GW, Kim HJ. How early must an acute Achilles tendon rupture be repaired? Injury 2017; 48:776-780. [PMID: 28088376 DOI: 10.1016/j.injury.2017.01.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/04/2017] [Accepted: 01/07/2017] [Indexed: 02/02/2023]
Abstract
An acute Achilles tendon rupture is the most common tendon rupture of the lower extremities, yet the optimal timing for an early surgical repair is unclear. To identify the optimal time for an early surgical repair with favorable results, we evaluated the isokinetic muscle strength and clinical outcomes of early surgical repairs of acute Achilles tendon ruptures performed at different time points after injury. Between January 2011 and July 2015, a total of 65 patients underwent an acute Achilles tendon rupture repair within 1 week after injury. To compare the outcomes at different time points post-injury, we divided patients into 3 groups: group 1, surgical treatment at ≤24h; group 2, surgery at ≥24h and ≤48h; and group 3, surgery at ≥48 hours and ≤1 week. The isokinetic muscle strength in both ankles were measured using a Cybex dynamometer, and the Achilles tendon total rupture score, the modified Tegner scoring system, the visual analog scale was used to assess clinical outcomes. Kruskal-Wallis and Fisher's exact tests were used to compare multiple results in the 3 groups. No significant differences were found among the groups in terms of ankle isokinetic muscle strength or clinical outcome scores (P>0.05). The complication rate was low in all groups. There were no significant differences in isokinetic muscle strength or clinical outcomes following acute Achilles tendon rupture repairs performed within 1 week after injury.
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Affiliation(s)
- Young Hwan Park
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Seong Min Jeong
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Gi Won Choi
- Department of Orthopedic Surgery, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Hak Jun Kim
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Republic of Korea.
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Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal SB. The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27 607 patients. Bone Joint J 2017; 99-B:78-86. [PMID: 28053261 DOI: 10.1302/0301-620x.99b1.bjj-2016-0434.r1] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/19/2016] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- U Sheth
- University of Toronto, Division of Orthopaedic Surgery, 160-500 University Avenue, Toronto, Ontario, Canada
| | - D Wasserstein
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada
| | - R Jenkinson
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada
| | - R Moineddin
- University of Toronto, 500 University Avenue, Ontario, Canada
| | - H Kreder
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada
| | - S B Jaglal
- Institute of Health Policy, Management and Evaluation, University of Toronto, Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
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173
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Miyamoto W, Imade S, Innami K, Kawano H, Takao M. Acute Achilles Tendon Rupture Treated by Double Side-Locking Loop Suture Technique With Early Rehabilitation. Foot Ankle Int 2017; 38:167-173. [PMID: 27765870 DOI: 10.1177/1071100716673589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although early accelerated rehabilitation is recommended for the treatment of acute Achilles tendon rupture, most traditional rehabilitation techniques require some type of brace. METHODS We retrospectively analyzed 44 feet of 44 patients (25 male and 19 female) with a mean age of 31.8 years who had an acute Achilles tendon rupture related to athletic activity. Patients had been treated by a double side-locking loop suture (SLLS) technique using double antislip knots between stumps and had undergone early accelerated rehabilitation, including active and passive range of motion exercises on the day following the operation and full weight-bearing at 4 weeks. No brace was applied postoperatively. The evaluation criteria included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS) score; active plantar flexion and dorsiflexion angles; and the intervals between surgery and the time when patients could walk normally without any support, perform double-leg heel raises, and perform 20 continuous single-leg heel raises of the operated foot. RESULTS Despite postoperative early accelerated rehabilitation, the AOFAS score and active dorsiflexion angles improved over time (6, 12, and 24 weeks and 2 years). A mean of 4.3 ± 0.6 weeks was required for patients to be able to walk normally without any support. The mean period to perform double-leg heel raises and 20 continuous single-leg heel raises of the injured foot was 8.0 ± 1.3 weeks and 10.9 ± 2.1 weeks, respectively. All patients, except one who was engaged in classical ballet, could return to their preinjury level of athletic activities, and the interval between operation and return to athletic activities was 17.1 ± 3.7 weeks. CONCLUSION The double SLLS technique with double antislip knots between stumps adjusted the tension of the sutured Achilles tendon at the ideal ankle position and provided good clinical outcomes following accelerated rehabilitation after surgery without the use of a brace. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Wataru Miyamoto
- 1 Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Shinji Imade
- 2 Department of Orthopaedic Surgery, Shimane University School of Medicine, Izumo, Japan
| | - Ken Innami
- 1 Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Hirotaka Kawano
- 1 Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Masato Takao
- 1 Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
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174
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Fröberg Å, Cissé AS, Larsson M, Mårtensson M, Peolsson M, Movin T, Arndt A. Altered patterns of displacement within the Achilles tendon following surgical repair. Knee Surg Sports Traumatol Arthrosc 2017; 25:1857-1865. [PMID: 28004174 PMCID: PMC5487597 DOI: 10.1007/s00167-016-4394-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 12/01/2016] [Indexed: 01/22/2023]
Abstract
PURPOSE Ultrasound speckle tracking was used to compare tendon deformation patterns between uninjured and surgically repaired Achilles tendons at 14-27-month follow-up. The hypothesis was that the non-homogenous displacement pattern previously described in uninjured tendons, where displacement within deep layers of the tendons exceeds that of superficial layers, is altered following tendon rupture and subsequent surgical repair. METHODS In the first part of this study, an in-house-developed block-matching speckle tracking algorithm was evaluated for assessment of displacement on porcine flexor digitorum tendons. Displacement data from speckle tracking were compared to displacement data from manual tracking. In the second part of the study, eleven patients with previous unilateral surgically treated Achilles tendon rupture were investigated using ultrasound speckle tracking. The difference in superficial and deep tendon displacement was assessed. Displacement patterns in the surgically repaired and uninjured tendons were compared during passive motion (Thompson's squeeze test) and during active ankle dorsiflexion. RESULTS The difference in peak displacement between superficial and deep layers was significantly (p < 0.01) larger in the uninjured tendons as compared to the surgically repaired tendons both during Thompson's test (-0.7 ± 0.2 mm compared to -0.1 ± 0.1 mm) and active dorsiflexion (3.3 ± 1.1 mm compared to 0.3 ± 0.2 mm). The evaluation of the speckle tracking algorithm showed correlations of r ≥ 0.89 between displacement data acquired from speckle tracking and the reference displacement acquired from manual tracking. Speckle tracking systematically underestimated the magnitude of displacement with coefficients of variation of less than 11.7%. CONCLUSIONS Uninjured Achilles tendons display a non-uniform displacement pattern thought to reflect gliding between fascicles. This pattern was altered after a mean duration of 19 ± 4 months following surgical repair of the tendon indicating that fascicle sliding is impaired. This may affect modulation of the action between different components of the triceps surae, which in turn may affect force transmission and tendon elasticity resulting in impaired function and risk of re-rupture.
