Achilles tendon injuries

Foot Posture and Ankle Dorsiflexion as Risk Factors for Developing Achilles Tendinopathy and Plantar Fasciitis: A Case-Control Study

BACKGROUND

Plantar fasciitis (PF) and Achilles tendinopathy (AT) are common injuries that primarily affect people engaged in sport or occupational weightbearing activities. Identifying modifiable risk factors is important for the treatment and prevention of these injuries. The purpose of this study was to evaluate whether foot posture or ankle dorsiflexion are risk factors for developing AT or PF, and if there were any differences between PF and AT patients.

METHODS

This was a case-control study of 108 patients with PF and 114 patients with AT, compared to the same number of referred patients in 2 control groups never having had these injuries, matched for sex, age, body mass index (BMI), sport, and occupational weightbearing activities. Included patients were 20-65 years with ultrasonographic-verified PF or midsubstance AT. Foot posture was assessed using Foot Posture Index (FPI) classifying the feet into 3 categories: FPI 0-5 normal foot, 6-12 hyperpronated, <0 hypopronated. Ankle dorsiflexion was measured with a goniometer in weightbearing with straight and bent knee.

RESULTS

Abnormal foot posture was associated with an increased risk for sustaining both AT (odds ratio [OR] 3.4-4.1) and PF (OR 3.2-3.8). Hyperpronation being the major reason for this association with ORs 5.4-5.5 compared with hypopronation with ORs 2.6-2.9. However, decreased dorsiflexion was not a risk factor: instead, there was an increased ankle dorsiflexion in patients with AT or PF compared with their control groups. Comparison between PF and AT patients demonstrated that PF affected mostly women, and AT mostly men, PF patients were 2.4 years (CI 0.2-4.5) younger, and had 25% more occupational weightbearing than AT patients. However, no differences in BMI or weightbearing physical activity was demonstrated.

CONCLUSION

Hypopronation and hyperpronation but not limited ankle dorsiflexion was associated with increased risk for AT or PF.

The effect of fatigue on peak Achilles tendon force in Irish dancing-specific landing tasks

Achilles tendinopathy is prevalent among Irish dancers, believed to be due to aesthetic technical requirements and high-impact landing tasks. However, the peak Achilles tendon force during Irish dancing-specific landing tasks has not been quantified. Furthermore, the influence of fatigue is unclear. This study aimed to quantify the peak Achilles tendon force during three common Irish dancing landing tasks and investigate the effects of fatigue on this force. Twelve nationally competitive Irish dancers completed the landing tasks prior to and following a fatigue protocol. A Vicon motion analysis system and AMTI force plates were used to calculate sagittal plane ankle joint kinematics during landing to estimate peak Achilles tendon force. Three independent measures (Rating-of-Fatigue scale, Flight time: Contraction during a counter movement jump and jump height during the landing trials) were used to evaluate participant fatigue between conditions. Results revealed a significant difference in peak Achilles tendon force between the three landing tasks, however, no significant difference was observed between pre- and post-fatigue. Further research is required to investigate the effects of the landing technique used in Irish Dancing on peak Achilles tendon force with the aim to reduce peak Achilles tendon force and the risk of developing Achilles tendinopathy.

[Surgical or non-operative treatment of acute Achilles tendon rupture : What does the current literature say?]

BACKGROUND

The Achilles tendon is the strongest tendon in humans and is frequently injured, especially in the physically active young to middle-aged population. An increasing frequency of Achilles tendon ruptures (ATR) has been reported in several studies. However, there is no international consensus regarding possible non-operative (N-OP) or operative (surgical) treatment (OP).

OBJECTIVES

The aim of this article is to semi-quantitatively compare both treatment options for ATR by analyzing the results reported in the literature.

MATERIAL AND METHODS

For this purpose, relevant categories were identified, and the literature was then evaluated in a PubMed analysis. Ten meta-analyses and two cost analyses were included. The data was extracted according to the categories and evaluated comparatively.

