What is the effect of the early weight-bearing mobilisation without using any support after endoscopy-assisted Achilles tendon repair?

Paratenon preserving repair of the midsubstance acute Achilles tendon rupture: a systematic review and meta-analysis with best- and worst-case analyses for rerupture rates

INTRODUCTION

Paratenon preserving techniques to facilitate acute Achilles tendon rupture repair (AATR) functions by maintaining vascularity and biology for optimal healing response. Therefore, the purpose is to evaluate the outcomes following paratenon preserving repair of the midsubstance AATR. The hypothesis was that paratenon-preserving techniques demonstrate high return to play rates and low complication rates for the repair of the midsubstance AATR.

MATERIALS AND METHODS

A systematic review of the PubMed, Embase, and the Cochrane Library databases was performed by two authors using specific search terms and eligibility criteria. The assessment of the evidence was two-fold: level and quality of evidence. A meta-analysis of proportions for the various complication rates was performed using the restricted maximum likelihood method following the Freeman-Tukey double-arcsine transformation. Fixed effects models were employed if I2 < 25% (low heterogeneity), and random effects models were employed if I2 ≥ 25% (moderate to high heterogeneity).

RESULTS

The pooled return to play rate was 90.3%. The pooled rerupture rate as reported was 0.9% (best-case scenario 0.8% and worst-case scenario 6.8%). No meaningful subgroup analysis for rerupture rates could be performed based on the meta-regression. The pooled complication rate other than reruptures was 4.8%. The pooled infection rates were 0.3%, DVT rates were 1.6%, and sural nerve injury rates were 0.3%.

CONCLUSIONS

Paratenon preserving techniques that are minimally invasive in nature demonstrated safe and favorable outcomes with high return to play rates and low complication rates for the repair of the midsubstance AATR.

Altered Ankle Muscle Activation at 2-Year Post Achilles Tendon Repair: An Age, Gender, and Activity Level-Matched Comparison With Healthy Subjects

CONTEXT

The study purpose was to compare the ankle muscle activation and dynamic ankle joint stability of subjects who underwent endoscopy-assisted Achilles tendon repair (ATR; at ≥ 2 y postsurgery) with age, gender, and activity level-matched healthy control group subjects.

DESIGN

Prospective, cross-sectional study. All functional tests were performed on the involved ankle of the ATR group, and at the matched side of healthy age, gender, and activity-level control group subjects.

METHODS

Fifteen men in each group were evaluated for medial and lateral gastrocnemius, soleus, tibialis anterior, and peroneus longus muscle activation during modified star excursion balance test and heel-rise test performance. The weight-bearing lunge test (ankle dorsiflexion) and heel-rise test distance (ankle plantar flexion) also determined weight-bearing, active ankle mobility magnitudes. The Achilles Tendon Total Rupture Score and Foot and Ankle Outcome Score provided patient-reported outcome perceptions specific to Achilles tendon rupture and comprehensive foot and ankle symptoms and function, respectively.

RESULTS

Medial (P = .005) and lateral (P = .012) gastrocnemius displayed greater activation amplitudes in the ATR group during the star excursion balance test, and peroneus longus displayed greater activation amplitudes during the heel-rise test (P = .006). The star excursion balance test reach distance was comparable between groups. Active weight-bearing ankle plantar flexion (heel-rise test) and dorsiflexion (weight-bearing lunge test) mobility magnitudes were lower in the ATR group.

CONCLUSIONS

Subjects who underwent endoscopy-assisted percutaneous ATR had reduced active weight-bearing ankle dorsiflexion and plantar flexion mobility magnitudes and greater gastrocnemius and peroneus longus neuromuscular activation when performing the same tasks as healthy control group subjects. As surgical approaches evolve to less invasive, soft tissue preserving methods with less tissue morbidity and faster healing, rehabilitation approaches may likewise need to evolve.

LEVEL OF EVIDENCE

Level III.

Systematic review of tendon transfers in the foot and ankle using interference screw fixation: Outcomes and safety of early versus standard postoperative rehabilitation

AIMS

To compare the outcomes of early and standard rehabilitation protocols following tendon transfers in the foot and ankle using interference screw fixation (ISF).

METHODS

A systematic review was performed for relevant articles (1998 to 2020) reporting foot tendon transfer using ISF in adults. The primary outcome was early tendon failure. Secondary outcomes included function and complications.

