1
|
Maffulli N, Sammaria G, Ziello S, Migliorini F, Oliva F. Percutaneous cruciate repair of ruptured Achilles tendon. J Orthop Surg Res 2023; 18:677. [PMID: 37700324 PMCID: PMC10496360 DOI: 10.1186/s13018-023-04167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023] Open
Abstract
Percutaneous repair is a safe and reliable method to restore continuity after acute Achilles tendon ruptures, with a lower incidence of wound complications compared to open techniques. We describe a novel percutaneous cruciate suture performed through 5 stab skin incisions, four of which are longitudinal and parallel to the course of the sural nerve to minimize the risk of injury and one transverse incision at the site of rupture, with a total of 16 suture threads and the knot outside the tendon body, increasing the tensile strength of the suture and minimizing the risk of re-rupture. Clinical studies are necessary to ascertain whether the theoretical advantages of the cruciate suture technique translate into better clinical outcomes compared to established percutaneous techniques.
Collapse
Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d'Aragona, 84131, Salerno, Italy
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, UK
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Thornburrow Drive, Stoke on Trent, ST4 7QB, UK
| | - Giuliano Sammaria
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d'Aragona, 84131, Salerno, Italy
| | - Salvatore Ziello
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi d'Aragona, 84131, Salerno, Italy
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
| | - Francesco Oliva
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, Rome, Italy
| |
Collapse
|
2
|
Barton D, Manoharan A, Khwaja A, Sorenson J, Taylor M. Return to Play Following Achilles Tendon Rupture in NFL Players Based on Position. Foot Ankle Spec 2023; 16:427-436. [PMID: 34609159 DOI: 10.1177/19386400211040351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to determine the return-to-play (RTP) rate and postinjury performance after Achilles tendon (AT) ruptures in National Football League (NFL) skill position players. METHODS The study included NFL skill positions with an AT rupture between the 2009-2010 and 2015-2016 seasons. Performance data were collected and compared against a matched control group. RTP was defined as playing in at least 1 game after repair. RESULTS RTP rate was 57% for the study cohort. The tight ends (TEs) had the highest RTP rate at 71% while the wide receivers (WRs) had the lowest RTP rate at 38%. Compared with the control group, WRs with successful RTP had significantly less receptions per game (P = .01). For defensive players with RTP there were significant decreases in postrepair performance in tackles, passes defended, and fumbles forced/recovered compared with the control group. CONCLUSION A total of 57% of players achieved RTP with WRs and running backs (RBs) having the lowest RTP rates and TEs and linebackers (LBs) having the highest RTP rates. RBs, defensive backs (DBs), and LBs with successful RTP had decreased performance in all categories. This updated information may be helpful for athletes, physicians, scouts, and coaches in evaluating players with a history of AT rupture. LEVELS OF EVIDENCE Analytic, level 3, retrospective cohort study, Epidemiologic study.
Collapse
Affiliation(s)
- Dane Barton
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona
| | - Aditya Manoharan
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona
| | - Ansab Khwaja
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona
| | - Jacob Sorenson
- University of Arizona School of Medicine, Tucson, Arizona
| | | |
Collapse
|
3
|
Seow D, Islam W, Randall GW, Azam MT, Duenes ML, Hui J, Pearce CJ, Kennedy JG. Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07411-1. [PMID: 37115231 DOI: 10.1007/s00167-023-07411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/30/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR. METHODS Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance. RESULTS There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3-5%) versus conservative treatment (3.9-13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5-10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation. CONCLUSION This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Dexter Seow
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wasif Islam
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Grace W Randall
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Mohammad T Azam
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Matthew L Duenes
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - James Hui
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christopher J Pearce
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - John G Kennedy
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA.
| |
Collapse
|
4
|
Kastoft R, Barfod K, Bencke J, Speedtsberg MB, Hansen SB, Penny JØ. 1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment. Knee Surg Sports Traumatol Arthrosc 2022; 30:3579-3587. [PMID: 35234975 DOI: 10.1007/s00167-022-06874-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics. METHODS The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control. RESULTS The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg. CONCLUSION The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain. LEVEL OF EVIDENCE II. CLINICAL TRIALS IDENTIFIER NCT02760784.
Collapse
Affiliation(s)
- Rasmus Kastoft
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Kristoffer Barfod
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jesper Bencke
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Merete B Speedtsberg
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Sanja Bay Hansen
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jeannette Ø Penny
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
| |
Collapse
|
5
|
Cramer A, Barfod KW, Hölmich P, Pedersen DA, Christensen K. Genetic contribution to the etiology of Achilles tendon rupture. A Danish nationwide register study of twins. Foot Ankle Surg 2022; 28:1050-1054. [PMID: 35227591 DOI: 10.1016/j.fas.2022.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND It is unknown if genetics contribute to the etiology of acute Achilles tendon rupture (ATR). The aims of the present study were, 1) To calculate the concordance rate for monozygotic (MZ) twins and same-sex dizygotic (SSDZ) twins and 2) to estimate the heritability of ATR. METHODS The study was performed as a registry study using the Danish Twin Registry and the Danish National Patient Registry. RESULTS The study sample consisted of 85,534 twins born from 1895 to 1995. Of these, 572 (0.67%) were registered with ATR in the period from 1994 to 2014. The concordance rate was 8.1% (95% CI 1.4-14.7%) for MZ twins and 4.3% (95% CI 0.7-7.9%) for SSDZ twins. The heritability of ATR was 47% (95% CI 31-62%). CONCLUSION This study found that genetics contribute substantially to the etiology of ATR with an estimated heritability of the liability to ATR of approximately 50%. The finding generates the hypothesis that genetics play a role in the pathological changes that occur in the Achilles tendon before a rupture. The risk of ATR for a twin within a 20 year period, if the co-twin has had an ATR, was 8% for MZ twins and 4% for SSDZ twins.
Collapse
Affiliation(s)
- Allan Cramer
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Per Hölmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Dorthe Almind Pedersen
- The Danish Twin Registry, University of Southern Denmark, Odense, Denmark; Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense, Denmark
| | - Kaare Christensen
- The Danish Twin Registry, University of Southern Denmark, Odense, Denmark; Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
6
|
Mosconi M, Pasta G, Annunziata S, Guerrieri V, Ghiara M, Perelli S, Torriani C, Grassi FA, Jannelli E. Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison. Diagnostics (Basel) 2022; 12:1824. [PMID: 36010175 PMCID: PMC9406849 DOI: 10.3390/diagnostics12081824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy. METHODS 33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery. RESULTS At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups. CONCLUSIONS fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.
Collapse
Affiliation(s)
- Mario Mosconi
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Specialization School in Orthopaedics and Traumatology, University of Pavia, 27100 Pavia, Italy
| | - Gianluigi Pasta
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
| | - Salvatore Annunziata
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Specialization School in Orthopaedics and Traumatology, University of Pavia, 27100 Pavia, Italy
| | - Viviana Guerrieri
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Specialization School in Orthopaedics and Traumatology, University of Pavia, 27100 Pavia, Italy
| | - Matteo Ghiara
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
| | - Simone Perelli
- Institut CAtalá de Traumatologia i Medicina de l’Esport (ICATME)—Hospital Universitari Dexeus, Universitat Autonoma de Barcelona, 08028 Barcelona, Spain;
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Hospital Del Mar, Universitat Autonoma de Barcelona, 08003 Barcelona, Spain
| | - Camilla Torriani
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
| | - Federico Alberto Grassi
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Specialization School in Orthopaedics and Traumatology, University of Pavia, 27100 Pavia, Italy
| | - Eugenio Jannelli
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| |
Collapse
|
7
|
The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors. Knee Surg Sports Traumatol Arthrosc 2022; 30:2457-2469. [PMID: 35018477 DOI: 10.1007/s00167-021-06824-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture. METHODS A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years. RESULTS Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050). CONCLUSION The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture. LEVEL OF EVIDENCE III.
Collapse
|
8
|
Saxena A, Giai Via A, Grävare Silbernagel K, Walther M, Anderson R, Gerdesmeyer L, Maffulli N. Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the "GAIT" Study Group. J Foot Ankle Surg 2022; 61:855-861. [PMID: 35120805 DOI: 10.1053/j.jfas.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Abstract
Surgical repair of acute mid-substance Achilles tendon ruptures is performed in active patients, but the postoperative rehabilitation program is often based on the experience of the surgeon or therapist, rather than on evidence-based protocols. The aim of the study is to establish an evidence-based protocol for rehabilitation. This study is a consensus statement. The "GAIT" study group (German, American, and Italian Tendon), an informal collection of 4 experienced foot and ankle surgeons, met to address the question of what items they felt were important relative to rehabilitate a surgically repaired Achilles tendon acute rupture. Thirty-three statements were formulated. A value of 100% agreement by all the members was set to produce a proposed consensus statement. A value of 80% consensus was set to produce "strong recommendation." A systematic review of the literature was also performed. The GAIT group reach 100% agreement on the average postoperative non-weightbearing for 2.3 weeks, the foot in plantarflexion for the first 4 weeks, avoiding ROM exercises beyond neutral, and both stretching and eccentric exercise, not started before 12 weeks. Concentric bilateral heel raises should be performed after 6 weeks, and the average return to initiate sports, was 24.4 weeks. The use of a 1/8th-1/4th inch heel cushions in daily shoes after 8 weeks, the use of an antigravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended. Given lack of established verified protocols, the recommendations by our experienced panel should be considered. These proposed consensus statements could be used as a basis for larger controlled trials, and develop best practices.
Collapse
Affiliation(s)
- Amol Saxena
- Department of Sports Medicine, Sutter-PAMF, Palo Alto, CA.
| | - Alessio Giai Via
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy
| | - Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, STAR Health Sciences Complex Campus, Newark, DE
| | - Markus Walther
- Schön Klinik München Harlaching - FIFA Medical Centre of Excellence, München, Germany
| | | | - Ludger Gerdesmeyer
- Department of Orthopaedic Surgery & Traumatology, Public Health Clinic, Kiel, Germany
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, England; School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, England
| |
Collapse
|
9
|
Maffulli N, Oliva F, Migliorini F. Check-rein technique for Achilles tendon elongation following conservative management for acute Achilles tendon ruptures: a two-year prospective clinical study. J Orthop Surg Res 2021; 16:690. [PMID: 34819119 PMCID: PMC8611836 DOI: 10.1186/s13018-021-02830-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/03/2021] [Indexed: 12/28/2022] Open
Abstract
Background Following conservative management for acute Achilles tendon (AT) ruptures, the tendon may heal in continuity, and some patients may present with an elongated Achilles tendon–gastrosoleus complex. This study investigated the efficacy and feasibility of a novel minimally invasive technique, which we named “check-rein procedure”, in patients with intact and elongated AT following conservative management for AT ruptures. Methods All patients who underwent the check-rein procedure for elongation of the gastrosoleus–AT complex by one experienced surgeon were prospectively enrolled. The AT resting angle (ATRA) and AT rupture score (ATRS) were assessed at baseline and repeated at 2-year follow-up, as were calf circumference and isometric plantarflexion strength of both ankles. Results Forty-three patients (43 procedures) were analysed. The mean time elapsed from injury to surgery was 28.7 ± 7.9 weeks. The mean age at surgery was 38.5 ± 5.7 years. At the last follow-up, ATRS, ATRA, isometric strength difference, and calf circumference of the affected side were increased (P < 0.0001). The rate of the return to sport was 98% (42 of 43). No wound complications or rupture were experienced by any patient. Conclusion The check-rein technique for AT elongation after conservative management of AT tears is effective and feasible to restore tendon length and calf function. The surgical outcome was influenced by the preoperative performance status, and longer time elapsed from injury to surgery worsens the outcomes.