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Affiliation(s)
- Åsa Fröberg
- Division of Orthopaedics and Biotechnology Karolinska University Hospital, Department of Clinical Sciences Intervention and Technology (Clintec), Karolinska University Hospital, Karolinska Institute, Huddinge, 141 86, Stockholm, Sweden.
| | - Ann-Sophie Cissé
- Division of Orthopaedics and Biotechnology Karolinska University Hospital, Department of Clinical Sciences Intervention and Technology (Clintec), Karolinska University Hospital, Karolinska Institute, Huddinge, 141 86 Stockholm, Sweden
| | - Matilda Larsson
- School of Technology and Health, KTH Royal Institute of Technology, Huddinge, Sweden
| | - Mattias Mårtensson
- School of Technology and Health, KTH Royal Institute of Technology, Huddinge, Sweden
| | | | - Tomas Movin
- Division of Orthopaedics and Biotechnology Karolinska University Hospital, Department of Clinical Sciences Intervention and Technology (Clintec), Karolinska University Hospital, Karolinska Institute, Huddinge, 141 86 Stockholm, Sweden ,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Anton Arndt
- Division of Orthopaedics and Biotechnology Karolinska University Hospital, Department of Clinical Sciences Intervention and Technology (Clintec), Karolinska University Hospital, Karolinska Institute, Huddinge, 141 86 Stockholm, Sweden ,The Swedish School of Sports and Health Sciences, Stockholm, Sweden
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175
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Abstract
Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow-derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.
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176
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Marican MM, Fook-Chong SMC, Rikhraj IS. Incidence of postoperative wound infections after open tendo Achilles repairs. Singapore Med J 2016; 56:549-54. [PMID: 26512146 DOI: 10.11622/smedj.2015150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Tendo Achilles (TA), which is the confluence of the gastrocnemius and soleus muscles, is one of the most commonly injured tendons. The surgical repair of TA ruptures is associated with a significant risk of infection. This study examined several factors (i.e. gender, age, body mass index, history of diabetes mellitus, steroid use, acute or chronic TA injuries, type of surgical incision and type of sutures used) that may be associated with postoperative wound infection after open TA repair. METHODS This was a retrospective study involving 60 patients who underwent open TA repair over an 18-month period. Patients who had prior TA surgery or open TA injuries, or who needed soft tissues flaps were excluded. RESULTS Among the patients, 7 (11.7%) developed superficial wound infections that were successfully treated with oral antibiotics, while 3 (5.0%) developed deep wound infections that required at least one debridement procedure. No significant association was found between the risk of postoperative wound infection and gender, age, the presence of diabetes mellitus, acute or chronic ruptures, site of surgical incision and type of deep or superficial sutures used. CONCLUSION While diabetes mellitus and age did not appear to be associated with postoperative wound infections after open TA repair, obese patients were found to be two times more likely to develop a wound infection than normal-weight patients. The incidence of superficial wound infections in this study was similar to previously published results (11.7% vs. 8.2%-14.6%), but the incidence of deep infections was higher (5% vs. 1%-2%).
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Affiliation(s)
- Mohd Mizan Marican
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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177
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Aujla R, Kumar A, Bhatia M. Non-surgical treatment of Achilles rupture: Does duration in functional weight bearing orthosis matter? Foot Ankle Surg 2016; 22:254-258. [PMID: 27810024 DOI: 10.1016/j.fas.2015.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 11/01/2015] [Accepted: 11/07/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of acute Achilles tendon ruptures is continually being debated. The success of non-surgical regimes is now evident yet there remains a high rate of surgery in the United States of America and Scandinavia. Recent studies have investigated functional outcome rather than complication rates as primary outcome but the current data are still sparse. We aimed to investigate whether there is any difference in functional outcomes between two dynamic regimes of differing durations for acute Achilles tendon ruptures. METHODS The patients in the two groups were matched for age, gender, follow-up duration and mechanism of injury. Forty-four patients were managed in a regime of 11 weeks and another 44 patients for 8 weeks. Demographics, injury details, complications and functional outcome were recorded. The validated Achilles Tendon Rupture Score (ATRS) was used to assess functional outcomes. Minimum follow-up was 1 year. RESULTS The 11-week group had a mean age of 50.8 years (range: 27-80) with 36 (82%) males. The 8-week group had a mean age of 52.0 years (range: 32-77) with 36 (82%) males. The mean ATRS for the 11-week group was 76.0 (range: 8-100). The mean ATRS for the 8-week group was 76.1 (range: 30-100). There were no re-ruptures in the 11-week group and one in the 8-week group. There were three episodes of venous thromboembolism in the 11-week group and four in the 8-week group. CONCLUSION A reduction in duration of dynamic rehabilitation for non-operative treatment of Achilles tendon rupture from 11 weeks to 8 weeks does not lead to a significant detriment in functional outcomes or complication rates.
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Affiliation(s)
- Randeep Aujla
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
| | - Amit Kumar
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maneesh Bhatia
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
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178
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Wu Y, Lin L, Li H, Zhao Y, Liu L, Jia Z, Wang D, He Q, Ruan D. Is surgical intervention more effective than non-surgical treatment for acute Achilles tendon rupture? A systematic review of overlapping meta-analyses. Int J Surg 2016; 36:305-311. [DOI: 10.1016/j.ijsu.2016.11.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 10/23/2016] [Accepted: 11/06/2016] [Indexed: 01/08/2023]
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179
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Freedman BR, Gordon JA, Bhatt PB, Pardes AM, Thomas SJ, Sarver JJ, Riggin CN, Tucker JJ, Williams AW, Zanes RC, Hast MW, Farber DC, Silbernagel KG, Soslowsky LJ. Nonsurgical treatment and early return to activity leads to improved Achilles tendon fatigue mechanics and functional outcomes during early healing in an animal model. J Orthop Res 2016; 34:2172-2180. [PMID: 27038306 PMCID: PMC5047851 DOI: 10.1002/jor.23253] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/29/2016] [Indexed: 02/04/2023]
Abstract
Achilles tendon ruptures are common and devastating injuries; however, an optimized treatment and rehabilitation protocol has yet to be defined. Therefore, the objective of this study was to investigate the effects of surgical repair and return to activity on joint function and Achilles tendon properties after 3 weeks of healing. Sprague-Dawley rats (N = 100) received unilateral blunt transection of their Achilles tendon. Animals were then randomized into repaired or non-repaired treatments, and further randomized into groups that returned to activity after 1 week (RTA1) or after 3 weeks (RTA3) of limb casting in plantarflexion. Limb function, passive joint mechanics, and tendon properties (mechanical, organizational using high frequency ultrasound, histological, and compositional) were evaluated. Results showed that both treatment and return to activity collectively affected limb function, passive joint mechanics, and tendon properties. Functionally, RTA1 animals had increased dorsiflexion ROM and weight bearing of the injured limb compared to RTA3 animals 3-weeks post-injury. Such functional improvements in RTA1 tendons were evidenced in their mechanical fatigue properties and increased cross sectional area compared to RTA3 tendons. When RTA1 was coupled with nonsurgical treatment, superior fatigue properties were achieved compared to repaired tendons. No differences in cell shape, cellularity, GAG, collagen type I, or TGF-β staining were identified between groups, but collagen type III was elevated in RTA3 repaired tendons. The larger tissue area and increased fatigue resistance created in RTA1 tendons may prove critical for optimized outcomes in early Achilles tendon healing following complete rupture. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2172-2180, 2016.