RESULTS

OP and N‑OP for acute ATR can lead to equally good restitution of clinical function if early functional rehabilitation is applied. The lower re-rupture rate is an advantage of OP, whereas the lower general complications speak in favor of N‑OP. The minimally invasive or percutaneous surgical technique (M-OP) appears to be advantageous over the open surgical technique (O-OP), although studies show an increased rate of lesions of the sural nerve.

CONCLUSION

There is no consensus regarding the superiority of OP or N‑OP for acute ATR, as several studies conducted since the introduction of early mobilization protocols have shown similar results for these two interventions. Results and complications of M‑OP and O‑OP are also comparable. Considering the available data on the various surgical procedures, the authors prefer the M‑OP technique with adequate sural nerve protection for repair of acute ATR, combined with an early mobilization protocol.

A Mesoporous Silica-Loaded Multi-Functional Hydrogel Enhanced Tendon Healing via Immunomodulatory and Pro-Regenerative Effects

Tendon injuries are pervasive orthopedic injuries encountered by the general population. Nonetheless, recovery after severe injuries, such as Achilles tendon injury, is limited. Consequently, there is a pressing need to devise interventions, including biomaterials, that foster tendon healing. Regrettably, tissue engineering treatments have faced obstacles in crafting appropriate tissue scaffolds and efficacious nanomedical approaches. To surmount these hurdles, an innovative injectable hydrogel (CP@SiO2), comprising puerarin and chitosan through in situ self-assembly, is pioneered while concurrently delivering mesoporous silica nanoparticles for tendon healing. In this research, CP@SiO2 hydrogel is employed for the treatment of Achilles tendon injuries, conducting extensive in vivo and in vitro experiments to evaluate its efficacy. This reults demonstrates that CP@SiO2 hydrogel enhances the proliferation and differentiation of tendon-derived stem cells, and mitigates inflammation through the modulation of macrophage polarization. Furthermore, using histological and behavioral analyses, it is found that CP@SiO2 hydrogel can improve the histological and biomechanical properties of injured tendons. This findings indicate that this multifaceted injectable CP@SiO2 hydrogel constitutes a suitable bioactive material for tendon repair and presents a promising new strategy for the clinical management of tendon injuries.

Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year

OBJECTIVE

The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results.

HYPOTHESES

There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols.

METHODS

This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review.

RESULTS

Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07).

CONCLUSIONS

This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes.

LEVEL OF EVIDENCE

III; retrospective comparative, non-randomized.

Heterotopic Ossification of the Achilles Tendon in a Patient with Type II Diabetes Mellitus: A Case Report and Comprehensive Management Overview

Introduction

Heterotopic ossification of the Achilles tendon (HOTA) is a rare but consequential complication to an inflammatory event, often presenting challenges in diagnosis and management.

Case Report

We report a case of a 42-year-old male with Type II diabetes mellitus, managed with Metformin, who presented with acute pain and swelling in the right ankle following a running activity. Clinical examination revealed tenderness and a visible swelling proximal to the calcaneum attachment of the tendon which was hard in consistency, and a positive Thompson test indicative of a potential Achilles tendon injury. Imaging, including X-ray and magnetic resonance imaging, confirmed a complete avulsion tear with cranial retraction of the torn tendon and heterotopic ossification seen proximal to the torn end of the tendon. Surgical intervention, employing a posterior paramedian approach under tourniquet control, involved tendon approximation using the Speed bridge technique, incision over the proximal tendon and removal of the ossified tendon, and repair of the incised tendon sheath. Postoperatively, the patient received a tailored medication regimen and was advised strict non-weight-bearing measures, wound management, and limb elevation. The patient was discharged in a stable condition.