RESULTS

In total, 21 studies met the inclusion criteria, totalling 494 patients. Seven studies reported early rehabilitation protocols. The rate of early tendon failure was zero for each protocol and studies consistently reported a significant improvement in function. No differences were found comparing different rehabilitation protocols for tendon transfer for Achilles tendon pathology and foot drop.

CONCLUSION

Both early and standard rehabilitation protocols are associated with high patient satisfaction and low complication rates, but currently there is a lack of evidence to support early loaded activities or motion.

LEVEL OF EVIDENCE

IV Systematic review including case series.

Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review

BACKGROUND

Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines.

PURPOSE

To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture.

RESULTS

A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53).

CONCLUSION

Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.

Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair

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.

Effects of boric acid on the healing of Achilles tendons of rats

PURPOSE

Tendinous lesions are among the most frequent pathologies encountered in sportsmen. The objectives of new treatments are to improve the healing process and reduce the recovery time. Boron plays an important role in the wound repair process by increasing components of extracellular matrix and angiogenesis. This animal study aimed to investigate the effect of boric acid on healing of the Achilles tendon.

METHODS

The right Achilles tendons of 40 rats were completely sectioned, and the rats were randomly divided into five groups. Each group consisted of eight rats. Groups 1 and 2 were oral boric acid groups with the doses of 4 and 8 mg/kg/day boric acid, respectively. Group 3 was the local boric acid group (8 mg/kg boric acid intratendinous injection). Group 4 was administered both oral and local boric acid (8 mg/kg/day orally and 8 mg/kg boric acid intratendinous injection), and group 5 was the control group with no boric acid application. At the end of the fourth week, all the rats were killed and histopathological examination of the Achilles tendon repair site was made.

RESULTS

Histopathological examination of the tissue sections revealed more properly oriented collagen fibres, more normal cellular distribution of tenocytes and more properly organized vascular bundles in group 1 and group 2, which were the groups administered oral boric acid. Pathological sum scores of groups 1 and 2 were less than those of the other groups, and the differences between the oral boric acid groups (group 1 and group 2) and the other three groups (groups 3, 4 and 5) were statistically significant (p = 0.001).

CONCLUSION

As boric acid is safe and toxicity even after very high doses is unusual, oral boric acid may be used as an agent to improve the healing process of tendon injuries. However, biomechanical tests should also be performed to show the effect of boric acid on strength and endurance of the tendon before it can be used in clinical practice.

Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play

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.

Biomechanical evaluation of different surgical techniques for treating patellar tendon ruptures

PURPOSE

The aim of this study was to biomechanically assess patellar tendon repair techniques with additional cable wire or polydioxanone suture (PDS) cord augmentation in comparison with a suture-anchor repair technique.

METHODS

Patellar tendon repair was performed in 60 specimens using a porcine bone model. Yield load, maximum load, stiffness and elongation of patellar tendon reconstructions with (1) cable wire augmentation, (2) PDS cord augmentation or (3) suture anchor repair were evaluated using a cyclic loading and load-to-failure test setup.

RESULTS

In comparison with suture anchor repair, augmentation of the reconstruction with either cable wires or PDS cords provides significantly higher maximum loads (527 and 460 N vs. 301 N; p < 0.01 and p = 0,012, respectively) under load-to-failure testing and less elongation (8.81 mm ± 1.55 mm and 10.56 mm ± 3.1 mm vs. 18.38 mm ± 7.51 mm; p = 0.037 and p = 0.033, respectively) under cyclic loading conditions.

CONCLUSION

Augmentation of a patellar tendon repair with either a cable wire or a PDS cord provides higher primary stability than suture anchor repair in patellar tendon ruptures. The study supports the use of additional augmentation of a tendon repair in the clinical setting in order to prevent loss of reduction and allow for early post-operative mobilisation.

Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis

BACKGROUND

The choice of rehabilitation management after the surgical repair of acute Achilles tendon (AT) ruptures remains controversial because of insufficient clinical evidence. The current study analyzes the postoperative rehabilitation of AT ruptures based on the current clinical evidence.

PURPOSE

To identify and analyze the high-level clinical evidence regarding postoperative rehabilitation after the surgical repair of AT ruptures. Subgroup analyses were also performed to obtain more reliable and specific results.