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Affiliation(s)
- BR Freedman
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - JA Gordon
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - PB Bhatt
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - AM Pardes
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - SJ Thomas
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA,Department of Kinesiology, Temple University, Philadelphia, PA, USA
| | - JJ Sarver
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA,Department of Biomedical Engineering, Drexel University, Philadelphia, PA, USA
| | - CN Riggin
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - JJ Tucker
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - AW Williams
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - RC Zanes
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - MW Hast
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - DC Farber
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - KG Silbernagel
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - LJ Soslowsky
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
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Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients. Knee Surg Sports Traumatol Arthrosc 2016; 24:3730-3737. [PMID: 25697284 DOI: 10.1007/s00167-015-3544-5] [Citation(s) in RCA: 218] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 02/12/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE The purpose of this study is to investigate the incidence of acute Achilles tendon rupture in Denmark from 1994 to 2013 with focus on sex, age, geographical areas, seasonal variation and choice of treatment. METHODS The National Patient Registry was retrospectively searched to find the number of acute Achilles tendon rupture in Denmark during the time period of 1994-2013. Regional population data were retrieved from the services of Statistics Denmark. RESULTS During the 20-year period, 33,160 ruptures occurred revealing a statistically significant increase in the incidence (p < 0.001, range = 26.95-31.17/100,000/year). Male-to-female ratio was 3:1 and average age 45 years for men and 44 years for women. There was a statistically significant increasing incidence for people over 50 years. A higher incidence in rural compared with urban geographical areas was found, but this was not statistically significant. There was a statistically significant decreasing incidence of patients treated with surgery from 16.9/105 in 1994 to 6.3/105 in 2013. CONCLUSIONS The incidence of acute Achilles tendon rupture increased from 1994 to 2013 based on increasing incidence in the older population. There was no difference in incidence of acute Achilles tendon rupture in the rural compared with urban geographical areas. A steady decline in surgical treatment was found over the whole period, with a noticeable decline from 2009 to 2013, possibly reflecting a rapid change in clinical practice following a range of high-quality randomized clinical trials (RCT). LEVEL OF EVIDENCE IV.
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181
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Barfod KW, Hansen MS, Holmich P, Troelsen A, Kristensen MT. Efficacy of early controlled motion of the ankle compared with no motion after non-operative treatment of an acute Achilles tendon rupture: study protocol for a randomized controlled trial. Trials 2016; 17:564. [PMID: 27894329 PMCID: PMC5127004 DOI: 10.1186/s13063-016-1697-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 11/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early controlled ankle motion is widely used in the non-operative treatment of acute Achilles tendon rupture, though its safety and efficacy have never been investigated in a randomized setup. The objectives of this study are to investigate if early controlled motion of the ankle affects functional and patient-reported outcomes. METHODS/DESIGN The study is performed as a blinded, randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients aged from 18 to 70 years are eligible for inclusion. The intervention group performs early controlled motion of the ankle in weeks 3-8 after rupture. The control group is immobilized. In total, 130 patients will be included from one big orthopedic center over a period of 2½ years. The primary outcome is the patient-reported Achilles tendon Total Rupture Score evaluated at 12 months post-injury. Secondary outcome measures are the heel-rise work test, Achilles tendon elongation, and the rate of re-rupture. The primary analysis will be conducted as intention-to-treat analyses. DISCUSSION This trial is the first to investigate the safety and efficacy of early controlled motion in the treatment of acute Achilles tendon rupture in a randomized setup. The study uses the patient-reported outcome measure, the Achilles tendon Total Rupture Score, as the primary endpoint, as it is believed to be the best surrogate measure for the tendon's actual capability to function in everyday life. TRIAL REGISTRATION ClinicalTrials.gov: NCT02015364 . Registered on 13 December 2013.
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Affiliation(s)
- Kristoffer Weisskirchner Barfod
- Department of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, 2650, Denmark.
| | - Maria Swennergren Hansen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, 2650, Denmark
| | - Per Holmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, 2650, Denmark
| | - Morten Tange Kristensen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, Hvidovre, 2650, Denmark
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Westin O, Nilsson Helander K, Grävare Silbernagel K, Möller M, Kälebo P, Karlsson J. Acute Ultrasonography Investigation to Predict Reruptures and Outcomes in Patients With an Achilles Tendon Rupture. Orthop J Sports Med 2016; 4:2325967116667920. [PMID: 27781212 PMCID: PMC5066526 DOI: 10.1177/2325967116667920] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: The optimal treatment for acute Achilles tendon ruptures is still an ongoing debate. Acute ultrasonography (US) investigation to measure the diastasis between the tendon ends has previously been used to classify acute Achilles tendon ruptures; however, no study has used US to predict reruptures and functional outcomes. Purpose: To investigate whether acute US can be used to predict the risk of reruptures and outcomes after treatment of an acute Achilles tendon rupture. Study Design: Cohort study; Level of evidence, 2. Methods: Forty-five patients (37 men, 8 women) with a mean age of 39 ± 9.2 years (range, 23-59 years) from a cohort of 97 patients participating in a randomized controlled study comparing surgical and nonsurgical treatment were included. US was performed within 72 hours from the index injury. Diastasis between the tendon ends was documented. Reruptures were documented, and the patients’ functional outcomes were measured 12 months after injury. Results: Patients with a diastasis of >10 mm treated nonsurgically had a higher degree of rerupture. In the nonsurgically treated group, 3 of 4 patients with a diastasis of >10 mm suffered from rerupture (P < .001). Moreover, in the nonsurgical group, there was significantly worse outcomes in patients with a diastasis of >5 mm in terms of patient-reported outcomes using the Achilles tendon Total Rupture Score (ATRS) (P = .004) and heel-rise height at 12 months (P = .048) compared with the group with a lesser degree of tendon separation. Conclusion: US may be a useful tool to predict the risk of rerupture and greater degree of functional deficit. It may be an important measure in a clinical treatment algorithm for deciding whether a patient will benefit from surgical intervention after an acute Achilles tendon rupture.
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Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.; Sahlgrenska University Hospital, Mölndal, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.; Hallands Sjukhus, Kungsbacka, Sweden
| | - Karin Grävare Silbernagel
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.; Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Michael Möller
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.; Sahlgrenska University Hospital, Mölndal, Sweden
| | - Peter Kälebo
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.; Sahlgrenska University Hospital, Mölndal, Sweden
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183
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Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med 2016; 44:2406-14. [PMID: 27307495 DOI: 10.1177/0363546516651060] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment of acute Achilles tendon ruptures for active patients is under debate. PURPOSE To compare clinical outcomes and calf muscle strength recovery after the nonsurgical treatment and open surgical repair of acute Achilles tendon ruptures with identical accelerated rehabilitation programs. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS From 2009 to 2013, a total of 60 patients with an acute Achilles tendon rupture were randomized to surgery or nonsurgical treatment. Nonsurgical treatment included first a week of cast immobilization, followed by a functional orthosis for 6 weeks, allowing full weightbearing after week 1 and active plantar flexion after week 5. Surgery was simple end-to-end open repair, and postoperative treatment was identical to nonsurgical treatment. Outcome measures included the Leppilahti Achilles tendon performance score, isokinetic calf muscle strength, and RAND 36-Item Health Survey at 18-month follow-up. RESULTS At 18-month follow-up, the mean Leppilahti score was 79.5 and 75.7 for the surgically and nonsurgically treated groups, respectively (mean difference, 3.8; 95% CI, -1.9 to 9.5; P = .19). Angle-specific peak torque results of affected legs showed that surgery resulted in faster and better recovery of calf muscle strength over the entire range of motion of the ankle joint: at 6 months, the difference varied from 16% to 24% (P = .016), favoring the surgically treated group, whereas at 18 months, surgically treated patients had 10% to 18% greater strength results (P = .037). At 18 months, a 14% difference in the peak torque of the affected leg favored the surgical group versus the nonsurgical group (mean peak torque, 110.3 vs 96.5 N·m, respectively; mean difference, 13.6 N·m; 95% CI, 2.0-25.1 N·m; P = .022). The RAND 36-Item Health Survey indicated better results in the domains of physical functioning (P = .006) and bodily pain (P = .037) for surgically treated patients. CONCLUSION Surgical and nonsurgical treatments of acute Achilles tendon ruptures have similar results in terms of the Achilles tendon performance score, but surgery restores calf muscle strength earlier over the entire range of motion of the ankle joint, with a 10% to 18% strength difference favoring surgery at 18 months. Surgery may also result in better health-related quality of life in the domains of physical functioning and bodily pain compared with nonsurgical treatment. REGISTRATION NCT02012803 (ClinicalTrials.gov).