Conclusion

This case underscores the importance of early recognition and prompt surgical intervention in managing HOTA, particularly in patients with underlying risk factors. The presented surgical approach and postoperative management contribute to the evolving strategies for addressing this rare clinically significant condition.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Delayed Achilles Tendon Rupture at 17 Years of Age After Treatment of Clubfoot with Ponseti Method: A Case Report

CASE

Traumatic pediatric Achilles ruptures are rare, and few cases have been reported among patients with a history of Achilles tenotomy. A 17-year-old boy with a history of Achilles tenotomies for congenital clubfoot as an infant presented with acute midsubstance Achilles tendon rupture of the right leg. The gastrocnemius fascia was dissected to allow for approximation of the ruptured Achilles tendon segments. Furthermore, the plantaris tendon was harvested and sutured around the Achilles tendon-rupture site to improve strength.

CONCLUSIONS

Patients with a history of clubfoot and chronic Achilles tendon pain should be alerted to the risk of Achilles tendon rupture.

Open and Percutaneous Approaches Have Similar Biomechanical Results for Primary Midsubstance Achilles Tendon Repair: A Meta-analysis

Purpose

To evaluate the biomechanical properties of open versus percutaneous Achilles tendon repair.

Methods

A systematic review of original research articles was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. To qualify for study inclusion, articles were required to be published in English, use a laboratory design using either human or animal tissue, and directly compare the biomechanical properties of open Achilles repair using a Krackow or Kessler technique with percutaneous repair using either a locking or nonlocking suture construct. The biomechanical outcomes evaluated were displacement (millimeters) and load to failure (Newtons).

Results

Twelve studies met inclusion criteria, including 234 specimens (open: 97, percutaneous locking: 73; percutaneous nonlocking: 64) that underwent primary midsubstance Achilles tendon repair. Pooled analysis demonstrated no statistically significant difference in displacement (P = .240) or load to failure (P = .912) between the open and percutaneous techniques. Among the percutaneous approaches, there was no difference in displacement (P = .109) between the locking and nonlocking tendon repair systems.

Conclusions

The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary midsubstance Achilles tendon repair.

Clinical Relevance

In clinical studies, similar rerupture rates have been observed after open or percutaneous Achilles tendon repair. It may be beneficial for surgeons to understand whether biomechanical differences exist between these repair techniques.

Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis

Background

This systematic review and meta-analysis investigated the treatment for Achilles tendon rupture (ATR) associated with the lowest risk of rerupture in older patients.

Methods

Five databases were searched through September 2022 for studies published in the past 10 years analyzing operative and nonoperative ATR treatment. Studies were categorized as "nonelderly" if they reported only on patients aged 18-60 years. Studies that included at least 1 patient older than age 70 were categorized as "elderly inclusive." Of 212 studies identified, 28 were eligible for inclusion. Of 2965 patients, 1165 were treated operatively: 429 (37%) from elderly-inclusive studies and 736 (63%) from nonelderly studies. Of the 1800 nonoperative patients 553 (31%) were from nonelderly studies and 1247 (69%) were from elderly-inclusive studies.

Results

For nonoperative treatment, the rate of rerupture was higher in nonelderly studies (83/1000 cases, 95% CI = 58, 113) than in elderly-inclusive studies (38/1000 cases, 95% CI = 22, 58; P<.001). For operative treatment no difference was found in the rate of rerupture between nonelderly studies (7/1000 cases, 95% CI = 0, 21) and elderly-inclusive studies (12/1000 cases, 95% CI = 0, 35; P<.78). Overall, operative treatment was associated with a rerupture rate of 1.5% (95% CI: 1.0%, 2.8%) (P<.001), which was lower than the 5% rate reported by other studies for nonoperative management (P<.001).

Conclusion

Older patients may benefit more than younger patients from nonoperative treatment of ATR. More studies are needed to determine the age at which rerupture rates decrease among nonoperatively treated patients.

Level of Evidence

3.

Clinical anatomy of the human Achilles subtendons twist - meta-analysis

PURPOSE

This study aimed to provide a comprehensive and current overview of the anatomy of the Achilles tendon (AT) twisted structure, as there is a discrepancy in the literature regarding its rotating morphology.