Collapse
Affiliation(s)
- Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| |
Collapse
|
10
|
Sikorski Ł, Czamara A. Ground Reaction Forces during Vertical Hops Are Correlated with the Number of Supervised Physiotherapy Visits after Achilles Tendon Surgery. J Clin Med 2021; 10:jcm10225299. [PMID: 34830581 PMCID: PMC8620226 DOI: 10.3390/jcm10225299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 12/26/2022] Open
Abstract
The objective of this study was to assess the effectiveness of, and the correlation between, an average of 42 supervised physiotherapy (SVPh) visits for the vertical ground reaction forces component (vGRF) using ankle hops during two- and one-legged vertical hops (TLH and OLH, respectively), six months after the surgical suturing of the Achilles tendon using the open method (SSATOM) via Keesler’s technique. Hypothesis: Six months of supervised physiotherapy with a higher number of visits (SPHNVs) was positively correlated with higher vGRF values during TLH and OLH. Group I comprised male patients (n = 23) after SSATOM (SVPh x = 42 visits), and Group II comprised males (n = 23) without Achilles tendon injuries. In the study groups, vGRF was measured during TLH and OLH in the landing phase using two force plates. The vGRF was normalized to the body mass. The limb symmetry index (LSI) of vGRF values was calculated. The ranges of motion of the foot and circumferences of the ankle joint and shin were measured. Then, 10 m unassisted walking, the Thompson test, and pain were assessed. A parametric test for dependent and independent samples, ANOVA and Tukey’s test for between-group comparisons, and linear Pearson’s correlation coefficient calculations were performed. Group I revealed significantly lower vGRF values during TLH and OLH for the operated limb and LSI values compared with the right and left legs in Group II (p ≤ 0.001). A larger number of visits correlates with higher vGRF values for the operated limb during TLH (r = 0.503; p = 0.014) and OLH (r = 0.505; p = 0.014). An average of 42 SVPh visits in 6 months was insufficient to obtain similar values of relative vGRF and their LSI during TLH and OLH, but the hypothesis was confirmed that SPHNVs correlate with higher relative vGRF values during TLH and OLH in the landing phase.
Collapse
Affiliation(s)
- Łukasz Sikorski
- Department of Physiotherapy, College of Physiotherapy in Wrocław, 50-038 Wrocław, Poland;
- Correspondence: ; Tel.: +48-601-911-013
| | - Andrzej Czamara
- Department of Physiotherapy, College of Physiotherapy in Wrocław, 50-038 Wrocław, Poland;
- Center of Rehabilitation and Medical Education, 50-038 Wrocław, Poland
| |
Collapse
|
11
|
Park CH, Yan H, Park J, Chang MC. Mini-open Repair for Acute Achilles Tendon Rupture: Ring Forceps vs the Achillon Device. Am J Sports Med 2021; 49:3613-3619. [PMID: 34612717 DOI: 10.1177/03635465211044464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Repair of acute Achilles tendon rupture using the Achillon device is a representative mini-open repair technique; however, the limitations of this technique include the need for special instruments and decreased repair strength. A modified mini-open repair using ring forceps might overcome these limitations. PURPOSE To compare the Achillon device with ring forceps in mini-open repairs of acute Achilles tendon rupture. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Fifty patients (41 men and 9 women) with acute Achilles tendon rupture on 1 foot were consecutively treated using mini-open repair techniques. The first 20 patients were treated using the Achillon device (Achillon group), and the subsequent 30 were treated using a ring forceps (forceps group). Clinical, functional, and isokinetic results and postoperative complications were compared between the groups at the last follow-up. Clinical evaluations were performed using the AOFAS (American Orthopaedic Foot and Ankle Society) score, Achilles Tendon Total Rupture Score, length of incision, and operation time. Functional evaluations included active range of motion of the ankle joint, maximum calf circumference, hopping test, and single-limb heel rise (SLHR). Isokinetic evaluations were performed using the isokinetic test for ankle plantar flexion. RESULTS The AOFAS score (P = .669), Achilles Tendon Total Rupture Score (P = .753), and length of incision (P = .305) were not significantly different between the groups (mean ± SD, 90.1 ± 8.7, 88.3 ± 9.9, and 2.7 ± 0.3 cm in the Achillon group vs 92.2 ± 9.4, 89.9 ± 10.9, and 2.5 ± 0.4 cm in the forceps group, respectively). Operation times in the Achillon group were significantly shorter than those in the forceps group (41.4 ± 9.6 vs 62.8 ± 14.1 minutes, P < .001). The maximum height of the SLHR (P = .042) and the number of SLHRs (P = .043) in the forceps group (79.7% ± 7.4% and 72.9% ± 10.2%) were significantly greater than those in the Achillon group (75.3% ± 7.1% and 66.7% ± 11.0%). No significant differences were detected between the groups in mean peak torques for plantar flexion at angular speeds of 30 deg/s (P = .185) and 120 deg/s (P = .271). There was no significant difference in the occurrence of postoperative complications between the groups (P = .093). CONCLUSION The ring forceps technique is comparable to the Achillon technique with respect to clinical, functional, and isokinetic results and postoperative complications. Given that no special instrument is required, the ring forceps technique could be a better option for acute Achilles tendon rupture repair.
Collapse
Affiliation(s)
- Chul Hyun Park
- Department of Orthopaedic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Hongfei Yan
- Department of Orthopaedic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jeongjin Park
- Department of Orthopaedic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Korea
| |
Collapse
|
12
|
Slagers AJ, Dams OC, van Zalinge SD, Geertzen JHB, Zwerver J, Reininga IHF, van den Akker-Scheek I. Psychological Factors Change During the Rehabilitation of an Achilles Tendon Rupture: A Multicenter Prospective Cohort Study. Phys Ther 2021; 101:6380795. [PMID: 34636920 PMCID: PMC8697845 DOI: 10.1093/ptj/pzab226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The authors sought to gain insight into the changes in psychological factors during rehabilitation after Achilles tendon rupture (ATR) and to explore the association between psychological factors during rehabilitation and functional outcome 12 months after ATR. METHODS Fifty patients clinically diagnosed with ATR were invited to visit the hospital 3, 6, and 12 months after injury for data collection. They completed questionnaires assessing psychological factors: psychological readiness to return to sport (Injury Psychological Readiness to Return to Sport Questionnaire); kinesiophobia (Tampa Scale for Kinesiophobia); expectations, motivation, and outcome measures related to symptoms and physical activity (Achilles Tendon Total Rupture Score); and sports participation and performance (Oslo Sports Trauma Research Centre Overuse Injury Questionnaire). To determine whether psychological factors changed over time, generalized estimating equation analyses were performed. Multivariate regression analyses were used to study the association between psychological factors at 3, 6, and 12 months and outcome measures at 12 months after ATR. RESULTS Psychological readiness to return to sport improved, and kinesiophobia decreased significantly during rehabilitation. Psychological readiness at 6 and 12 months showed significant associations with sports participation and performance. Kinesiophobia at 6 months was significantly associated with symptoms and physical activity. Motivation remained high during rehabilitation and was highly associated with symptoms and physical activity, sports participation, and performance. CONCLUSION Psychological factors change during rehabilitation after ATR. Patients with lower motivation levels during rehabilitation, low psychological readiness to return to sports, and/or high levels of kinesiophobia at 6 months after ATR need to be identified. IMPACT According to these results, psychological factors can affect the rehabilitation of patients with ATR. Physical therapists can play an important role in recognizing patients with low motivation levels and low psychological readiness for return to sport and patients with high levels of kinesiophobia at 6 months post-ATR. Physical therapist interventions to enhance motivation and psychological readiness to return to sport and to reduce kinesiophobia need to be developed and studied in the post-ATR population. LAY SUMMARY With Achilles tendon rupture, level of motivation, psychological readiness for return to sport, and fear of movement can affect rehabilitation outcome. A physical therapist can help recognize these factors.
Collapse
Affiliation(s)
- Anton J Slagers
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, the Netherlands,Address all correspondence to Mr Slagers at:
| | - Olivier C Dams
- University of Groningen, University Medical Center Groningen, Department of Orthopaedics, Groningen, The Netherlands
| | - Sara D van Zalinge
- University of Groningen, University Medical Center Groningen, Department of Orthopaedics, Groningen, The Netherlands
| | - Jan HB Geertzen
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Johannes Zwerver
- University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Department of Rehabilitation Medicine, Groningen, the Netherlands,University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, Groningen, The Netherlands,Gelderse Vallei Hospital, Sports Valley, Department of Sports Medicine, Ede, The Netherlands
| | - Inge HF Reininga
- University of Groningen, University Medical Center Groningen, Department of Trauma Surgery, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- University of Groningen, University Medical Center Groningen, Department of Orthopaedics, Groningen, The Netherlands
| |
Collapse
|
13
|
Oppy A, Mohtadi N, Buckley R. Achilles tendon rupture in a healthy 37yo male. Injury 2021; 52:2756-2758. [PMID: 34719427 DOI: 10.1016/j.injury.2020.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew Oppy
- Royal Melbourne Hospital - Orthopedic Department, Grattan Street, Melbourne 3050, Australia
| | - Nick Mohtadi
- Dip. Sport Med; Clinical Professor in Orthopaedics, Department of Surgery, Cumming School of Medicine; Adjunct Professor Faculty of Kinesiology; Medical Director Sport Medicine Centre, University of Calgary, Alberta, Canada
| | - Richard Buckley
- Clinical Professor in Orthopedics, Department of Surgery, Cumming School of Medicine, University of Calgary, 0490 McCaig Tower, 3134 Hospital Drive NW, Foothills Hospital, Calgary, Alberta, Canada.
| |
Collapse
|
14
|
Shi F, Wu S, Cai W, Zhao Y. Multiple comparisons of the efficacy and safety for six treatments in Acute Achilles Tendon Rupture patients: A systematic review and network meta-analysis. Foot Ankle Surg 2021; 27:468-479. [PMID: 32732151 DOI: 10.1016/j.fas.2020.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/21/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The choice of the best therapeutic regimen for Acute Achilles Tendon Rupture (AATR) remains controversial. Our study aims to evaluate the efficacy and safety of therapeutic regimens in AATR patients using a network meta-analysis of data from clinical randomized controlled trials. MATERIAL/METHODS The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA). RESULTS 38 randomized controlled trials involving 2480 participants were included. The studies were published between 1981 and 2019. A total of 6 therapeutic regimens -open repair (OR), minimally invasive repair (MIR) and nonoperative treatment (non) combined with traditional standard rehabilitation (TSR) and accelerated functional rehabilitation (AFR) - were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the re-rupture rate, the therapeutic regimens were ranked as follows: OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR. In terms of the wound-related complication, the therapeutic regimens were ranked as follows: MIR&AFR, nonoperative treatment &AFR, MIR&TSR, nonoperative treatment &TSR, OR&AFR and OR&TSR. In terms of the sural nerve injury, the therapeutic regimens were ranked as follows: non, OR and MIR. In terms of the deep venous thrombosis, the therapeutic regimens were ranked as follows: MIR&AFR, OR&AFR, nonoperative treatment &AFR, OR&TSR, MIR&TSR and nonoperative treatment &TSR. In terms of the returning back to sport, the therapeutic regimens were ranked as follows: MIR&TSR, OR&AFR, OR&TSR, nonoperative treatment &AFR, nonoperative treatment &TSR and MIR&AFR. CONCLUSIONS MIR can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications. AFR is superior to TSR without increasing the risk of rerupture. MIR&AFR is the best therapeutic regime for AATR. More RCTs focused on AATR are needed to further indicate this conclusion.