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Affiliation(s)
- Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Tapio Flinkkila
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Pertti Siira
- Department of Physical and Rehabilitation Medicine, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Vesa Laine
- Department of Physical and Rehabilitation Medicine, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
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184
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Ozer H, Selek HY, Harput G, Oznur A, Baltaci G. Achilles Tendon Open Repair Augmented With Distal Turndown Tendon Flap and Posterior Crural Fasciotomy. J Foot Ankle Surg 2016; 55:1180-1184. [PMID: 27567345 DOI: 10.1053/j.jfas.2016.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Indexed: 02/03/2023]
Abstract
The aim of the present study was to investigate the outcomes after open repair of Achilles tendon rupture augmented with a distal turndown gastrocnemius flap and deep posterior crural fasciotomy based on the modified Lindholm technique. Twenty-three patients with acute Achilles tendon injury underwent open end-to-end tendon repair augmented with a distal turndown gastrocnemius flap and deep posterior compartment fasciotomy. The concentric and eccentric muscle strength was measured using a functional squat system, and dynamic balance was assessed using the Y-balance test with anterior, posteromedial, and posterolateral reach distances. Jump performance was assessed using the vertical jump and 1-leg hop tests. All patients returned to their preinjury activity level, and their mean American Orthopaedic Foot and Ankle Society hindfoot scale score was 98.2 ± 2.3 after surgery. No significant difference was found between the involved and uninvolved extremities in terms of concentric and eccentric muscle strength (p = .82 and p = .53, respectively). In addition, no significant differences were seen between legs in the vertical jump (p = .16), one-leg hop (p = .15), and balance (p > .05) tests. Open end-to-end repair of the Achilles tendon rupture with augmentation and fasciotomy of the deep posterior compartment healed without any major complications. Functional performance of the involved leg after recovery was similar to that of the uninvolved leg. The modified Lindholm surgical technique described in our report appears to be a useful intervention for acute Achilles tendon rupture.
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Affiliation(s)
- Hamza Ozer
- Professor, Department of Orthopaedics and Trauma, University of Gazi, Ankara, Turkey.
| | - Hakan Y Selek
- Professor, Department of Orthopaedics and Trauma, University of Gazi, Ankara, Turkey
| | - Gulcan Harput
- Professor, Academy of Health Sciences, Physiotherapy and Rehabilitation, University of Hacettepe, Ankara, Turkey
| | - Ali Oznur
- Associate Professor, Department of Orthopaedics and Traumatology, Private Guven Hospital, Ankara, Turkey
| | - Gul Baltaci
- Professor, Department of Physical Therapy and Rehabilitation, Private Guven Hospital, Ankara, Turkey
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185
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Chang YP, Shih KS, Chiang H, Ma HL, Lin LC, Peng WC, Wen CS, Wang HK. Characteristics of Intratendinous Microcirculation Shortly After an Achilles Rupture and Subsequent Treatment Outcomes. PM R 2016; 9:32-39. [PMID: 27317915 DOI: 10.1016/j.pmrj.2016.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 06/04/2016] [Accepted: 06/10/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early microcirculatory responses after experimental tenotomy are critical to the healing of tendons and their ultimate tensile strength. The effects of changes in microcirculation on the outcomes of tendon healing, however, have not been determined. OBJECTIVES To assess microcirculation values in injured Achilles tendons in the first 3 months after surgical repair and to correlate the inter-limb microcirculatory changes with functional outcomes at 3 and 6 months after surgery. DESIGN Case-control study. SETTING A university sports physiotherapy laboratory. PARTICIPANTS Thirteen subjects (median age: 45 years; range: 34.8-51.9 years) with a repaired Achilles tendon were recruited. METHODS OR INTERVENTION Surgical repair. MAIN OUTCOME MEASUREMENTS Measurements were obtained at 1, 2, 3, and 6 months after surgery. Bilateral measurements of tendon microcirculation (total hemoglobin [THb] and oxygen saturation [StO2]) were recorded at the first 3 time points, whereas outcome measures of a Taiwan Chinese version of the Victorian Institute of Sport Assessment Scale-Achilles questionnaire, one-leg hopping distance, the star excursion balance test, and the heel raise index were conducted at the third and fourth time points. Correlations between the inter-limb microcirculatory changes, eg, between the measurements at 2 months and 1 month (2-1) after surgery, at 3 months and 2 months (3-2) after surgery, and at 3 months and 1 month (3-1) after surgery, and the outcome measures were investigated. RESULTS Compared with the noninjured tendons, the repaired Achilles demonstrated greater THb (at 1, 2, and 3 months; P = .017, .008, and .012 respectively) and StO2 (at 3 months; P = .017). Furthermore, the THb2-1 and THb3-2, StO2 2-1, and StO2 3-2 showed correlations with the heel raise index, differences in the star excursion balance test and one-leg hopping distance between the noninjured leg and injured leg, and Taiwan Chinese version of the Victorian Institute of Sport Assessment Scale-Achilles questionnaire scores (rho -0.921 to 0.855). CONCLUSIONS Changes in the inter-limb microcirculation shortly after Achilles repair were correlated with subsequent symptoms and functional symmetry. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yi-Ping Chang
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University; and Center of Physical Therapy, National Taiwan University Hospital, Taipei, Taiwan, Republic of China(∗)
| | - Kao-Shang Shih
- Department of Orthopedic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Republic of China(†)
| | - Hongsen Chiang
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan, Republic of China(‡)
| | - Hsiao-Li Ma
- Sports Medicine Department, Orthopedic Department, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China(§)
| | - Leou-Chyr Lin
- Division of Sports Medicine, Department of Orthopedics, Tri-Service General Hospital, Taipei, Taiwan, Republic of China(¶)
| | - Wei-Chen Peng
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University; and Center of Physical Therapy, National Taiwan University Hospital, Taipei, Taiwan, Republic of China(#)
| | - Che-Sheng Wen
- Department of Orthpaedics, Chen Hsin General Hospital, Taipei, Taiwan, Republic of China(∗∗)
| | - Hsing-Kuo Wang
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University; and Center of Physical Therapy, National Taiwan University Hospital, Floor 3, No.17, Xuzhou Rd., Zhongzheng District, Taipei City 100, Taiwan, Republic of China(††).