METHODS

An extensive literature search was conducted across multiple databases to identify all studies that reported relevant data on the AT torsion, with no date or language restrictions applied. Data was extracted and assessed for this meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of the included articles was examined using the anatomical quality assessment (AQUA) tool.

RESULTS

Seven articles (n=690 limbs) were pooled into this meta-analysis. The prevalence of Achilles tendon torsion types was as follows: type II was the most common (46.7%, 95% CI: 31.6-60.9%), followed by type I (44.7%, 95% CI: 29.8-59.0%), and least commonly, type III (8.6%, 95% CI: 1.8-18.8%). Additionally, morphometric analysis, utilizing the method described by van Gils et al., revealed a mean Achilles tendon torsion of 46.5° (95% CI: 25.1-67.9°).

CONCLUSIONS

This meta-analysis underscores the prominent and variable twist within the Achilles tendon among individuals, emphasizing the inherent diversity in AT morphology. Furthermore, the study highlights the importance of considering torsion angle as a potential factor influencing AT pathologies and biomechanical function.

Bilateral Acute Achilles Tendon Rupture Can Be Effectively Treated Non-operatively

Acute rupture of the Achilles tendon (AT) is a common but debilitating injury that requires immediate diagnosis and effective management. Spontaneous bilateral AT rupture is rare; however, it can lead to severe disability for a significant period. This case report presents a 76-year-old patient who suffered a bilateral AT rupture while engaging in a non-strenuous activity. Upon confirmation of the diagnosis by physical examination and radiologic evaluation, conservative treatment was decided due to the presence of numerous comorbidities. A personalized rehabilitation protocol was implemented, allowing weight-bearing activities using Achilles boots at six weeks. Healing of both ATs was confirmed by an MRI at three months. Our case shows that non-operative treatment of these injuries can result in exceptionally favorable outcomes and should not be disregarded. However, thorough patient compliance and surveillance are prerequisites.

Exploring Ascorbic Acid's Role in Orthopedic Practices: Present Theories, Innovative Approaches, and Prospects

In the human body, ascorbic acid (AA) is known for its potent antioxidant and reducing properties and also plays a vital role in supporting the growth of bones and cartilage. It has been used extensively in orthopedic surgery. Ongoing studies under the umbrella of ascorbic acid research investigate its impact on bone and tendon physiology, as well as its influence on joint replacement and postoperative pain. The majority of both laboratory and human studies link the usage of ascorbic acid to enhanced bone health and improved tendon healing. Recent literature suggest that ascorbic acid administration may have a positive impact on the outcome of orthopedic procedures. On the other hand, controversy exists regarding the efficacy of ascorbic acid in reducing the incidence of complex regional pain syndrome. In brief, the effectiveness of ascorbic acid in enhancing orthopedic procedure outcomes remains a subject of ongoing investigation. Although certain studies have hinted at the potential positive influence of ascorbic acid on these outcomes, further research is required to validate its effectiveness and ascertain the ideal dosage and method of administration for maximizing its anticipated advantages. To establish the efficacy of ascorbic acid in improving orthopedic procedure outcomes, rigorous human trials of high quality are imperative. The aim of this review was to provide an overview of ascorbic acid's utilization in orthopedic practices and to pinpoint prospective areas for future research.

The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment

The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Hyperuricemia as an independent risk factor for achilles tendon rupture in male: a case-control study

OBJECTIVE

To study the correlation between achilles tendon rupture (ATR) and hyperuricemia, also verify the known risk factors for ATR.

METHODS

A retrospective review of 488 subjects was performed (182 with Achilles tendon rupture, 306 controls with ankle sprains). Demographic variables and risk factors for rupture were tabulated and compared. The baseline data and related indicators were compared, and the risk factors of ATR were analyzed by constructing a binary logistic regression model.