Collapse
Affiliation(s)
- Fangling Shi
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shiyuan Wu
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Cai
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Youming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China.
| |
Collapse
|
15
|
Röell AE, Timmers TK, van der Ven DJC, van Olden GDJ. Rehabilitation After Surgical Repair of Acute Achilles Tendon Rupture: Functional Outcome With a Minimum Follow-Up of 6 Months. J Foot Ankle Surg 2021; 60:482-488. [PMID: 33546991 DOI: 10.1053/j.jfas.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 05/02/2020] [Accepted: 09/03/2020] [Indexed: 02/03/2023]
Abstract
The best treatment and rehabilitation of Achilles tendon ruptures remains controversial. Current literature focuses mainly on objective outcomes despite possible incongruity with patient-reported functional outcomes. Therefore, we aimed to identify the course of patient-reported symptoms, function and quality of life during the early rehabilitation period. In this prospective cohort study, 33 patients with an acute Achilles tendon rupture treated with minimally invasive tendon repair were included in this study. They were followed up at 6, 12, 18 and 24 weeks after surgery with the Foot and Ankle Outcome Score questionnaire. At 6 weeks, patient-reported outcomes were poor regarding quality of life and sports. They however were quite high in the domains activities of daily living, symptoms and pain. All scores improved over the course of 6 months (symptoms (p = .03), activities of daily living (p = .001), sports (p = .002) and quality of life (p = .001). Pain did not improve significantly (p = .12), but patients had good pain scores from the start. There were no significant differences between patients with or without physical therapy. There were 3 minor complications and no re-ruptures in this cohort. In conclusion, patient-reported outcomes improve significantly during the first 6 months after surgery, except for pain. Scores for sports and quality of life remain suboptimal.
Collapse
Affiliation(s)
- Anna E Röell
- Junior Doctor, Department of Surgery, Meander Medical Center Amersfoort, Amersfoort, the Netherlands; Junior Doctor, Department of Intensive Care, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Tim K Timmers
- Trauma Surgeon, Department of Surgery, Meander Medical Center Amersfoort, Amersfoort, the Netherlands
| | - Denise J C van der Ven
- Surgical Resident, Department of Surgery, Meander Medical Center Amersfoort, Amersfoort, the Netherlands
| | - Ger D J van Olden
- Trauma Surgeon, Department of Surgery, Meander Medical Center Amersfoort, Amersfoort, the Netherlands
| |
Collapse
|
16
|
Wang T, Mu Y, Diao Y, Liu W, Wu Y, Wang Z, Luo Y, Xie Y, Yin L. Biomechanical Comparison of Panda Rope Bridge Technique and Other Minimally Invasive Achilles Tendon Repair Techniques In Vitro. Orthop J Sports Med 2021; 9:23259671211008436. [PMID: 34179202 PMCID: PMC8202294 DOI: 10.1177/23259671211008436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/03/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Although nonoperative management of acute Achilles tendon rupture (ATR) is a reasonable option, surgical repair has attracted attention for young and active patients. More reliable Achilles tendon repair techniques are needed to enhance recovery after ATR in this population. Purpose/Hypothesis: To biomechanically analyze the panda rope bridge technique (PRBT) and compare it with other minimally invasive repair techniques over a simulated, progressive rehabilitation program. It was hypothesized that PRBT would result in better biomechanical properties and enhanced recovery after ATR. Study Design: Controlled laboratory study. Methods: An Achilles tendon rupture was created 4 cm from the distal tendon insertion site in 40 bovine lower extremities, and specimens were then randomly allocated to 5 Achilles tendon repair techniques: (1) Achillon, (2) modified Achillon, (3) Percutaneous Achilles Repair System (PARS), (4) modified PARS, and (5) PRBT. Each group was subjected to a cyclic loading protocol that was representative of progressive postoperative rehabilitation for ATR (250 cycles at 1 Hz for each loading stage: 20-100 N, 20-200 N, 20-300 N, and 20-400 N). Results: The PRBT technique demonstrated significantly less elongation (1.62 ± 0.25 mm) than the 4 other repair techniques after the first loading stage of 20 to 100 N (P < .05). All specimens in the 4 other groups developed a large gap (elongation ≥5 mm) at the 20- to 200-N loading stage. When overall biomechanical performance was examined, the PRBT group exhibited higher strength (20-400 N) and more mean loading cycles (984 ± 10) compared with the 4 other groups (P < .05). Conclusion: In this bovine model, PRBT biomechanically outperformed the other minimally invasive Achilles tendon repair techniques that were tested and could therefore meet the requirements of accelerated rehabilitation. Clinical Relevance: The reduced tendency for premature rerupture and the overall improved biomechanical properties of PRBT suggest that ATR patients treated with PRBT may more readily complete early and aggressive postoperative rehabilitation protocols. In addition, they may have a lower risk of early irreversible suture failure.
Collapse
Affiliation(s)
- Ting Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Mu
- Department of Orthopaedics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yulei Diao
- Department of Orthopaedics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenke Liu
- Department of Orthopaedics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yahong Wu
- Department of Orthopaedics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhuoqun Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanfeng Luo
- Bioengineering College, Chongqing University, Chongqing, China
| | - Yangli Xie
- State Key Laboratory of Trauma, Burns and Combined Injury, Army Medical University, Chongqing, China
| | - Liangjun Yin
- Department of Orthopaedics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
17
|
Liu X, Dai TJ, Li BL, Li C, Zheng ZY, Liu Y. Early functional rehabilitation compared with traditional immobilization for acute Achilles tendon ruptures : a meta-analysis. Bone Joint J 2021; 103-B:1021-1030. [PMID: 34058871 DOI: 10.1302/0301-620x.103b6.bjj-2020-1890.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this meta-analysis was to assess the prognosis after early functional rehabilitation or traditional immobilization in patients who underwent operative or nonoperative treatment for rupture of the Achilles tendon. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched for randomized controlled trials (RCTs) from their inception to 3 June 2020, using keywords related to rupture of the Achilles tendon and rehabilitation. Data extraction was undertaken by independent reviewers and subgroup analyses were performed based on the form of treatment. Risk ratios (RRs) and weighted mean differences (WMDs) (with 95% confidence intervals (CIs)) were used as summary association measures. RESULTS We included 19 trials with a total of 1,758 patients. There was no difference between the re-rupture rate (RR 0.84 (95% CI 0.56 to 1.28); p = 0.423), time to return to work (WMD -1.29 (95% CI -2.63 to 0.05); p = 0.060), and sporting activity (WMD -1.50 (95% CI -4.36 to 1.37); p = 0.306) between the early functional rehabilitation and the traditional immobilization treatment strategies. Early rehabilitation up to 12 weeks yielded significantly better Achilles tendon Total Rupture Scores ((ATRS) WMD 5.11 (95% CI 2.10 to 8.12); p < 0.001). Patients who underwent functional rehabilitation had significantly lower limb symmetry index of heel-rise work ((HRW) WMD -4.19 (95% CI -8.20 to 0.17); p = 0.041) at one year. CONCLUSION Early functional rehabilitation is safe and provides better early function and the same functional outcome in the longer term. Cite this article: Bone Joint J 2021;103-B(6):1021-1030.
Collapse
Affiliation(s)
- Xuan Liu
- Beijing Sport University, Beijing, China
| | - Tian-Jiao Dai
- Beijing Sport University, Beijing, China.,Jiangsu College of Nursing, Jiangsu, China
| | - Bao-Lin Li
- Beijing Sport University, Beijing, China
| | - Chen Li
- Beijing Sport University, Beijing, China
| | | | - Ye Liu
- Beijing Sport University, Beijing, China
| |
Collapse
|
18
|
Parisien RL, Trofa DP, Gualtieri AP, Dodson CC, Li X, Levine WN, Vosseller JT. How Do Sports Medicine and Foot and Ankle Specialists Treat Acute Achilles Tendon Ruptures? Foot Ankle Spec 2021; 14:114-119. [PMID: 31971006 DOI: 10.1177/1938640019901055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. The purpose of this study is to evaluate the treatment considerations and surgical techniques utilized by fellowship-trained orthopaedic sports medicine and foot and ankle specialists in the management of Achilles tendon ruptures. Methods. A blinded electronic survey was distributed to 2062 fellowship-trained sports medicine and 1319 fellowship-trained foot and ankle orthopaedic surgeons. The total number of acute Achilles tendon ruptures managed per year, patient-specific factors associated with surgical decision making and surgical techniques were evaluated. Results. Of the 3381 surveys distributed, 524 responses were included for analysis. Only 9% of respondents manage more than 20 acute Achilles tendon ruptures per year with the majority (75%) managing less than 10 per year. Operative management is the treatment of choice for 76% of total respondents with only 8% managing acute ruptures nonoperatively. Activity level and patient age were the single most important factors for 60.8% and 29.3% of surgeons, respectively, with regard to operative versus nonoperative decision making. Socioeconomic status and workers compensation were the least important patient factors. Conclusion. Surgical repair in the young and active patient is the preferred treatment for the majority of fellowship-trained subspecialists who most commonly encounter this pathology.Levels of Evidence: Therapeutic, Level V: Consensus of Expert Analysis.
Collapse
Affiliation(s)
- Robert L Parisien
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - David P Trofa
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Anthony P Gualtieri
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Christopher C Dodson
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - William N Levine
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - J Turner Vosseller
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| |
Collapse
|
19
|
The influence of an orthopaedic walker boot on forefoot force. Foot (Edinb) 2021; 46:101739. [PMID: 33285492 DOI: 10.1016/j.foot.2020.101739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/07/2020] [Accepted: 08/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND In the treatment of an Achilles tendon rupture the patients are commonly equipped with an orthopaedic walker boot with wedges. To what extent this influences the tensile force placed on the Achilles tendon is unclear. PURPOSE To assess the forefoot force and describe changes in muscle activity of the medial gastrocnemius, soleus and tibialis anterior when using one or three wedges during ambulation in a weightbearing orthopaedic walker boot. METHODS The force on the forefoot was measured with a force sensor insole and muscle activity of the medial gastrocnemius, soleus and tibialis anterior were measured using surface electromyography in 10 healthy participants. Three different types of ambulation were performed (walking without crutches (unass.), walking with crutches (+crutch) and walking with crutches and verbal instructions to place body weight on heel (heel+crutch) with one and three heel wedges respectively. FINDINGS The total peak force displayed an interaction where forefoot force decreased when wearing three wedges only for the +crutch ambulation type (80N, p=0.001) although there was a trend to decrease with three wedges also for the heel+crutch ambulation type (48N, p=0.05). The relative peak force on the forefoot showed a main effect with a significant decrease when using three wedges compared to one wedge across all three ambulation types (19.1%, p=0.009). INTERPRETATION The force on the forefoot and hereby the Achilles tendon significantly decreased when using three wedges compared to one wedge. These findings have important implications for the rehabilitation post Achilles tendon rupture.
Collapse
|
20
|
Tarantino D, Palermi S, Sirico F, Corrado B. Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play. J Funct Morphol Kinesiol 2020; 5:jfmk5040095. [PMID: 33467310 PMCID: PMC7804867 DOI: 10.3390/jfmk5040095] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
The Achilles tendon is the thickest, strongest and largest tendon in the human body, but despite its size and tensile strength, it frequently gets injured. Achilles tendon ruptures (ATRs) mainly occur during sports activities, and their incidence has increased over the last few decades. Achilles tendon tears necessitate a prolonged recovery time, sometimes leaving long-term functional limitations. Treatment options include conservative treatment and surgical repair. There is no consensus on which is the best treatment for ATRs, and their management is still controversial. Limited scientific evidence is available for optimized rehabilitation regimen and on the course of recovery after ATRs. Furthermore, there are no universally accepted outcomes regarding the return to play (RTP) process. Therefore, the aim of this narrative review is to give an insight into the mechanism of injuries of an ATR, related principles of rehabilitation, and RTP.