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186
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Zellers JA, Carmont MR, Grävare Silbernagel K. Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Br J Sports Med 2016; 50:1325-1332. [PMID: 27259751 DOI: 10.1136/bjsports-2016-096106] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 12/26/2022]
Abstract
AIM This systematic review and meta-analysis sought to identify return to play (RTP) rates following Achilles tendon rupture and evaluate what measures are used to determine RTP. DESIGN A systematic review and meta-analysis were performed. Studies were assessed for risk of bias and grouped based on repeatability of their measure of RTP determination. DATA SOURCES PubMed, CINAHL, Web of Science and Scopus databases were searched to identify potentially relevant articles. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies reporting RTP/sport/sport activity in acute, closed Achilles tendon rupture were included. RESULTS 108 studies encompassing 6506 patients were included for review. 85 studies included a measure for determining RTP. The rate of RTP in all studies was 80% (95% CI 75% to 85%). Studies with measures describing determination of RTP reported lower rates than studies without metrics described, with rates being significantly different between groups (p<0.001). CONCLUSIONS 80 per cent of patients returned to play following Achilles tendon rupture; however, the RTP rates are dependent on the quality of the method used to measure RTP. To further understand RTP after Achilles tendon rupture, a standardised, reliable and valid method is required.
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Affiliation(s)
- Jennifer A Zellers
- Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA
| | - Michael R Carmont
- Department of Orthopaedic Surgery, The Princess Royal Hospital, Telford, Shropshire, UK.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Grävare Silbernagel
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
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187
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Mark-Christensen T, Troelsen A, Kallemose T, Barfod KW. Functional rehabilitation of patients with acute Achilles tendon rupture: a meta-analysis of current evidence. Knee Surg Sports Traumatol Arthrosc 2016; 24:1852-9. [PMID: 25051909 DOI: 10.1007/s00167-014-3180-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 07/08/2014] [Indexed: 12/28/2022]
Abstract
PURPOSE The optimal treatment for acute Achilles tendon rupture (ATR) is continuously debated. Recent studies have proposed that the choice of either operative or non-operative treatment may not be as important as rehabilitation, suggesting that functional rehabilitation should be preferred over traditional immobilization. The purpose of this meta-analysis of randomized controlled trials (RCTs) was to compare functional rehabilitation to immobilization in the treatment of ATR. METHOD This meta-analysis was conducted using the databases: PubMed, EMBASE, Rehabilitation and Sports Medicine Source, AMED, CINAHL, Cochrane Library and PEDro using the search terms: "Achilles tendon," "rupture," "mobilization" and "immobilization". Seven RCTs involving 427 participants were eligible for inclusion, with a total of 211 participants treated with functional rehabilitation and 216 treated with immobilization. RESULTS Re-rupture rate, other complications, strength, range of motion, duration of sick leave, return to sport and patient satisfaction were examined. There were no statistically significant differences between groups. A trend favoring functional rehabilitation was seen regarding the examined outcomes. CONCLUSION Functional rehabilitation after acute Achilles tendon rupture does not increase the rate of re-rupture or other complications. A trend toward earlier return to work and sport, and increased patient satisfaction was found when functional rehabilitation was used. The present literature is of low-to-average quality, and the basic constructs of the examined treatment and study protocols vary considerably. Larger, randomized controlled trials using validated outcome measures are needed to confirm the findings. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Troels Mark-Christensen
- Physiotherapist at Fysiocenter Århus, Brendstrupgaardsvej 9B 1.005, 8200, Aarhus N, Denmark.
| | - Anders Troelsen
- Department of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Thomas Kallemose
- Department of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Department of Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Denmark
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188
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Silbernagel KG, Shelley K, Powell S, Varrecchia S. Extended field of view ultrasound imaging to evaluate Achilles tendon length and thickness: a reliability and validity study. Muscles Ligaments Tendons J 2016; 6:104-10. [PMID: 27331037 DOI: 10.11138/mltj/2016.6.1.104] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Achilles tendon structural changes are common after injury and correlate with recovery of function. Having simple, inexpensive, yet valid and reliable measures of Achilles tendon structure are useful both in research and clinical. The purpose of this study was to perform reliability and validity measures of extended field of view (EFOV) ultrasound (US) imaging of the Achilles tendon. METHODS eight cadavers (16 tendons) were used for the validation study to compare Achilles tendon length measurements from US images with actual measured length from dissected tendons. Nine healthy subjects (18 tendons) were included in the test-retest evaluation. RESULTS the correlation between the US images and cadaveric measurements was excellent (ICC=0.895) for the length between calcaneus and the gastrocnemius and good (ICC=0.744) for the length between the calcaneus and the soleus. The between-limb reliability was excellent (ICC 0.886-0.940) for the tendon length measurements with standard error of measurements (SEM) of 0.64 cm for calcaneus to soleus and 0.67 cm for calcaneus to gastrocnemius. Between-day test-retest reliability was also excellent (ICC=0.898-0.944). CONCLUSION this study supports the use of EFOV US imaging as a reliable and valid method to determine Achilles tendon length and thickness, and using the uninjured limb for comparison.
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Affiliation(s)
| | - Kristen Shelley
- Department of Physical Therapy for University of the Sciences, Philadelphia, USA
| | - Stephen Powell
- Department of Physical Therapy for University of the Sciences, Philadelphia, USA
| | - Shaun Varrecchia
- Department of Physical Therapy for University of the Sciences, Philadelphia, USA
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189
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Flynn S, Ross KA, Hannon CP, Yasui Y, Newman H, Murawski CD, Deyer TW, Do HT, Kennedy JG. Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus. Foot Ankle Int 2016; 37:363-72. [PMID: 26666678 DOI: 10.1177/1071100715620423] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Autologous osteochondral transplantation (AOT) is used to treat osteochondral lesions (OCLs) of the talus, typically reserved for lesions greater than 150 mm(2). Few studies exist examining the functional and magnetic resonance imaging (MRI) outcomes following this procedure. The purpose of this study was to investigate functional and MRI outcomes, including quantitative T2 mapping following AOT. METHODS Eighty-five consecutive patients who underwent AOT were identified. Functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used to assess cartilage incorporation. Quantitative T2 MRI relaxation time of graft tissue and adjacent normal cartilage values were recorded in a subset of 61 patients. The mean clinical follow-up was 47.2 months, with mean MRI follow-up of 24.8 months. RESULTS Mean FAOS improved pre- to postoperatively from 50 to 81 (P < .001). The mean MOCART score was 85.8. Lesion size was negatively correlated with MOCART score (r = -0.36, P = .004). Superficial T2 values in graft tissue were higher than control tissue (42.0 vs 35.8, P < .001). Deep T2 values in graft tissue were similar to the control values (30.9 vs 30.0, P = .305). Functional outcomes were similar in patients irrespective of whether they had previous microfracture or concomitant procedures. CONCLUSION AOT was an effective treatment for large OCLs of the talus in the current study. MOCART scoring indicated good structural integrity of the graft. Quantitative T2 mapping suggests that graft tissue may not always mirror native hyaline cartilage. The long-term implications of this are not yet known. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Seán Flynn
- Hospital for Special Surgery, New York, NY, USA
| | - Keir A Ross
- Hospital for Special Surgery, New York, NY, USA
| | | | - Youichi Yasui
- Hospital for Special Surgery, New York, NY, USA Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | | | | | | | - Huong T Do
- Hospital for Special Surgery, New York, NY, USA
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190
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Ecker TM, Bremer AK, Krause FG, Müller T, Weber M. Prospective Use of a Standardized Nonoperative Early Weightbearing Protocol for Achilles Tendon Rupture: 17 Years of Experience. Am J Sports Med 2016; 44:1004-10. [PMID: 26818449 DOI: 10.1177/0363546515623501] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute traumatic rupture of the Achilles tendon can be treated operatively or nonoperatively. Throughout the literature, there is no consensus regarding the optimal treatment protocol. PURPOSE To report on 17 years of experience with treating this injury with a standardized nonoperative treatment protocol. STUDY DESIGN Case Series; Level of evidence, 4. METHODS The treatment protocol was based on a combination of an equinus cast and rehabilitation boot, which promoted immediate full weightbearing and early functional rehabilitation. A total of 171 patients were consecutively treated and prospectively followed from 1996 to 2013. Assessed were subjective parameters such as pain, loss of strength, return to previous activity level, meteosensitivity, and general satisfaction with the treatment outcome. Clinical assessment included testing of plantar flexion strength and endurance, calf circumference, and tendon length. Subjective and clinical parameters were then used to calculate a modified Thermann score. The correlation between tendon lengthening and function was calculated using the Pearson correlation coefficient. RESULTS A total of 114 patients were followed for a minimum of 12 months (mean, 27 ± 20 months; range, 12-88 months). The mean Thermann score was 82 ± 13 (range, 41-100), and subjective satisfaction was rated "very good" and "good" in 90%. An inverse correlation was found between tendon length and muscle strength (R = -0.3). There were 11 reruptures (8 with and 3 without an adequate trauma). General complications were 5 deep venous thromboses, 1 complex regional pain syndrome, and minor problems such as transient heel pain (n = 3), heel numbness (n = 1), and cast-associated skin abrasions (n = 4). CONCLUSION Seventeen years of experience with a nonoperative treatment protocol for acute rupture of the Achilles tendon confirmed good functional outcome and patient satisfaction. Reruptures mostly occurred with new traumatic events in the vulnerable phase from 6 to 12 weeks after the initial injury. Muscle strength correlated to tendon length, making its assessment a crucial follow-up parameter. The protective equinus cast and boot can protect against excessive tendon lengthening during the healing process.