RESULTS

Univariate logistic analysis showed that BMI, smoking, and hyperuricemia were risk factors for the development of ATR (OR = 1.65, 95%CI 1.13-2.42, P = 0.01; OR = 1.47, 95%CI 1.00-2.24, P < 0.05; OR = 2.85, 95%CI 1.84-4.42, P < 0.01). Multifactorial analysis showed that BMI ≥ 25 kg/m2, smoking, and hyperuricemia were independent risk factors for the development of ATR (OR = 1.66, 95%CI 1.11-2.49, P = 0.01; OR = 2.15, 95%CI 1.28-3.60, P < 0.01; OR = 3.06, 95%CI 1.92-4.89, P < 0.01). Among the blood biochemical indicators, total cholesterol (TC) and uric acid (UA) were independent risk factors for the occurrence of ATR (OR = 1.54, 95% CI 1.12-2.12, P = 0.01; OR = 1.01, 95% CI 1.01-1.01, P < 0.01).

CONCLUSION

Our study confirmed that, as in previous results, higher BMI, smoking, and total cholesterol are risk factors for ATR, Hyperuricemia may contribute to the development of ATR, and adjunctive tests for TC and UA in the blood biochemistry may be helpful in predicting the risk of ATR.

Evaluation of Anti-Nociceptive, Anti-Inflammatory, and Anti-Fibrotic effects of noscapine against a rat model of Achilles tendinopathy

During tendinopathy, prolonged inflammation results in fibrosis and the adherence of tendons to the adjacent tissues, causing discomfort and movement disorders. As a natural compound, noscapine has several anti-inflammatory and anti-fibrotic properties. Therefore, we aimed to investigate the effects of noscapine against a rat model of tendinopathy. We created a surgical rat model of Achilles tendon damage to emulate tendinopathy. Briefly, an incision was made on the Achilles tendon, and it was then sutured using an absorbable surgical thread. Immediately, the injured area was topically treated with the vehicle, noscapine (0.2, 0.6, and 1.8 mg/kg), or dexamethasone (0.1 mg/kg) as a positive control. During the 19-day follow-up period, animals were assessed for weight, behavior, pain, and motor coordination testing. On day 20th, the rats were sacrificed, and the tendon tissue was isolated for macroscopic scoring, microscopic (H&E, Masson's trichrome, Ki67, p53) analyses, and cytokine secretion levels. The levels of macroscopic parameters, including thermal hyperalgesia, mechanical and cold allodynia, deterioration of motor coordination, tendon adhesion score, and microscopic indices, namely histological adhesion, vascular prominence and angiogenesis, and Ki67 and p53 levels, as well as fibrotic and inflammatory biomarkers (IL-6, TNF-α, TGF-β, VEGF) were significantly increased in the vehicle group compared to the sham group (P < 0.05-0.001 for all cases). In contrast, the administration of noscapine (0.2, 0.6, and 1.8 mg/kg) attenuated the pain, fibrosis, and inflammatory indices in a dose-dependent manner compared to the vehicle group (P < 0.05-0.001). Histological research indicated that noscapine 0.6 and 1.8 mg/kg had the most remarkable healing effects. Interestingly, two higher doses of noscapine had impacts similar to those of the positive control group in both clinical and paraclinical assessments. Taken together, our findings suggested that noscapine could be a promising medicine for treating tendinopathies.

Risk factors and clinical characteristics of surgical site infections in athletes undergoing Achilles tendon repair surgery

Achilles tendon ruptures are common in athletes, requiring surgical intervention. However, the risk of surgical site infections (SSIs) post-surgery poses significant challenges. This study aims to analyse the risk factors and microbial aetiology associated with SSIs in athletes undergoing Achilles tendon repair. A comprehensive retrospective analysis was conducted from May 2021 to July 2023. The study included 25 patients with SSIs (case group) and 50 patients without SSIs (control group) post Achilles tendon repair surgery. Inclusion criteria encompassed patients with medically confirmed Achilles tendon ruptures who underwent surgical repair. Exclusion criteria included prior tendon pathologies and significant chronic illnesses. Diagnostic criteria for SSIs involved symptoms like elevated body temperature and localized tenderness, along with laboratory confirmations such as positive microbiological cultures. The study utilized VITEK® 2 for bacterial identification and involved statistical analyses like univariate and multivariate logistic regression. The study identified Staphylococcus aureus as the primary pathogen in SSIs. Significant risk factors included lack of prophylactic antibiotic use, presence of diabetes, open wounds and prolonged surgery duration. Univariate analysis revealed stark contrasts in these factors between infected and non-infected groups, while multivariate analysis underscored their importance in SSI development. S. aureus emerged as the predominant pathogen in SSIs post Achilles tendon repair. Critical risk factors such as absence of prophylactic antibiotics, diabetes, open wounds and extended surgery duration play a vital role in SSIs. Addressing these factors is essential for better postoperative outcomes in Achilles tendon repair surgeries.