Collapse
|
21
|
Dai W, Leng X, Wang J, Hu X, Ao Y. Rehabilitation regimen for non-surgical treatment of Achilles tendon rupture: A systematic review and meta-analysis of randomised controlled trials. J Sci Med Sport 2020; 24:536-543. [PMID: 33388266 DOI: 10.1016/j.jsams.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To compare re-rupture rate, functional and quality-of-life outcomes, return to sports and work, complications, and resource use in patients treated non-surgically with different rehabilitation regimens for Achilles tendon rupture. DESIGN Systematic review and meta-analysis. METHODS We performed a systematic literature search in PubMed, Embase, Scopus and the Cochrane Library through May 2020 to identify randomized controlled trials (RCTs) that included patients treated non-surgically for Achilles tendon rupture. All analyses were stratified according to rehabilitation protocols. RESULTS Eight RCTs with a total of 978 patients were included. There was no significant difference about re-rupture rate (P=0.38), return to sports (P=0.85) and work (P=0.33), functional outcome (P=0.34), quality of life (P=0.50), and complication rate (P=0.29) between early weight bearing with functional ankle motion and traditional ankle immobilisation with non-weight bearing. Similarly, no significant difference in re-rupture rate (P=0.88), return to sports (P=0.45) and work (P=0.20), functional outcome (P=0.26), and complication rate (P=0.49) was seen between ankle immobilisation with non-weight bearing and early weight bearing without functional ankle motion. CONCLUSIONS Traditional ankle immobilisation with non-weight bearing was not found to be superior to early weight bearing with or without functional ankle motion for patients treated non-surgically for Achilles tendon rupture. Clinicians may consider early weight bearing in functional brace as a safe and cost-effective alternative to non-weight bearing with plaster casting.
Collapse
Affiliation(s)
- Wenli Dai
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, People's Republic of China
| | - Xi Leng
- Medical Imaging Center, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, People's Republic of China
| | - Jian Wang
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, People's Republic of China
| | - Xiaoqing Hu
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, People's Republic of China.
| | - Yingfang Ao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, People's Republic of China.
| |
Collapse
|
22
|
Liu W, Diao Y, Wang Z, Guo L, Yang W, Luo Y, Chen L, Yin L. Optimization of the knot configuration for early accelerated rehabilitation after Achilles tendon rupture. Clin Biomech (Bristol, Avon) 2020; 80:105139. [PMID: 32781396 DOI: 10.1016/j.clinbiomech.2020.105139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 07/16/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
Background Panda Rope Bridge Technique (PRBT) was an new minimally invasive technique consisted of two bridge anchors (proximal anchors at calcaneus and distal anchors at myotendinous junction) and strong ropes (threads of the suture anchors) stretched between them, which was suitable for early accelerated rehabilitation of Achilles tendon rupture. However, the optimal knot configuration with PRBT was unknow. The purpose of this study was identify minimum number of half hitches necessary to maintain knot security for PRBT. Methods Using an Instron device we tested the effect of different knot configuration in two kinds of suture threads (Ethibond™ #5 and Ultrabraid™ #2). According to the result of it, we put the optimal knot configuration into Part 1 with PRBT test model and Part 2 with modified PRBT test model, to evaluate whether the optimal knot configuration could complete the cyclic loading test simulated early rehabilitation. Findings In the first part of the study, the optimal knot configuration of Ethibond™ #5 suture thread was the combination of three half hitches and one double throw half knot, and the optimal knot configuration of Ultrabraid™ #2 suture thread was the combination of five half hitches and one double throw half knot. In the second part of the study, only Ultrabraid™ #2 suture thread with optimal knot configuration had finished all test in Part 1. Interpretation The Ultrabraid™ #2 suture thread with optimal knot configuration was suitable for PRBT with early accelerated rehabilitation after Achilles tendon repair.
Collapse
Affiliation(s)
- Wenke Liu
- Department of Orthopaedics, , Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yulei Diao
- Department of Orthopaedics, , Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhuoqun Wang
- Department of Orthopaedics, , Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lifeng Guo
- Department of Orthopaedics, , Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Yang
- Bioengineering College of Chongqing University, Chongqing, China
| | - Yanfeng Luo
- Bioengineering College of Chongqing University, Chongqing, China
| | - Lin Chen
- Army Medical University, State key Laboratory of Trauma, Burns and Combined Injury, Chongqing, China; Army Medical University, Research Institute of Surgery, Daping Hospital, Chongqing, China
| | - Liangjun Yin
- Department of Orthopaedics, , Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| |
Collapse
|
23
|
Maempel JF, Clement ND, Duckworth AD, Keenan OJF, White TO, Biant LC. A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures. Am J Sports Med 2020; 48:2755-2764. [PMID: 32816521 DOI: 10.1177/0363546520944905] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been a shift toward functional nonoperative rehabilitation in the treatment of Achilles tendon rupture (ATR) despite a shortage of studies directly comparing nonoperative functional rehabilitation with traditional nonoperative immobilization. PURPOSE To compare patient-reported outcome measures and functional outcomes for nonoperatively treated ATR with traditional cast immobilization or functional rehabilitation in a walking boot. STUDY DESIGN Randomized controlled clinical trial; Level of evidence, 2. METHODS In a single-center nonblinded study, 140 patients were randomized to compare treatment for acute ATR in (1) an immobilizing cast in reducing degrees of equinus over a 10-week period with 8 weeks of nonweightbearing mobilization or (2) a walking boot for 8 weeks with reducing equinus and immediate full weightbearing. Exclusion criteria were delayed presentation >2 weeks after injury, tendon reruptures, and latex allergy. Analysis was undertaken on an intention-to-treat basis. RESULTS A total of 69 patients (median age, 41 years [interquartile range, 33-50.5 years]) were randomized to walking boot treatment and 71 patients (41 [32-49]) to cast treatment. At 6 months, patients treated in a walking boot reported better Short Musculoskeletal Function Assessment (SMFA) dysfunction index (6.62 [2.21-12.50] vs 10.66 [4.96-13.42]; P = .050), SMFA bother index (7.29 [2.08-14.58] vs 10.42 [5.73-19.27]; P = .04), Achilles Tendon Total Rupture Score (71.5 [53.50-84.25] vs 54.0 [37-76]; P = .01), and Foot and Ankle Questionnaire core score (91 [81.89-97.55] vs 85 [78.25-92.09]; P = .04). At 1 year, there was no difference in SMFA dysfunction index (2.21 [0.74-5.88] vs 2.94 [1.47-6.62]; P = .25), SMFA bother index (2.08 [0-9.38] vs 5.21 [0.52-11.98]; P = .25), Achilles Tendon Total Rupture Score (92 [72.50-96] vs 87.5 [66.0-94.75]; P = .21), or Foot and Ankle Questionnaire core score (97.75 [89.46-99.00] vs 95.50 [90.88-97.50]; P = .18). Rerupture occurred in 5 and 11 patients (P = .075) and venous thromboembolism in 2 and 3 patients (P = .67) in the boot and cast groups, respectively. Fifteen patients in the boot group but none in the cast group had skin problems (P < .001). Patients treated in a boot returned to driving at a median 12 weeks (vs 13 weeks for cast; P = .045), but there was no difference in time to return to work (P = .48). CONCLUSION Functional rehabilitation with early weightbearing is a safe alternative to traditional immobilizing treatment for ATR, giving better early functional outcomes, albeit with a higher incidence of transient minor skin complications. REGISTRATION NCT02598843 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Julian F Maempel
- Royal Prince Alfred Hospital, Sydney, Australia.,University of Malta Medical School, Msida, Malta
| | | | - Andrew D Duckworth
- Royal Infirmary of Edinburgh, Edinburgh, UK.,University of Edinburgh, Edinburgh, UK
| | | | - Tim O White
- Royal Infirmary of Edinburgh, Edinburgh, UK.,University of Edinburgh, Edinburgh, UK
| | - Leela C Biant
- University of Manchester Medical School, Manchester, UK.,Manchester Orthopaedic Centre, Manchester University NHS Foundation Trust, Manchester, UK
| |
Collapse
|
24
|
Maempel JF, Clement ND, Wickramasinghe NR, Duckworth AD, Keating JF. Operative repair of acute Achilles tendon rupture does not give superior patient-reported outcomes to nonoperative management. Bone Joint J 2020; 102-B:933-940. [DOI: 10.1302/0301-620x.102b7.bjj-2019-0783.r3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Aims The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial. Methods PROMs including the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS), EuroQol five-dimension (EQ-5D), satisfaction, net promoter score and data regarding re-rupture, and venous thromboembolic rates were collected for patients randomized to receive either operative or nonoperative treatment for acute Achilles tendon rupture in a previous study. Of the 80 patients originally randomized, 64 (33 treated surgically, 31 nonoperatively) patients were followed up at a mean of 15.7 years (13.4 to 17.7). Results There was no statistically significant difference between operatively and nonoperatively treated patients, in SMFA Dysfunction Index (median 1.56 (interquartile range (IQR) 0 to 5.51) vs 1.47 (IQR 0 to 5.15); p = 0.289), SMFA Bother Index (2.08 (IQR 0 to 12.50) vs 0.00 (IQR 0 to 6.25); p = 0.074), ATRS (94 (IQR 86 to 100) vs 95 (IQR 81 to 100); p = 0.313), EQ-5D-5L (1 (IQR 0.75 to 1) vs 1 (IQR 0.84 to 1); p = 0.137) or EQ-5D health today visual analogue score (85 (IQR 72.5 to 95) vs 85 (IQR 8 to 95); p = 0.367). There was no statistically significant difference between operative and nonoperative groups in terms of satisfaction (84% vs 100%; p = 0.119) or willingness to recommend treatment to friends or family (79% vs 87%; p = 0.255). Four nonoperative patients and two in the operative group sustained a re-rupture (p = 0.306). Conclusion Both patient groups reported good results at long-term follow-up. The findings give no evidence of superior long-term patient reported outcomes (as measured by the SMFA) for surgical treatment over nonoperative treatment. There was no demonstrable difference in other patient reported outcome measures, satisfaction, or re-rupture rates at long-term follow-up. Cite this article: Bone Joint J 2020;102-B(7):933–940.
Collapse
Affiliation(s)
- Julian F. Maempel
- Royal Prince Alfred Hospital, Sydney, Australia
- University of Malta Medical School, University of Malta, Malta
| | | | | | - Andrew D. Duckworth
- Royal Infirmary of Edinburgh, Edinburgh, UK
- Honorary Clinical Senior Lecturer, University of Edinburgh, Edinburgh, UK
| | | |
Collapse
|
25
|
Westin O, Sjögren T, Svedman S, Horvath A, Hamrin Senorski E, Samuelsson K, Ackermann P. Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis. BMC Musculoskelet Disord 2020; 21:358. [PMID: 32513228 PMCID: PMC7282056 DOI: 10.1186/s12891-020-03320-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/28/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND While numerous clinical studies have compared the surgical and non-surgical treatment of acute Achilles tendon rupture (ATR), there are no studies that have performed a non-inferiority analysis between treatments. METHODS Data from patients who were included in five randomised controlled trials from two different centres in Sweden were used. Outcomes at 1 year after ATR consisted of the patient-reported Achilles tendon Total Rupture Score (ATRS) and the functional heel-rise tests reported as the limb symmetry index (LSI). The non-inferiority statistical 10% margin was calculated as a reflection of a clinically acceptable disadvantage in ATRS and heel-rise outcome when comparing treatments. RESULTS A total of 422 patients (350 males and 72 females) aged between 18 and 71 years, with a mean age of 40.6 (standard deviation 8.6), were included. A total of 363 (86%) patients were treated surgically. The ATRS (difference (Δ) = - 0.253 [95% confidence interval (CI); - 5.673;5.785] p = 0.36) and LSI of heel-rise height (difference = 1.43 [95% CI; - 2.43;5.59] p = 0.81), total work (difference = 0.686 [95% CI; - 4.520;6.253] p = 0.67), concentric power (difference = 2.93 [95% CI; - 6.38;11.90] p = 0.063) and repetitions (difference = - 1.30 [95% CI; - 6.32;4.13] p = 0.24) resulted in non-inferiority within a Δ - 10% margin for patients treated non-surgically. CONCLUSION The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes.