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Affiliation(s)
- Timo M Ecker
- Department of Orthopaedic Surgery, Inselspital, University of Berne, Bern, Switzerland
| | - Anne K Bremer
- Department of Orthopaedic Surgery, Siloah Hospital, Bern, Switzerland
| | - Fabian G Krause
- Department of Orthopaedic Surgery, Inselspital, University of Berne, Bern, Switzerland
| | - Thorsten Müller
- Department of Orthopaedic Surgery, Inselspital, University of Berne, Bern, Switzerland
| | - Martin Weber
- Department of Orthopaedic Surgery, Siloah Hospital, Bern, Switzerland
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191
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De la Fuente C, Peña y Lillo R, Carreño G, Marambio H. Prospective randomized clinical trial of aggressive rehabilitation after acute Achilles tendon ruptures repaired with Dresden technique. Foot (Edinb) 2016; 26:15-22. [PMID: 26802945 DOI: 10.1016/j.foot.2015.10.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/04/2015] [Accepted: 10/07/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rupture of the Achilles tendon is a common injury during working years. Aggressive rehabilitation may provide better outcomes, but also a greater chance of re-rupture. OBJECTIVE To determine if aggressive rehabilitation has better clinical outcomes for Achilles tendon function, Triceps surae function, one-leg heel rise capacity and lower complication rate during twelve weeks after percutaneous Achilles tendon repair compared to conventional rehabilitation. DESIGN Randomized controlled trial. METHOD Thirty-nine patients were prospectively randomized. The aggressive group (n=20, 41.4 ± 8.3 years) received rehabilitation from the first day after surgery. The conventional group (n=19, 41.7 ± 10.7 years) rested for 28 days, before rehabilitation started. The statistical parameters were the Achilles tendon rupture score (ATRS), verbal pain scale, time to return to work, pain medication consumption, Achilles tendon strength, dorsiflexion range of motion (RoM), injured-leg calf circumference, calf circumference difference, one-leg heel rise repetition and difference, re-rupture rate, strength deficit rate, and other complication rates. Mixed-ANOVA and Bonferroni's post hoc test were performed for multiple comparisons. Student's t-test was performed for parameters measured on the 12th week. RESULTS The aggressive group with respect to the conventional group had a higher ATRS; lower verbal pain score; lower pain medication consumption; early return to work; higher Achilles tendon strength; higher one-leg heel rise repetitions; and lower one-leg heel rise difference. The re-rupture rate was 5% and 5%, the strength deficit rate was 42% and 5%, and other complications rate was 11% and 15% in the conventional and aggressive group, respectively. CONCLUSION Patients with Dresden repair and aggressive rehabilitation have better clinical outcomes, Achilles tendon function and one-leg heel rise capacity without increasing the postoperative complications rate after 12 weeks compared to rehabilitation with immobilization and non-weight-bearing during the first 28 days after surgery.
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Affiliation(s)
- Carlos De la Fuente
- Biomechanics Unit, Centro de Investigaciones Médicas del Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile; Carrera de Kinesiología, UDA Cs Salud, Facultad Medicina, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile; Mechanics Department, Engineer Faculty, USACH, Santiago 717835, Chile; Kinesiology and Clinical Biomechanics Program, UMCE, Santiago 7780450, Chile.
| | - Roberto Peña y Lillo
- Foot and Ankle Unit, Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile; Servicio de Kinesiterapia y Terapia Ocupacional, Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile.
| | - Gabriel Carreño
- Laboratorio de Movimiento Humano, Escuela de Kinesiología, Facultad de Salud y Odontología, Universidad Diego Portales, Santiago 8370109, Chile; Facultad de Ciencias de la Salud, Universidad Iberoamericana de Ciencias y Tecnología, Santiago 8330440, Chile.
| | - Hugo Marambio
- Trauma Service, Clínica Santa María, Santiago 7520378, Chile; Exercise Science Laboratory, School of Kinesiology, Faculty of Medicine, Universidad Finis Terrae, Santiago 7501015, Chile.