Achilles tendon disorders: An overview of diagnosis and conservative treatment

ABSTRACT

Achilles tendon-related pain affects up to 6% of the US population during their lifetime and is commonly encountered by primary care providers. An accurate diagnosis and early conservative management can improve patient quality of life and reduce unnecessary surgical consultations, saving healthcare dollars. Achilles tendon pathologies can be categorized into acute (pain lasting less than 6 weeks), chronic (pain lasting more than 6 weeks), and acute on chronic (worsening of pain with preexisting chronic Achilles tendon pathology). This article describes the diagnosis, conservative management, indications for imaging, and indications for surgical referral for acute and chronic Achilles tendon rupture, Achilles tendinitis, gastrocnemius strain, plantaris rupture, insertional Achilles tendinopathy, Haglund deformity, and noninsertional Achilles tendinopathy.

An overview of the material science and knowledge of nanomedicine, bioscaffolds, and tissue engineering for tendon restoration

Tendon wounds are a worldwide health issue affecting millions of people annually. Due to the characteristics of tendons, their natural restoration is a complicated and lengthy process. With the advancement of bioengineering, biomaterials, and cell biology, a new science, tissue engineering, has developed. In this field, numerous ways have been offered. As increasingly intricate and natural structures resembling tendons are produced, the results are encouraging. This study highlights the nature of the tendon and the standard cures that have thus far been utilized. Then, a comparison is made between the many tendon tissue engineering methodologies proposed to date, concentrating on the ingredients required to gain the structures that enable appropriate tendon renewal: cells, growth factors, scaffolds, and scaffold formation methods. The analysis of all these factors enables a global understanding of the impact of each component employed in tendon restoration, thereby shedding light on potential future approaches involving the creation of novel combinations of materials, cells, designs, and bioactive molecules for the restoration of a functional tendon.

Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study

OBJECTIVE

To develop and user-test a patient decision aid portraying the benefits and harms of non-surgical management and surgery for Achilles tendon ruptures.

DESIGN

Mixed methods.

SETTING

A draft decision aid was developed using guidance from a multidisciplinary steering group and existing patient decision aids. Participants were recruited through social media.

PARTICIPANTS

People who have previously sustained an Achilles tendon rupture and health professionals who manage these patients.

PRIMARY AND SECONDARY OUTCOMES

Semi-structured interviews and questionnaires were used to gather feedback on the decision aid from health professionals and patients who had previously suffered an Achilles tendon rupture. The feedback was used to redraft the decision aid and assess acceptability. An iterative cycle of interviews, redrafting according to feedback and further interviews was used. Interviews were analysed using reflexive thematic analysis. Questionnaire data were analysed descriptively.

RESULTS

We interviewed 18 health professionals (13 physiotherapists, 3 orthopaedic surgeons, 1 chiropractor, 1 sports medicine physician) and 15 patients who had suffered an Achilles tendon rupture (median time since rupture was 12 months). Most health professionals and patients rated the aid's acceptability as good-excellent. Interviews showcased agreement among health professionals and patients on most aspects of the decision aid: introduction, treatment options, comparing benefits and harms, questions to ask health professionals and formatting. However, health professionals had differing views on details about Achilles tendon retraction distance, factors that modify the risk of harms, treatment protocols and evidence on benefits and harms.