Collapse
Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Tony Sjögren
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Svedman
- Integrative Orthopedic Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Horvath
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Paul Ackermann
- Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
26
|
Binkley HM, Douglass D, Phillips K, Wise SL. Rehabilitation and Return to Sport After Nonsurgical Treatment of Achilles Tendon Rupture. Strength Cond J 2020. [DOI: 10.1519/ssc.0000000000000536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
27
|
Barfod KW, Nielsen EG, Olsen BH, Vinicoff PG, Troelsen A, Holmich P. Risk of Deep Vein Thrombosis After Acute Achilles Tendon Rupture: A Secondary Analysis of a Randomized Controlled Trial Comparing Early Controlled Motion of the Ankle Versus Immobilization. Orthop J Sports Med 2020; 8:2325967120915909. [PMID: 32426409 PMCID: PMC7222258 DOI: 10.1177/2325967120915909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Immobilization of the ankle joint has been suggested as a key element in the
pathogenesis leading to deep vein thrombosis (DVT). Purpose: To investigate whether early controlled ankle motion (ECM) could reduce the
incidence of DVT compared with immobilization (IM) in the treatment of acute
Achilles tendon rupture. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients aged 18 to 70 years were eligible for inclusion, and treatment was
nonoperative. The ECM group performed movements of the ankle 5 times a day
from weeks 3 to 8 after rupture. The control group was immobilized for 8
weeks. The outcome measure was DVT diagnosed with color Doppler ultrasound
for above- and below-knee DVT at 2 and 8 weeks. The Achilles tendon Total
Rupture Score, the heel-rise work test, and the Copenhagen Achilles
ultrasonographic Length Measurement were performed at 4-, 6-, and 12-month
follow-up. Results: A total of 189 patients were assessed for eligibility from February 2014 to
December 2016. Of these, 130 were randomized: 68 patients were allocated to
the ECM group and 62 to the IM group. All patients participated in follow-up
at 8 weeks assessing for DVT. In total, 62 (47.7%) patients were diagnosed
with DVT: 33 of 68 (48.5%) in the ECM group and 28 of 61 (46.8%) in the IM
group (P = .84). DVT did not affect treatment outcomes at
4, 6, and 12 months. D-dimer had low sensitivity (71%) for detecting
DVT. Conclusion: We found that 1 in 2 patients presented with DVT in nonoperative treatment of
acute Achilles tendon rupture. The ECM protocol revealed no benefit versus
IM in reducing the incidence of DVT. DVT did not influence functional and
patient-reported outcomes the first year after rupture. D-dimer seems an
inappropriate test for detection of DVT in patients with acute Achilles
tendon rupture. Registration: NCT02015364 (ClinicalTrials.gov
identifier).
Collapse
Affiliation(s)
- Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center-Copenhagen, Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
| | - Emil Graakjær Nielsen
- Department of Radiology, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
| | - Beth Hærsted Olsen
- Department of Radiology, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
| | - Pablo Gustavo Vinicoff
- Department of Radiology, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopedic Research Amager-Hvidovre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Per Holmich
- Sports Orthopedic Research Center-Copenhagen, Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
| |
Collapse
|
28
|
Changes of Material Elastic Properties during Healing of Ruptured Achilles Tendons Measured with Shear Wave Elastography: A Pilot Study. Int J Mol Sci 2020; 21:ijms21103427. [PMID: 32408704 PMCID: PMC7279368 DOI: 10.3390/ijms21103427] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 12/28/2022] Open
Abstract
Therapy options for ruptured Achilles tendons need to take into account the right balance of timing, amount and intensity of loading to ensure a sufficient biomechanical resilience of the healing tendon on the one hand, and to enable an adequate tensile stimulus on the other hand. However, biomechanical data of human Achilles tendons after rupture during the separate healing stages are unknown. Shear wave elastography is an ultrasound technique that measures material elastic properties non-invasively, and was proven to have a very good correlation to biomechanical studies. Taking advantage of this technology, 12 patients who suffered from an acute Achilles tendon rupture were acquired and monitored through the course of one year after rupture. Nine of these patients were treated non-operatively and were included for the analysis of biomechanical behaviour. A significant increase of material elastic properties was observed within the first six weeks after trauma (up to 80% of baseline value), where it reached a plateau phase. A second significant increase occurred three to six months after injury. This pilot study suggests a time correlation of biomechanical properties with the biological healing phases of tendon tissue. In the reparative phase, a substantial amount of biomechanical resilience is restored already, but the final stage of biomechanical stability is reached in the maturation phase. These findings can potentially be implemented into treatment and aftercare protocols.
Collapse
|
29
|
Hansen MS, Vestermark MT, Hölmich P, Kristensen MT, Barfod KW. Individualized treatment for acute Achilles tendon rupture based on the Copenhagen Achilles Rupture Treatment Algorithm (CARTA): a study protocol for a multicenter randomized controlled trial. Trials 2020; 21:399. [PMID: 32398120 PMCID: PMC7218535 DOI: 10.1186/s13063-020-04332-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/19/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND An individualized treatment algorithm (Copenhagen Achilles Rupture Treatment Algorithm (CARTA)) based on the ultrasonographic appearance of an acute Achilles tendon rupture has been developed aiming to select the correct patients for operative and non-operative treatment. The objective of this study is to investigate if this individualized treatment algorithm gives a better functional outcome than treating all patients either operatively or non-operatively per default. METHODS/DESIGN This study is conducted as a multicenter, three-armed randomized controlled trial. Participants are included from four hospitals in Denmark and randomized 1:1:1 to one of three parallel groups: 1) Intervention group-participants are treated according to an individualized treatment algorithm; 2) Control group A-participants are treated non-operatively; 3) Control group B-participants are treated operatively. The individualized treatment algorithm for the intervention group is based on an ultrasonographic examination; tendon overlap and elongation below 7% is to be treated non-operatively, while no tendon overlap and/or elongation above 7% will be treated operatively. Over a period of 3 years, 300 participants will be included. The primary outcome is the heel-rise work test at 12 months post-injury. Secondary outcomes are tendon elongation, the Achilles tendon Total Rupture Score (ATRS), the rate of re-ruptures, and other complications. The primary analysis will be conducted as an intention-to-treat analysis. DISCUSSION This trial will indicate if treatment of acute Achilles tendon rupture can be individualized based on elongation and tendon overlap. It is hypothesized that different patients will benefit from different treatments instead of offering all the same treatment. TRIAL REGISTRATION ClinicalTrials.gov, NCT03525964. Registered 16 May 2018.
Collapse
Affiliation(s)
- Maria Swennergren Hansen
- Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital, Kettegård Alle 30, 2650 Amager-Hvidovre, Denmark
- Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Kettegård Alle 30, 2650 Amager-Hvidovre, Denmark
| | - Marianne Toft Vestermark
- Department of Orthopedic Surgery, Viborg Regional Hospital, Heiberbs Allé 4, 8800 Viborg, Denmark
| | - Per Hölmich
- Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Kettegård Alle 30, 2650 Amager-Hvidovre, Denmark
| | - Morten Tange Kristensen
- Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital, Kettegård Alle 30, 2650 Amager-Hvidovre, Denmark
- Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Kettegård Alle 30, 2650 Amager-Hvidovre, Denmark
| |
Collapse
|
30
|
Functional and early weight-bearing protocol for achilles tendon ruptures: a retrospective study. Eur J Trauma Emerg Surg 2020; 47:2049-2054. [DOI: 10.1007/s00068-020-01376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/15/2020] [Indexed: 11/27/2022]
|
31
|
Aufwerber S, Heijne A, Edman G, Grävare Silbernagel K, Ackermann PW. Early mobilization does not reduce the risk of deep venous thrombosis after Achilles tendon rupture: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2020; 28:312-319. [PMID: 31679069 PMCID: PMC6971132 DOI: 10.1007/s00167-019-05767-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/21/2019] [Indexed: 11/06/2022]
Abstract
PURPOSE The hypothesis was that early functional mobilization would reduce the incidence of deep venous thrombosis (DVT) during leg immobilization after Achilles tendon rupture surgery. A secondary aim was to evaluate if the amount of weightbearing and daily steps influenced the risk of sustaining a DVT. METHODS One-hundred and fifty patients with Achilles tendon rupture repair were randomized to treatment with early functional mobilization, encouraging full weightbearing and ankle motion in orthosis, or treatment-as-usual, i.e., 2 weeks of unloading in plaster cast followed by 4 weeks weightbearing in orthosis. At 2 and 6 weeks postoperatively, all patients were screened for DVT using compression duplex ultrasound. During the first 2 weeks postoperatively, patient-reported loading, pain and step counts were assessed. RESULTS At 2 weeks, 28/96 (29%) of the patients in early functional mobilization group and 15/49 (31%) in the control group (n.s) had sustained a DVT. At 6 weeks, the DVT rate was 35/94 (37%) in the early functional mobilization and 14/49 (29%) in the control group (n.s). During the first postoperative week, the early functional mobilization group reported low loading and higher experience of pain vs. the control group (p = 0.001). Low patient-reported loading ≤ 50% (OR = 4.3; 95% CI 1.28-14.3) was found to be an independent risk factor for DVT, in addition to high BMI and higher age. CONCLUSIONS Early functional mobilization does not prevent the high incidence of DVT during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual. The low efficacy of early functional mobilization is mainly explained by postoperative pain and subsequent low weightbearing. To minimize the risk of DVT, patients should be encouraged to load at least 50% of body weight on the injured leg 1 week after surgery. LEVEL OF EVIDENCE Therapeutic, level 1.