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Renninger CH, Kuhn K, Fellars T, Youngblood S, Bellamy J. Operative and Nonoperative Management of Achilles Tendon Ruptures in Active Duty Military Population. Foot Ankle Int 2016; 37:269-73. [PMID: 26537241 DOI: 10.1177/1071100715615322] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal management of Achilles tendon ruptures continues to be a subject of debate in orthopedics. These injuries are common in the active duty military population. The purpose of this study was to retrospectively compare the results of operative and nonoperative management of Achilles tendon ruptures in the active duty military population following the publication of a landmark level I study that has influenced practice patterns. METHODS All Achilles tendon injuries in active duty patients were identified at a single military institution from January 1, 2011, to January 1, 2014. Inclusion and exclusion criteria were applied and charts were reviewed. Demographic and treatment information were recorded along with return to duty status, deep vein thrombosis (DVT), rerupture, and other complication data. Rates of DVT, rerupture, other complications, and return to duty (including time to return) were then compared. Demographic data were described. Fifty-seven male patients met inclusion criteria with an average age of 31 years. There were 27 in the operative group and 30 in the nonoperative group. There were no significant differences in group demographics. RESULTS There were no DVTs in either treatment group. There were no wound complications in the operative group. There were no significant differences in the rates of rerupture, return to duty, or other complications. There were 2 reruptures in the nonoperative group. Both were treated nonoperatively. There was one rerupture in the operative group that was treated nonoperatively. All reruptures were partial tears. Two patients underwent repair with flexor hallucis longus augmentation. Both of these patients were initially managed nonoperatively. When available data on time to return to duty was analyzed, patients who underwent operative management returned to duty on average approximately one and a half months earlier (6.7 vs 8.2 months) than nonoperative patients (P = .04). In 2011, 12% of injuries were treated nonoperatively; in 2012, 57%; and in 2013, 84%. CONCLUSIONS Similar to previously published work, this retrospective analysis found no significant difference in complication, DVT, or rerupture rates. The rate of rerupture in this study was slightly higher than previously published work in the era of functional rehabilitation, but the sample size was small. The data were limited with respect to functional outcome for comparison; however, the rate of return to active duty was not significantly different. The data also demonstrate a shift in institutional treatment pattern for Achilles injuries in this population over the 3-year study period. Operatively treated patients did have a statistically significant reduction in the time required to return to active duty of approximately one and a half months, which may represent a clinically significant difference in highly active workers or highly active people. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Christopher H Renninger
- Trauma and Foot and Ankle Surgery, Department of Orthopedics, Naval Medical Center San Diego, San Diego California, San Diego, CA, USA
| | - Kevin Kuhn
- Trauma and Foot and Ankle Surgery, Department of Orthopedics, Naval Medical Center San Diego, San Diego California, San Diego, CA, USA
| | - Todd Fellars
- Trauma and Foot and Ankle Surgery, Department of Orthopedics, Naval Medical Center San Diego, San Diego California, San Diego, CA, USA
| | - Scot Youngblood
- Trauma and Foot and Ankle Surgery, Department of Orthopedics, Naval Medical Center San Diego, San Diego California, San Diego, CA, USA
| | - Joseph Bellamy
- Trauma and Foot and Ankle Surgery, Department of Orthopedics, Naval Medical Center San Diego, San Diego California, San Diego, CA, USA
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193
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Wang D, Sandlin MI, Cohen JR, Lord EL, Petrigliano FA, SooHoo NF. Operative versus nonoperative treatment of acute Achilles tendon rupture: An analysis of 12,570 patients in a large healthcare database. Foot Ankle Surg 2015; 21:250-3. [PMID: 26564726 DOI: 10.1016/j.fas.2015.01.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 12/29/2014] [Accepted: 01/21/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to compare the latest patient demographics and rerupture rates of operative versus nonoperative treatment of acute Achilles tendon rupture in the United States. METHODS Patients undergoing treatment of an acute Achilles tendon rupture from 2007 to 2011 were identified by cross-referencing ICD-9-CM and CPT codes through the PearlDiver Patient Record Database. RESULTS In total, 12,570 patients were treated for an acute Achilles tendon rupture. The ratio of operative to nonoperative treatment increased from 1.41 to 1.65. Males were more likely to undergo surgery than females. There were no significant differences in short-term rerupture rate for operative (2.1%) versus nonoperative (2.4%) treatment. CONCLUSIONS The proportion of patients who received operative treatment for an acute Achilles tendon rupture increased slightly during the 5 year period, suggesting that surgeons in the United States have been slower to adopt nonoperative treatment than their European counterparts.
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Affiliation(s)
- Dean Wang
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA 90095, USA
| | - M Isiah Sandlin
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA 90095, USA
| | - Jeremiah R Cohen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA 90095, USA
| | - Elizabeth L Lord
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA 90095, USA
| | - Frank A Petrigliano
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA 90095, USA
| | - Nelson F SooHoo
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA 90095, USA.
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194
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Labib SA, Hoffler CE, Shah JN, Rolf RH, Tingan A. The Gift Box Open Achilles Tendon Repair Method: A Retrospective Clinical Series. J Foot Ankle Surg 2015; 55:39-44. [PMID: 26422650 DOI: 10.1053/j.jfas.2015.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Indexed: 02/03/2023]
Abstract
Previous biomechanical studies have shown that the gift box technique for open Achilles tendon repair is twice as strong as a Krackow repair. The technique incorporates a paramedian skin incision with a midline paratenon incision, and a modification of the Krackow stitch is used to reinforce the repair. The wound is closed in layers such that the paratenon repair is offset from paramedian skin incision, further protecting the repair. The present study retrospectively reviews the clinical results for a series of patients who underwent the gift box technique for treatment of acute Achilles tendon ruptures from March 2002 to April 2007. The patients completed the Foot Function Index and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale. The tendon width and calf circumference were measured bilaterally and compared using paired t tests with a 5% α level. A total of 44 subjects, mean age 37.5 ± 8.6 years, underwent surgery approximately 10.8 ± 6.5 days after injury. The response rate was 35 (79.54%) patients for the questionnaire and 20 (45.45%) for the examination. The mean follow-up period was 35.7 ± 20.1 months. The complications included one stitch abscess, persistent pain, and keloid formation. One (2.86%) respondent reported significant weakness. Five (14.29%) respondents indicated persistent peri-incisional numbness. The range of motion was full or adequate. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score was 93.2 ± 6.8) and the mean Foot Function Index score was 7.0 ± 10.5. The calf girth and tendon width differences were statistically significantly between the limbs. The patients reported no repeat ruptures, sural nerve injuries, dehiscence, or infections. We present the outcomes data from patients who had undergone this alternative technique for Achilles tendon repair. The technique is reproducible, with good patient satisfaction and return to activity. The results compared well with the historical repeat rupture rates and incidence of nerve injury and dehiscence for open and percutaneous Achilles tendon repairs.
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Affiliation(s)
- Sameh A Labib
- Associate Professor of Orthopaedic Surgery, Emory University, Atlanta, GA.
| | - C Edward Hoffler
- Orthopaedic Surgeon, The Miami Hand and Upper Extremity Institute, Miami, FL
| | - Jay N Shah
- Orthopaedic Surgeon, Sports Medicine Fellow, Emory University, Atlanta, GA
| | - Robert H Rolf
- Orthopaedic Surgeon, Beacon Orthopaedics and Sports Medicine, Cincinnati, OH
| | - Alexis Tingan
- Physical Medicine and Rehabilitation Resident, Hospital of the University of Pennsylvania, Philadelphia, PA
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195
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Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Kangas J, Siira P, Leppilahti J. Early functional treatment versus cast immobilization in tension after achilles rupture repair: results of a prospective randomized trial with 10 or more years of follow-up. Am J Sports Med 2015; 43:2302-9. [PMID: 26229048 DOI: 10.1177/0363546515591267] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are no long-term prospective controlled trials comparing postoperative regimens after Achilles tendon rupture repair. PURPOSE To compare ≥10-year outcomes of 2 postoperative regimens after Achilles tendon rupture repair: early weightbearing with early mobilization versus early weightbearing with early immobilization in tension. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 50 patients with acute Achilles tendon ruptures were randomized postoperatively to receive either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks (group 1) or Achilles tendon immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks (group 2). Patients were assessed at 3, 6, and 14 months and 11 years postoperatively. RESULTS There were 37 patients (74%) evaluated at a mean (±SD) of 11.0 ± 0.9 years. The mean Leppilahti score was 92.9 ± 5.6 in group 1 and 93.6 ± 7.2 in group 2 (P = .68). The mean isokinetic plantar flexion peak torque deficits or average work deficits in plantar flexion showed no differences between the groups with any angular velocity. Isokinetic strength changed minimally between 1 and 11 years compared with the unaffected ankle, but a mean deficit of 5% in peak torque and mean deficit of 8% in average work were still present after 11 years. On the contrary, isometric plantar flexion strength recovered significantly, with only a 2.4% difference at 11-year follow-up. CONCLUSION After the 11-year follow-up, early mobilization and immobilization in tension after Achilles rupture repair resulted in similar clinical outcomes and isokinetic strengths. Regardless of patient satisfaction with the operative treatment, calf muscle strength did not recover normally even at 11-year follow-up.