STUDY DESIGN

Meta-analysis.

METHODS

The studies were retrieved by searching the Medline, Embase, and Cochrane databases through the OVID retrieval engine from 1990 to August 14, 2013. Two independent reviewers critically reviewed the studies using preset inclusion and exclusion criteria. The quality of the eligible studies was assessed by the Cochrane 12-item scale. All included studies were summarized, and their data were extracted. Subgroup analyses were performed according to the different protocols of early functional rehabilitation.

RESULTS

Nine studies, consisting of 6 randomized controlled trials and 3 quasi-randomized studies, were ultimately included. A total of 402 patients were identified. Six of the included studies utilized early weightbearing combined with early ankle motion exercises, while the other 3 only employed early ankle motion exercises. The subgroup analyses demonstrated that 11 of the 15 functional outcome measurements were significantly superior for patients who underwent both early weightbearing and ankle motion exercises than for those who underwent conventional cast immobilization. Similar rates of reruptures (odds ratio [OR], 1.36; 95% CI, 0.38-4.91; P = .64) and major complications (OR, 0.67; 95% CI, 0.24-1.87; P = .44) as well as a significantly lower rate of minor complications (OR, 0.51; 95% CI, 0.27-0.95; P = .03) were also observed in this early functional rehabilitation group. For the patients who solely performed early ankle motion exercises, only 2 of the 14 functional measurements were observed to be significantly superior to immobilization. There were also no significant differences in the rates of reruptures (OR, 0.47; 95% CI, 0.08-2.70; P = .40) and other complications (OR, 1.09; 95% CI, 0.41-2.92; P = .86) between the 2 groups.

CONCLUSION

Postoperative early weightbearing combined with early ankle motion exercises is associated with a lower minor complication rate and achieves superior and more rapid functional recovery than conventional immobilization after surgical AT repair. In contrast, few advantages were identified when only early ankle motion exercises were applied.

A novel repair method for the treatment of acute Achilles tendon rupture with minimally invasive approach using button implant: a biomechanical study

BACKGROUND

Minimally invasive Q3 repair has been proposed for acute Achilles tendon rupture with low rate of complications. However there are still controversies about optimal technique. In this study we aimed to describe Endobutton-assisted modified Bunnell configuration as a new Achilles tendon repair technique and evaluate its biomechanical properties comparing with native tendon and Krackow technique.

METHODS

27 ovine Achilles tendons were obtained and randomly placed into 3 groups with 9 specimens ineach. The Achilles tendons were repaired with Endobutton-assisted modified Bunnell technique in group 1, Krackow suture technique in group 2 and group 3 was defined as the control group including native tendons. Unidirectional tensile loading to failure was performed at 25mm/min. Biomechanicalproperties such as peak force to failure (N), stress at peak (MPa), elongation at failure, and Young'smodulus (GPa) was measured for each group. All groups were compared with each other using one-wayANOVA followed by the Tukey HSD multiple comparison test (a=0.05).

RESULTS

The average peak force (N) to failure of group 1 and group 2 and control group was 415.6±57.6, 268.1±65.2 and 704.5±85.8, respectively. There was no statistically significant difference between native tendon and group 1 for the amount elongation at failure (p>0.05).

CONCLUSIONS

Regarding the results, we concluded that Endobutton-assisted modified Bunnell technique provides stronger fixation than conventional techniques. It may allow early range of motion and can be easily applied in minimally invasive and percutaneous methods particularly for cases with poor quality tendon at the distal part of rupture.

LEVEL OF EVIDENCE

Level II, Biomechanical research study.

Achilles tendon ruptures

The incidence of acute Achilles tendon ruptures is on the rise. This is thought to be due to the increasing number of middle-aged persons participating in athletic and/or strenuous activity. Ruptures of the Achilles tendon can be severely debilitating, with deficits seen years after the initial incident. Also, these injuries can have substantial socioeconomic impacts regardless of the treatment selected. Debate continues over the optimal treatment of Achilles tendon ruptures, especially the argument whether to treat patients nonoperatively or surgically. Newer evidence shows that functional rehabilitation, including early weight-bearing, should be an integral part of successful treatment of acute Achilles ruptures. Further research is needed to further investigate the ideal treatment and rehabilitation protocols.