Collapse
Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. .,Functional Area Occupational Therapy and Physiotherapy, Allied Health Professionals Function, A6:U1, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Annette Heijne
- grid.4714.60000 0004 1937 0626Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden
| | - Gunnar Edman
- R&D, Norrtälje Hospital, Tiohundra AB, Norrtälje, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Karin Grävare Silbernagel
- grid.33489.350000 0001 0454 4791Department of Physical Therapy, University of Delaware, Newark, DE USA
| | - Paul W. Ackermann
- grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
32
|
Barfod KW, Hansen MS, Hölmich P, Kristensen MT, Troelsen A. Efficacy of early controlled motion of the ankle compared with immobilisation in non-operative treatment of patients with an acute Achilles tendon rupture: an assessor-blinded, randomised controlled trial. Br J Sports Med 2019; 54:719-724. [DOI: 10.1136/bjsports-2019-100709] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2019] [Indexed: 01/29/2023]
Abstract
BackgroundEarly controlled motion (ECM) of the ankle is widely used in the non-operative treatment of acute Achilles tendon rupture, although its safety and efficacy have not been investigated properly in a randomised set-up.Purpose/Aim of the studyTo investigate if ECM of the ankle was superior to immobilisation in the treatment of acute Achilles tendon rupture.Materials and methodsThis was an assessor-blinded, randomised controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients aged 18–70 years were eligible for inclusion. The ECM group performed movements of the ankle five times a day from week 3 to week 8 after rupture. The control group was immobilised for 8 weeks. The primary outcome was the Achilles tendon Total Rupture Score (ATRS) evaluated at 1-year postinjury. The secondary outcomes were heel-rise work test (HRW), Achilles tendon elongation and rate of rerupture. Analysis was conducted as intention-to-treat using inverse probability weighting.Findings/Results189 patients were assessed for eligibility and 130 were included from February 2014 to December 2016. There were 64 patients in the ECM group and 58 in the immobilisation group. There were no statistically significant differences (p>0.3) between the ECM and the immobilisation groups at 1 year: mean (SD) ATRS was 74 (18) and 75 (18), respectively. HRW was 60% (21) and 60% (21) of the uninjured limb, and elongation was 18 mm (13) and 16 mm (11), respectively. Correspondingly, there were six and seven reruptures.ConclusionsECM revealed no benefit compared with immobilisation in any of the investigated outcomes.Trial registration numberNCT02015364
Collapse
|
33
|
Early weight-bearing in nonoperative treatment of acute Achilles tendon rupture did not influence mid-term outcome: a blinded, randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 2019; 27:2781-2788. [PMID: 30030579 DOI: 10.1007/s00167-018-5058-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Acute Achilles tendon rupture leads to impaired outcome at short term, but little is known concerning medium-term results. The aim of the present study was to investigate the influence of early weight-bearing on clinical outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. METHOD The study was performed as a medium-term follow-up on patients included in a randomised controlled trial. Both groups were treated with nonoperative management and controlled early motion. The intervention group was allowed full weight-bearing from day 1, and the control group was non-weight-bearing for 6 weeks. 60 patients were randomised 1:1. Of those, 56 were eligible for inclusion in the medium-term follow-up and 37 participated (18 control, 19 intervention). The outcomes were Achilles tendon Total Rupture Score (ATRS) and heel raise work performed at an average of 4.5 years after the initial injury. Statistical analysis was performed using paired t tests and linear regression. RESULTS No differences were found between control and intervention groups at 4.5 years. ATRS scores consistently improved in both the intervention and the control groups from 0.5 to 1 year and from 1 to 4.5 years, ending up at 80.5 on average after 4.5 years. Heel raise height kept improving from 0.5 to 4.5 years, reaching a limb symmetry index of 82.4%. The heel raise work improvement from 0.5 to 1 year did not continue. No significant change was found from 1 to 4.5 years, ending at a limb symmetry index of 60%. CONCLUSION Early weight-bearing did not influence outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. The calf muscle of the injured limb performs 40% less work, when compared to the healthy limb, though lifting height recovers better. LEVEL OF EVIDENCE II. CLINICAL TRIALS IDENTIFIER NCT02760784.
Collapse
|
34
|
Lu J, Liang X, Ma Q. Early Functional Rehabilitation for Acute Achilles Tendon Ruptures: An Update Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg 2019; 58:938-945. [PMID: 31474405 DOI: 10.1053/j.jfas.2018.12.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Indexed: 02/03/2023]
Abstract
The aim of this study was to investigate the role of early functional rehabilitation in acute Achilles tendon ruptures. Eligible studies were identified from PubMed, Embase, and the Cochrane Library using the following search keywords: "Achilles tendon rupture" and "rehabilitation" or "function" or "functional" or "mobilization" and "randomized" or "random" or "blind" or "control" or "compare" or "comparative." A heterogeneity test based on I2 statistic and Cochran's Q test was conducted. The pooled risk ratio and weighted mean difference with 95% confidence interval was calculated for each outcome using the random-effect (p < .05 or I2 > 50% for significant heterogeneity) or fixed-effect (p > .05 or I2 < 50% for nonsignificant heterogeneity) model. A subgroup analysis was also performed. Fourteen randomized controlled trials were identified. Pooled data demonstrated no difference in the complication rates, time taken to return to sports, total number of patients returning to work or sports, and satisfaction rate between the early functional rehabilitation and conventional cast immobilization groups. Early functional rehabilitation significantly decreased the time taken to return to work (weighted mean difference -1.56; 95% confidence interval -3.09 to 0.04; p = .04]. Early functional rehabilitation for acute Achilles tendon ruptures appeared to be related to a shorter time taken to return to work; however, it did not affect the other variables between the groups.
Collapse
Affiliation(s)
- Jun Lu
- Surgeon, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China
| | - Xiaojun Liang
- Professor, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China
| | - Qiang Ma
- Surgeon, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China.
| |
Collapse
|
35
|
Zhao J, Guo W, Zeng X, Kan S. [Research progress of early postoperative rehabilitation for acute Achilles tendon rupture after surgical repair]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:382-386. [PMID: 30874399 PMCID: PMC8337926 DOI: 10.7507/1002-1892.201807146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/07/2019] [Indexed: 12/28/2022]
Abstract
Objective To summarize the latest research progress of early postoperative rehabilitation for acute Achilles tendon rupture after surgical repair. Methods The high-quality randomized controlled trials and systematic reviews/meta-analyses regarding early postoperative rehabilitation for acute Achilles tendon rupture in recent years were reviewed. Results There are three functional rehabilitations after acute Achilles tendon rupture surgery, including early postoperative mobilization, early weight-bearing with immobilization, and early weight-bearing combined with mobilization. The results of randomized controlled trials show that the effectiveness of early postoperative rehabilitation is similar or better than the early postoperative immobilization. The results of systematic reviews/meta-analyses show that the early postoperative rehabilitation is beneficial to the early function recovery of the Achilles tendon, can reduce the time for functional recovery, and do not adversely affect the outcomes. Conclusion Early postoperative rehabilitation is beneficial to the functional recovery, and do not increase postoperative complications. There is still no uniform protocol of early postoperative rehabilitation and the timing of weight-bearing, and further studies are needed in the future.
Collapse
Affiliation(s)
- Jiaguo Zhao
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211,
| | - Wenxuan Guo
- School of Graduates, Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, P.R.China
| | - Xiantie Zeng
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China
| | - Shilian Kan
- Department of Hand Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China
| |
Collapse
|
36
|
Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Bosma E, van Raaij TM, Munzebrock AV, Zijlstra WP, Zwerver J, Reininga IHF. The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study. BMC Musculoskelet Disord 2019; 20:69. [PMID: 30744626 PMCID: PMC6371453 DOI: 10.1186/s12891-019-2437-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 01/28/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Achilles tendon rupture (ATR) is a common sports injury, with a rising incidence and significant impairments. Due to the lack of treatment guidelines, there is no consensus about diagnostic methods, primary treatment (non-surgical or surgical) and rehabilitation. It is hypothesized that this lack of consensus and guidelines leads to sub-optimal recovery and higher societal costs. The primary aim of this study is to give a broad insight into the recovery after ATR. Secondarily this study aims to explore factors contributing to recovery and gain insight into the cost-effectiveness of ATR management. METHODS This multicenter prospective cohort study will include all adult (≥ 18 years) patients with an ATR treated at the three main hospitals in the Northern Netherlands: University Medical Center Groningen, Martini Hospital Groningen and Medical Center Leeuwarden. All subjects will be invited for three visits at 3, 6 and 12 months post-injury. The following data will be collected: patient-reported outcome measures (PROMs), physical tests, imaging and economic questionnaires. At 3 months post-injury personal, injury, and treatment data will be collected through a baseline questionnaire and assessment of the medical file. The PROMs concern the Dutch version of the Achilles Tendon Total Rupture Score, EQ-5D-5 L, Oslo Sport Trauma Research Center Overuse Injury Questionnaire, Injury Psychological Readiness Return to Sport Scale, Tampa Scale of Kinesiophobia, Expectations, Motivation and Satisfaction questionnaire and a ranking of reasons for not returning to sport. The administered physical tests are the heel-rise test, standing dorsiflexion range of motion, resting tendon length and single leg hop for distance. Ultrasound Tissue Characterization will be used for imaging. Finally, economic data will be collected using the Productivity Cost Questionnaire and Medical Consumption Questionnaire. DISCUSSION This prospective cohort study will contribute to optimal decision making in the primary treatment and rehabilitation of ATRs by providing insight into (1) ATR recovery (2) novel imaging for monitoring recovery (3) (barriers to) return to sport and (4) cost-effectiveness of management. The analysis of these data strives to give a broad insight into the recovery after ATR as well as provide data on novel imaging and costs, contributing to individualized ATR management. TRIAL REGISTRATION Trialregister.nl. NTR6484 . 20/06/2017. 20/07/2017.
Collapse
Affiliation(s)
- Olivier C. Dams
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ron L. Diercks
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaus W. Wendt
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eelke Bosma
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Tom M. van Raaij
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Arvid V. Munzebrock
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Wierd P. Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Johannes Zwerver
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | |
Collapse
|
37
|
Qi H, Ji X, Cui Y, Wang L, Chen H, Tang P. Comparison of channel-assisted minimally invasive repair and 3 common Achilles tendon restoration techniques. Exp Ther Med 2019; 17:1426-1434. [PMID: 30680024 DOI: 10.3892/etm.2018.7075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/23/2018] [Indexed: 12/28/2022] Open
Abstract
The present study aimed to investigate the biomechanical comparison of channel-assisted minimally invasive restoration and three common Achilles tendon restoration techniques in an in vitro model via a progressive rehabilitation program. The 42 porcine tendons were randomly assigned to the following six groups of tendons (n=7/group): Achillon, percutaneous Achilles repair system (PARS), Krackow, channel-assisted minimally invasive repair (CAMIR), CAMIR augmentation (CAMIR+), CAMIR-5 (repair with No. 5 Ethibond suture). There was no significant difference in elongation among groups following the first 10 loading cycles, which consisted of 20-100 N at 1 Hz. The elongation of the CAMIR group (7.51±1.77 mm) was significantly longer than the Achillon group (3.19±0.57 mm) and PARS group (3.73±0.66 mm; P<0.05) following 1,000 cycles. However, the CAMIR group exhibited no significant difference vs. the Krackow (7.32±1.09 mm) and CAMIR+ groups (7.11±1.50 mm) following 1,000 cycles. Following 2,000 cycles, there was no significant difference between the CAMIR-5 (7.99±1.68 mm) group, and the Achillon (3.19±0.57 mm) and PARS groups (3.73±0.66 mm). At the point of restoration construct failure, the total cycles of the CAMIR group (median, 1,000; range, 1,000-1,000) were significantly less than the Achillon group (median, 2,000; range, 2,000-2,013) and PARS group (median, 2,000; range, 2,000-2,010; P<0.05), but had no significant difference compared with the Krackow group (median, 1,000; range, 1,000-1,000) and CAMIR+ group 1,000 (median, 1,000; range, 1,000-1,004). There was also no significant difference between the CAMIR-5 group (median, 2,000; range, 2,000-2,000), and the Achillon group (median, 2,000; range, 2,000-2,013) and PARS group (median, 2,000; range, 2,000-2,010). Restricted by the strength of suture, the one-suture CAMIR restoration technique was weaker than the three-suture Achillon and PARS restoration techniques, but there was no significant difference with the open Krackow restoration technique, which provides a reliable mechanical strength for repairing. CAMIR has an advantage of reducing the risk of suture reactivity.