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Affiliation(s)
- Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tapio Flinkkila
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Jarmo Kangas
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pertti Siira
- Department of Physical Medicine and Rehabilitation, Oulu University Hospital, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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196
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Brorsson A, Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Silbernagel KG. Recovery of calf muscle endurance 3 months after an Achilles tendon rupture. Scand J Med Sci Sports 2015; 26:844-53. [DOI: 10.1111/sms.12533] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2015] [Indexed: 01/26/2023]
Affiliation(s)
- A. Brorsson
- Department of Orthopaedics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- IFK Kliniken Rehab; Gothenburg Sweden
| | - N. Olsson
- Department of Orthopaedics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Orthocenter IFK-Kliniken; Gothenburg Sweden
- Sahlgrenska University Hospital; Mölndal Sweden
| | - K. Nilsson-Helander
- Department of Orthopaedics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Hallands sjukhus; Kungsbacka Sweden
| | - J. Karlsson
- Department of Orthopaedics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Sahlgrenska University Hospital; Mölndal Sweden
| | - B. I. Eriksson
- Department of Orthopaedics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Sahlgrenska University Hospital; Mölndal Sweden
| | - K. G. Silbernagel
- Department of Orthopaedics; Institute of Clinical Sciences at Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Physical Therapy; University of Delaware; Newark Delaware USA
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197
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Silbernagel KG, Brorsson A, Olsson N, Eriksson BI, Karlsson J, Nilsson-Helander K. Sex Differences in Outcome After an Acute Achilles Tendon Rupture. Orthop J Sports Med 2015; 3:2325967115586768. [PMID: 26665094 PMCID: PMC4622365 DOI: 10.1177/2325967115586768] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Tendon healing differs between the sexes. Comparisons in outcome between the sexes after an Achilles tendon rupture are often not possible because of the small cohort (<20%) of women. Purpose: To evaluate whether there are any differences in outcome between the sexes by combining the data from 2 large randomized controlled trials that used identical outcome measures. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the evaluation were patients from 2 consecutive randomized controlled trials comparing surgical and nonsurgical treatment performed at our research laboratory. Patients who had a rerupture were excluded from analysis. A total of 182 patients (152 males, 30 females), with mean ± SD age of 40 ± 11 years, were included; 94 (76 males, 18 females) were treated with surgery and 88 (76 males, 12 females) nonsurgically. Patient-reported outcome was evaluated using the Achilles tendon Total Rupture Score (ATRS), and the functional outcome was measured with a heel-rise test (measurement of muscular endurance and heel-rise height) at 6 and 12 months after injury. Results: Male patients had a greater improvement in heel-rise height at 12 months (P = .004). When each treatment group was analyzed separately, it was found that female patients had significantly (P < .03) more symptoms after surgical treatment (mean ± SD ATRS, 59 ± 24) compared with males at 6 (73 ± 19) and 12 months (74 ± 27 vs 86.5 ± 17). This sex difference was not found in the nonsurgical treatment group. For the entire group, there were no significant differences between treatments on ATRS at 6 and 12 months. The surgical group had significantly better results compared with the nonsurgical group in heel-rise endurance at 6 and 12 months and in heel-rise height recovery at 6 months (P < .03 for both). Conclusion: Sex differences were demonstrated, and female patients had a greater degree of deficit in heel-rise height as compared with males, irrespective of treatment. Females had more symptoms after surgery both at 6 and 12 months, but this difference was not found when treated nonsurgically. Clinical Relevance: Further research is needed to determine whether women will benefit more from nonsurgical compared with surgical treatment after an Achilles tendon rupture.
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Affiliation(s)
- Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA. ; Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. ; IFK Kliniken Rehab, Gothenburg, Sweden
| | - Nicklas Olsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. ; Sahlgrenska University Hospital, Mölndal, Sweden
| | - Bengt I Eriksson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. ; Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. ; Sahlgrenska University Hospital, Mölndal, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. ; ¶Hallands Sjukhus, Kungsbacka, Sweden
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198
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Affiliation(s)
- John A Tanksley
- Department of Orthopaedic Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908
| | - Richard Ma
- Missouri Orthopaedic Institute, 1100 Virginia Avenue, Columbia, MO 65212
| | - MaCalus V Hogan
- Department of Orthopaedic Surgery, Kaufmann Medical Building, 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA 15213
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908
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199
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Guss D, Smith JT, Chiodo CP. Acute Achilles Tendon Rupture: A Critical Analysis Review. JBJS Rev 2015; 3:01874474-201504000-00002. [PMID: 27490254 DOI: 10.2106/jbjs.rvw.n.00015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Daniel Guss
- MGM Comprehensive Foot and Ankle Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | - Jeremy T Smith
- Brigham Foot and Ankle Center, Department of Orthopaedic Surgery, Brigham and Women's Faulkner Hospital, 1153 Centre Street, Suite 56, Boston, MA 02130
| | - Christopher P Chiodo
- Brigham Foot and Ankle Center, Department of Orthopaedic Surgery, Brigham and Women's Faulkner Hospital, 1153 Centre Street, Suite 56, Boston, MA 02130
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200
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Stein BE, Stroh DA, Schon LC. Outcomes of acute Achilles tendon rupture repair with bone marrow aspirate concentrate augmentation. INTERNATIONAL ORTHOPAEDICS 2015; 39:901-5. [PMID: 25795246 DOI: 10.1007/s00264-015-2725-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 02/25/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE Optimal treatment of acute Achilles tendon ruptures remains controversial. Positive results using stem-cell-bearing concentrates have been reported with other soft-tissue repairs, but no studies exist on outcomes of bone marrow aspirate concentrate (BMAC) augmentation in primary Achilles tendon repair. METHODS We reviewed patients with sport-related Achilles tendon ruptures treated via open repair augmented with BMAC injection from 2009 to 2011. Data on operative complications, strength, range of motion, rerupture, calf circumference and functional improvement through progressive return to sport and the Achilles tendon Total Rupture Score (ATRS) were analysed. RESULTS A total of 27 patients (28 tendons) treated with open repair and BMAC injection were identified (mean age 38.3 ± 9.6 years). At mean follow-up of 29.7 ± 6.1 months, there were no reruptures. Walking without a boot was at 1.8 ± 0.7 months, participation in light activity was at 3.4 ± 1.8 months and 92% (25 of 27) of patients returned to their sport at 5.9 ± 1.8 months. Mean ATRS at final follow-up was 91 (range 72-100) points. One case of superficial wound dehiscence healed with local wound care. No soft-tissue masses, bone formation or tumors were observed in the operative extremity. CONCLUSIONS Excellent results, including no re-ruptures and early mobilisation, were observed in this small cohort with open Achilles tendon repair augmented by BMAC. No adverse outcomes of biologic treatment were observed with this protocol. The efficacy of BMAC in the operative repair of acute Achilles tendon ruptures warrants further study. LEVEL OF EVIDENCE IV - Therapeutic.
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Affiliation(s)
- Benjamin E Stein
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, 3333 North Calvert Street, Suite 400, Baltimore, MD, 21218, USA
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