Collapse
Affiliation(s)
- Hongzhe Qi
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China.,Department of Orthopaedic Surgery, Chinese People's Liberation Army 306th Hospital, Beijing 100101, P.R. China
| | - Xinran Ji
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Yalin Cui
- Key Laboratory for Biomechanics and Mechanobiology, Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, P.R. China
| | - Lizhen Wang
- Key Laboratory for Biomechanics and Mechanobiology, Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, P.R. China
| | - Hua Chen
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Peifu Tang
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| |
Collapse
|
38
|
Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Zwerver J, Reininga IHF. Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines. Knee Surg Sports Traumatol Arthrosc 2019; 27:2754-2764. [PMID: 29971520 PMCID: PMC6706364 DOI: 10.1007/s00167-018-5049-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 06/29/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE This study aimed to describe and analyse usual care of Achilles tendon ruptures (ATRs) by orthopaedic surgeons and trauma surgeons in the Netherlands. METHODS A nationwide online survey of ATR management was sent to all consultant orthopaedic and trauma surgeons in the Netherlands, requesting participation of those involved in ATR management. Data on individual characteristics and the entire ATR management (from diagnosis to rehabilitation) were gathered. Consensus was defined as ≥ 70% agreement on an answer. RESULTS A total of 91 responses (70 orthopaedic surgeons and 21 trauma surgeons) were analysed. There was consensus on the importance of the physical examination in terms of diagnosis (> 90%) and a lack of consensus on diagnostic imaging (ultrasound/MRI). There was consensus that non-surgical treatment is preferred for sedentary and systemically diseased patients and surgery for patients who are younger and athletic and present with larger tendon gap sizes. There was consensus on most of the non-surgical methods used: initial immobilisation in plaster cast with the foot in equinus position (90%) and its gradual regression (82%) every 2 weeks (85%). Only length of immobilisation lacked consensus. Surgery was generally preferred, but there was a lack of consensus on the entire followed protocol. Orthopaedic and trauma surgeons differed significantly on their surgical (p = 0.001) and suturing techniques (p = 0.002) and methods of postoperative immobilisation (p < 0.001). Orthopaedic surgeons employed open repair and Bunnell sutures more often, whereas trauma surgeons used minimally invasive approaches and bone anchors. Rehabilitation methods and advised time until weight-bearing and return to sport varied. Orthopaedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment (p = 0.001) and surgery (p = 0.002) than trauma surgeons. CONCLUSION This is the first study to describe the entire ATR management. The results show a lack of consensus and wide variation in management of ATRs in the Netherlands. This study shows that especially the methods of the perioperative and rehabilitation phases were inconclusive and differed between orthopaedic and trauma surgeons. Further research into optimal ATR management regimens is recommended. In addition, to achieve uniformity in management more multidisciplinary collaboration between Dutch and international surgeons treating ATRs is needed. LEVEL OF EVIDENCE Cross-sectional survey, Level V.
Collapse
Affiliation(s)
- Olivier C. Dams
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands ,0000 0000 9558 4598grid.4494.dDepartment of Orthopaedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Ron L. Diercks
- 0000 0000 9558 4598grid.4494.dDepartment of Orthopaedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Klaus W. Wendt
- 0000 0000 9558 4598grid.4494.dDepartment of Trauma Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johannes Zwerver
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Inge H. F. Reininga
- 0000 0000 9558 4598grid.4494.dDepartment of Trauma Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| |
Collapse
|
39
|
El-Akkawi AI, Joanroy R, Barfod KW, Kallemose T, Kristensen SS, Viberg B. Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis. J Foot Ankle Surg 2018; 57:346-352. [PMID: 28974345 DOI: 10.1053/j.jfas.2017.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Indexed: 02/03/2023]
Abstract
Achilles tendon ruptures can be either surgically or conservatively treated with either early functional mobilization or cast immobilization. The purpose of the present study was to conduct a meta-analysis comparing the effect of early versus late weightbearing in conservatively treated adult patients, including only randomized controlled trials (RCTs). The primary endpoint was rerupture, and the secondary endpoints were strength, quality of life during treatment, range of motion, deep venous thrombosis, return to sports, and return to work. The search for studies was conducted using PubMed, EMBASE, and the Cochrane Central Register of Controlled trials. A search was performed, and 2 reviewers independently screened the studies by title, abstract, and, finally, by reading the full text. Four studies met the inclusion criteria. The reference lists of the included studies were scanned and 1 additional RCT study was included. The critical appraisal skills program checklist was applied for study appraisal. A statistician performed the data management and analysis. No statistically significant differences were found between the 2 treatment groups concerning rerupture (p = .796), return to sports (p = .455), or return to work (p = .888). One RCT found 1 case of deep venous thrombosis in the late weightbearing group. One RCT reported significant improvement in quality of life and one reported a significantly improved range of dorsiflexion in the early weightbearing group. No statistically significant difference was found between early and late weightbearing with conservative treatment regarding the rerupture rate. The results of the other outcomes were limited by the low number of studies included in the present meta-analysis. Larger randomized studies are needed to investigate these outcomes. From the results in the present study, we would recommend early weightbearing when an Achilles tendon rupture is treated conservatively.
Collapse
Affiliation(s)
- Ali Imad El-Akkawi
- Junior Doctor, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.
| | - Rajzan Joanroy
- Junior Doctor, Fellowship in Orthopedic Surgery, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Kristoffer Weisskirchner Barfod
- Doctor, Fellowship in Orthopedic Surgery, Clinical Orthopedic Research Hvidovre, Department of Orthopedics, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Thomas Kallemose
- Scientific Statistician, Clinical Research Centre, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Skydt Kristensen
- Senior Doctor and Chief Physician, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Bjarke Viberg
- Doctor, Fellowship in Orthopedic Surgery, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Doctor, Fellowship in Orthopedic Surgery, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
40
|
Krill MK, Hoffman J, Yang J, Hodax JD, Owens BD, Hewett TE. Previous foot injuries associated with a greater likelihood of Achilles tendon ruptures in professional American football players. PHYSICIAN SPORTSMED 2018; 46:342-348. [PMID: 29860909 DOI: 10.1080/00913847.2018.1482188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The purpose of this study was to build on current understanding of Achilles tendon (AT) ruptures in football through the examination of lower extremity injury rates (IR) in the season prior to AT rupture. METHODS An online review was conducted to document AT ruptures in the National Football League (NFL) from the 2010-11 through 2016-17 seasons. Player-specific information was gathered through the online search, injury reports, or video analysis. Injury incidence was recorded for each season. Descriptive statistics were calculated for all variables. IRs per 1000 athlete-exposures with 95% confidence intervals (CI) were established. Injury rate ratios (IRR) with 95% CI were calculated to evaluate differences in IR with statistical significance established at p < 0.05. RESULTS From the 2010-11 to 2016-17 NFL seasons, 109 AT ruptures were identified. 36 athletes participated in the NFL the season prior and sustained a total of 40 injuries. Thirty-two (32/40, 80%) of the injuries involved the lower extremity. The most frequent body parts injured in the NFL season prior to AT rupture were the knee (n = 8, 22.5%), upper leg and thigh (n = 7, 17.5%), lower leg and shin (n = 5, 12.5%), and ankle (n = 5, 12.5%). The overall IR for the AT rupture group was not significantly different than the NFL group (IRR: 0.94, 0.68-1.31 95% CI, p = 0.73). The AT rupture group demonstrated a significantly increased rate of foot injuries compared to the NFL cohort (IRR: 2.58, 1.16-5.77 95% CI, p = 0.02). CONCLUSION There was an increased identified incidence of AT ruptures in the NFL from 2010 to 2017 compared to AT ruptures reported from 1997 to 2002. There was no significant difference in lower extremity IR the season prior to AT rupture. Only foot injuries demonstrated an increased IR the season prior to AT rupture compared to an NFL cohort. Eleven athletes sustained 2 AT ruptures and all 11 players sustained the subsequent AT rupture to the contralateral limb.
Collapse
Affiliation(s)
- Michael K Krill
- a James Crane Sports Medicine Institute, Motion Analysis and Performance Laboratory , The Ohio State University Wexner Medical Center , Columbus , OH , USA.,b Charles E. Schmidt College of Medicine , Florida Atlantic University , Boca Raton , FL , USA.,c Physical Medicine and Rehabilitation, Department of Neurology, Division of Neurorehabilitation , Washington University in St. Louis , St. Louis , MO , USA
| | - Joshua Hoffman
- a James Crane Sports Medicine Institute, Motion Analysis and Performance Laboratory , The Ohio State University Wexner Medical Center , Columbus , OH , USA
| | - JaeWon Yang
- d Warren Alpert Medical School of Brown University , Providence , RI
| | - Johnathan D Hodax
- e Department of Orthopaedic Surgery , Warren Alpert Medical School of Brown University , Providence , RI , USA
| | - Brett D Owens
- e Department of Orthopaedic Surgery , Warren Alpert Medical School of Brown University , Providence , RI , USA
| | - Timothy E Hewett
- f Sports Medicine Center , Mayo Clinic , Rochester , MN , USA.,g Department of Orthopedic Surgery , Mayo Clinic , Rochester , MN , USA.,h Department of Physiology and Biomedical Engineering , Mayo Clinic , Rochester , MN , USA.,i Department of Physical Medicine & Rehabilitation , Mayo Clinic , Rochester , MN , USA
| |
Collapse
|
41
|
Eliasson P, Agergaard AS, Couppé C, Svensson R, Hoeffner R, Warming S, Warming N, Holm C, Jensen MH, Krogsgaard M, Kjaer M, Magnusson SP. The Ruptured Achilles Tendon Elongates for 6 Months After Surgical Repair Regardless of Early or Late Weightbearing in Combination With Ankle Mobilization: A Randomized Clinical Trial. Am J Sports Med 2018; 46:2492-2502. [PMID: 29965789 DOI: 10.1177/0363546518781826] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim of this project was to examine whether tendon elongation, mechanical properties, and functional outcomes during rehabilitation of surgically repaired acute Achilles tendon ruptures were influenced by different rehabilitation regimens during the early postsurgical period. HYPOTHESIS Restricted early weightbearing that permits only limited motion about the ankle in the early phase of tendon healing limits tendon elongation and improves functional outcome. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS 75 consecutive patients with an acute Achilles tendon rupture were included. They underwent surgical repair, and tantalum beads were placed in the distal and proximal parts of the tendon; thereafter, the patients were randomized into 3 groups. The first group was completely restricted from weightbearing until week 7. The second group was completely restricted from weightbearing until week 7 but performed ankle joint mobilization exercises. The first and second groups were allowed full weightbearing after week 8. The third group was allowed partial weightbearing from day 1 and full weightbearing from week 5. All patients received the same instructions in home exercise guidelines starting from week 9. RESULTS The rehabilitation regimen in the initial 8 weeks did not significantly influence any of the measured outcomes including tendon elongation. Achilles tendon elongation and tendon compliance continued for up to 6 months after surgery, and muscle strength, muscle endurance, and patient-reported functional scores did not reach normal values at 12 months. CONCLUSION Differences in rehabilitation loading pattern in the initial 8 weeks after the repair of an Achilles tendon rupture did not measurably alter the outcome. The time to recover full function after an Achilles tendon rupture is at least 12 months. Registration: NCT02422004 ( ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Pernilla Eliasson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Anne-Sofie Agergaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Christian Couppé
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - René Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Susan Warming
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Nichlas Warming
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Christina Holm
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Mikkel Holm Jensen
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| |
Collapse
|
42
|
Achilles tendon elastic properties remain decreased in long term after rupture. Knee Surg Sports Traumatol Arthrosc 2018; 26:2080-2087. [PMID: 29147741 DOI: 10.1007/s00167-017-4791-4] [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: 05/09/2017] [Accepted: 11/06/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE Rupture of the Achilles tendon results in inferior scar tissue formation. Elastography allows a feasible in vivo investigation of biomechanical properties of the Achilles tendon. The purpose of this study is to investigate the biomechanical properties of healed Achilles tendons in the long term. MATERIALS AND METHODS Patients who suffered from Achilles tendon rupture were recruited for an elastographic evaluation. Unilateral Achilles tendon ruptures were included and scanned in the mid-substance and calcaneal insertion at least 2 years after rupture using shear wave elastography. Results were compared to patients' contralateral non-injured Achilles tendons and additionally to a healthy population. Descriptive statistics, reliability analysis, and correlation analysis with clinical scores were performed. RESULTS Forty-one patients were included in the study with a mean follow-up-time of 74 ± 30; [26-138] months after rupture. Significant differences were identified in shear wave elastography in the mid-substance of healed tendons (shear wave velocity 1.2 ±1.5 m/s) compared to both control groups [2.5 ±1.5 m/s (p < 0.01) and 2.8 ±1.6 m/s (p < 0.0001) contralateral and healthy population, respectively]. There was no correlation between the measurements and the clinical outcome. CONCLUSIONS This study shows that the healed Achilles tendon after rupture has inferior elastic properties even after a long-term healing phase. Differences in elastic properties after rupture mainly originate from the mid-substance of the Achilles tendon, in which most of the ruptures occur. Elastographic results do not correspond with subjective perception. Clinically, sonoelastographical measurements of biomechanical properties can be useful to provide objective insights in tendon recovery.
Collapse
|
43
|
Ellison P, Molloy A, Mason LW. Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus? J Foot Ankle Surg 2018; 56:960-963. [PMID: 28842105 DOI: 10.1053/j.jfas.2017.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Indexed: 02/03/2023]
Abstract
Conservative "functional" management of acute Achilles tendon ruptures has become increasingly popular. Critical to this is the use of the walking orthosis, which positions the ankle in equinus to allow for early weightbearing. Our aim was to test whether 2 common orthoses achieved a satisfactory equinus position. A total of 11 sequentially treated Achilles tendon ruptures were assigned to either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus-corrected brace (EEB). The lateral radiographs of the cast immobilized tendons showed a mean tibiotalar angle (TTA) of 56° (range 54° to 57°) and a mean tibio-first metatarsal angle (1MTA) of 74° (range 62° to 85°). The FAWW resulted in a mean TTA of 28° (range 15° to 35°) and 1MTA of 37° (range 30° to 45°). The EEB resulted in a TTA of 48° (range 43° to 45°) and 1MTA of 54° (range 47° to 57°). Ankle equinus was significantly greater with the EEB than with the FAWW (p < .05) and similar to that with an equinus cast. The use of wedges produced an equinus appearance through the midfoot but not at the ankle. We express caution in the use of the FAWW because it is unlikely to achieve sufficient ankle equinus to shorten the Achilles tendon.
Collapse
Affiliation(s)
- Philip Ellison
- Lower Limb Extended Scope Practitioner, Trauma and Orthopaedic Department, University Hospital Aintree, Liverpool, UK.
| | - Andrew Molloy
- Consultant Foot and Ankle Surgeon, Trauma and Orthopaedic Department, University Hospital Aintree, Liverpool, UK
| | - Lyndon William Mason
- Consultant Foot and Ankle Surgeon, Trauma and Orthopaedic Department, University Hospital Aintree, Liverpool, UK
| |
Collapse
|
44
|
Rozis M, Benetos IS, Karampinas P, Polyzois V, Vlamis J, Pneumaticos SG. Outcome of Percutaneous Fixation of Acute Achilles Tendon Ruptures. Foot Ankle Int 2018. [PMID: 29528724 DOI: 10.1177/1071100718757971] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Conservative treatment of an acute Achilles rupture remains a viable and acceptable option as does surgical fixation, with open and percutaneous repair consisting the main operative techniques. The purpose of this study was to compare the outcomes and complication rates of open versus percutaneous surgical procedures. METHODS From 2009 to 2016, 131 patients were admitted to our department with clinically and radiologically confirmed acute Achilles tendon ruptures. Of those, 82 patients met our inclusion criteria and were randomized into 2 groups, group A (open repair) and group B (percutaneous suturing). Suture equipment was the same for both groups. All patients followed the same rehabilitation protocol. Functional evaluation was made using American Orthopaedic Ankle & Foot Society (AOFAS) hindfoot and Achilles tendon Total Rupture Score (ATRS) questionnaires at the 12-month follow-up. Ankle range of motion (ROM), return-to-work time, and complication rates were additionally measured. RESULTS Both techniques had similar results regarding complication rates and return-to-work time. The major complication in group A was superficial infection (7%) and skin necrosis (3%), whereas 3 patients in group B developed paresthesias due to sural nerve entrapment. Patients in group B had better AOFAS hindfoot (96/100) and ATRS (95/100) scores, but the difference was not significant. ROM was similar in both groups at the 12-month follow-up. CONCLUSION Percutaneous suturing seems to be a safe and effective technique that offers good functional outcomes and low complication rates in patients with acute Achilles tendon ruptures who elect to have surgery. LEVEL OF EVIDENCE Level II, prospective case series.
Collapse
Affiliation(s)
- Meletis Rozis
- 1 3rd Orthopaedic Department, KAT Hospital, University of Athens, Athens, Greece
| | - Ioannis S Benetos
- 1 3rd Orthopaedic Department, KAT Hospital, University of Athens, Athens, Greece
| | | | - Vasilios Polyzois
- 1 3rd Orthopaedic Department, KAT Hospital, University of Athens, Athens, Greece
| | - John Vlamis
- 1 3rd Orthopaedic Department, KAT Hospital, University of Athens, Athens, Greece
| | - Spyros G Pneumaticos
- 1 3rd Orthopaedic Department, KAT Hospital, University of Athens, Athens, Greece
| |
Collapse
|
45
|
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.
Collapse
|
46
|
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]
|
47
|
Fanchini M, Impellizzeri FM, Silbernagel KG, Combi F, Benazzo F, Bizzini M. Return to competition after an Achilles tendon rupture using both on and off the field load monitoring as guidance: A case report of a top-level soccer player. Phys Ther Sport 2017. [PMID: 28647204 DOI: 10.1016/j.ptsp.2017.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To describe the Return to competition after Achilles Tendon rupture (ATR) in an elite soccer player. DESIGN Case report. SETTING Return to sport (RTS) of a professional soccer player who suffered an ATR during a match. The RTS phase started 15 weeks after surgery and specific on-field activities were gradually introduced. Criteria used to monitor the transition through the different phases were strength and endurance of the calf muscle and ability to sustain specific on-field training loads (TL) monitored with Global Positioning System and heart-rate system. TLs were weekly compared to pre-injury values to evaluate recovery and to prescribe future sessions. PARTICIPANT A 39-year-old (height 178 cm, weight 75 kg) elite soccer defender player, playing in Italian Serie-A league. RESULTS Days of absence were lower compared to a cohort presented in UEFA study (119 versus 161 ± 65 days, respectively). External-TL and Internal-TL were organized to gradually increase during RTS and resulted in higher values prior to return to competition compared to pre-injury values. Concentric plantar flexion peak torque increased till 9th months after surgery. CONCLUSIONS Monitoring of the field activities allowed comparison with pre-injury values and provided a useful and functional criteria to pass return to team activity and competition.
Collapse
Affiliation(s)
- Maurizio Fanchini
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; FC Internazionale, Milan, Italy.
| | | | | | | | - Franco Benazzo
- Orthopaedic Clinic University of Pavia, Fondazione IRCCS Policlinico San Matteo, Italy
| | - Mario Bizzini
- Department of Research and Development, Schulthess Clinic, Zurich, Switzerland; FIFA Medical Assessment and Research Centre, Schulthess Clinic, Zurich, Switzerland
| |
Collapse
|
48
|
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.
Collapse
|
49
|
Zhao JG, Meng XH, Liu L, Zeng XT, Kan SL. Early functional rehabilitation versus traditional immobilization for surgical Achilles tendon repair after acute rupture: a systematic review of overlapping meta-analyses. Sci Rep 2017; 7:39871. [PMID: 28054658 PMCID: PMC5215510 DOI: 10.1038/srep39871] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/28/2016] [Indexed: 12/28/2022] Open
Abstract
Several meta-analyses comparing early functional rehabilitation and traditional immobilization following surgical Achilles tendon repair after acute rupture have been published. However, they have led to conflicting conclusions. The aims of this systematic review were to select high-quality meta-analyses from multiple discordant meta-analyses and to provide a postoperative rehabilitation strategy following surgical repair using currently available evidence. We performed a comprehensive search using the PubMed and Embase databases and the Cochrane Library. Assessment of Multiple Systematic Reviews (AMSTAR) instrument was used to assess the methodological quality. Three investigators independently applied the Jadad decision algorithm. Their results were then compared to ensure selection of a meta-analysis that provided the highest quality of evidence. Six meta-analyses met the eligibility criteria. AMSTAR scores ranged from 6 to 10. According to the Jadad decision algorithm, a high-quality meta-analysis with a greater number of RCTs was selected. This meta-analysis showed that early functional rehabilitation was superior to cast immobilization in terms of patient satisfaction and the time to return to pre-morbid sporting levels. There were no differences regarding major complications or the time before return to prior employment and sporting activity. Thus, we recommend early functional rehabilitation as the postoperative strategy for acute Achilles tendon ruptures.
Collapse
Affiliation(s)
- Jia-Guo Zhao
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| | - Xiao-Hui Meng
- Department of Orthopaedic Surgery, Yixing Traditional Chinese Medicine Hospital, Jiangsu Province, China
| | - Lin Liu
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xian-Tie Zeng
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| | - Shi-Lian Kan
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| |
Collapse
|
50
|
Hansen MS, Christensen M, Budolfsen T, Østergaard TF, Kallemose T, Troelsen A, Barfod KW. Achilles tendon Total Rupture Score at 3 months can predict patients' ability to return to sport 1 year after injury. Knee Surg Sports Traumatol Arthrosc 2016; 24:1365-71. [PMID: 26733273 DOI: 10.1007/s00167-015-3974-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To investigate how the Achilles tendon Total Rupture Score (ATRS) at 3 months and 1 year after injury is associated with a patient's ability to return to work and sports as well as to investigate whether sex and age influence ATRS after 3 months and 1 year. METHOD This is a retrospective study analysing the data from the Danish Achilles tendon Database. A total of 366 patients were included. Logistic regression was conducted to describe the effect of ATRS on return to work and sports. The effect of age and sex on ATRS was analysed by linear regression. RESULTS Three months after injury patients had a significantly increased chance of return to sport after 1 year with an increased ATRS (OR 1.06, p = 0.001) but a non-significant effect on return to work. After 1 year, patients had a significantly increased probability of having returned to sport (OR 1.11, p < 0.001) and also having returned to work (OR 1.05, p = 0.007) with an increased ATRS. Men had an average 7 (p = 0.006) points higher ATRS at 3 months and an average 22 (p = 0.006) points higher at 1 year. CONCLUSION ATRS is associated with patients' ability to return to sports and work. ATRS at 3 months can be used as a predictor of the patient's ability to return to sports after 1 year. Hereby, ATRS might help to individualise rehabilitation by identifying patients who do not respond adequately to the chosen treatment. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Maria Swennergren Hansen
- Department of Physiotherapy and Occupational Therapy, Danish Achilles Tendon Database, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.
| | - Marianne Christensen
- Department of Physiotherapy and Occupational Therapy and Department of Orthopaedic Surgery, Danish Achilles Tendon Database, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark
| | - Thomas Budolfsen
- Department of Physiotherapy and Occupational Therapy, Danish Achilles Tendon Database, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Thomas Friis Østergaard
- Department of Orthopaedic Surgery, Danish Achilles Tendon Database, Lillebaelt Hospital, Skovvangen 2-8, 6000, Kolding, Denmark
| | - Thomas Kallemose
- Department of Orthopaedics, Clinical Orthopaedic Research Hvidovre, Clinical Research Centre, Danish Achilles Tendon Database, Copenhagen University Hospital, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Danish Achilles Tendon Database, Copenhagen University Hospital, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Danish Achilles Tendon Database, Copenhagen University Hospital, Hvidovre, Denmark
| |
Collapse
|