CONCLUSION

Our patient decision aid is an acceptable tool to both patients and health professionals, and our study highlights the views of key stakeholders on important information to consider when developing a patient decision aid for Achilles tendon rupture management. A randomised controlled trial evaluating the impact of this tool on the decision-making of people considering Achilles tendon surgery is warranted.

Return to sport after surgical repair of the Achilles tendon

Achilles tendon rupture is among the most common sports injuries. In patients with high functional demands, surgical repair is preferred to facilitate early return to sporting function. This article reviews the literature and provides evidence-based guidance for return to sport after operative management of Achilles tendon rupture. A search was performed using PubMed, Embase and Cochrane Library for all studies reporting on return to sport after operative management of Achilles tendon rupture. The review included 24 studies reporting on 947 patients, and found that 65-100% of patients were able to return to sport between 3 and 13.4 months post-injury, with incidence of rupture recurrence 0-5.74%. These findings will help patients and healthcare professionals plan a recovery timeline, discuss athletic functionality post-recovery, and understand complications of repair and risk of tendon re-rupture.

Taekwondo Athlete's Bilateral Achilles Tendon Rupture: A Case Report

(1) Background: Achilles tendon rupture is a common sports injury that may result in severe disability. The overall incidence of Achilles tendon rupture is increasing as a result of growing sports participation. However, cases of spontaneous bilateral Achilles tendon rupture with no underlying disease or risk factors, such as systemic inflammatory disease, steroid or (fluoro)quinolone antibiotics use, are rare. (2) Objective: Here, we report a case of a Taekwondo athlete's bilateral Achilles tendon rupture after kicking and landing. By sharing the experience of treatment and the patient's course, we suggest one of the possible treatment options and the need to establish a treatment method. (3) Procedure: A 23-year-old male Taekwondo athlete visited the hospital, presenting foot plantar flexion failure and severe pain in both tarsal joints, which had occurred upon kicking and landing on both feet earlier that day. During surgery, no degenerative changes or denaturation were observed in the ruptured areas of the Achilles tendons. Bilateral surgery was performed using the modified Bunnel method on the right side and minimum-section suturing on the left side was performed using the Achillon system, followed by lower limb casting. (4) Result: Good outcomes were observed on both sides at 19 months postoperatively. (5) Conclusion: The possibility of bilateral Achilles tendon rupture during exercise in young subjects with no risk factors should be acknowledged, especially in association with landing. In addition, in athletes, even if there is a possibility of complications, surgical treatment should be considered for functional recovery.

Global trends in research of achilles tendon injury/rupture: A bibliometric analysis, 2000–2021

Background

The Achilles tendon is the strongest and most susceptible tendon in humans. Achilles tendon injuries and ruptures have gradually attracted research attention. However, a bibliometric analysis of global research in this field is lacking. This study involved a bibliometric analysis of the developmental trends and research hotspots in Achilles tendon injuries/ruptures from 2000 to 2021.

Methods

Articles published between 2001 and 2021 were retrieved from an extended database of the Science Citation Index using Web of Science. VOSviewer and CiteSpace were used to analyze the relationships between publications, countries, institutions, journals, authors, references, and keywords.

Results

This study included 3,505 studies of 73 countries, 3,274 institutions, and 12,298 authors and explored the cooperation between them and the relationships between citations. Over the past 22 years, the number of publications has significantly increased. Foot Ankle International has published the most papers on Achilles tendon injuries/ruptures, and British Journal of Sports Medicine is the most famous journal. Re-rupture, exosomes, acute Achilles tendon rupture, and tendon adhesions gradually become the research focus over the past few years.

Conclusion

Achilles tendon injury and rupture are important research topics. A vast number of newly published papers on this topic have demonstrated that clinicians and researchers are interested in their study. Over time, these recent studies will be widely cited; therefore, this bibliometric analysis should be constantly updated.

Percutaneous Achilles Tendon Repair Using Ultrasound Guidance: An Intraoperative Ultrasound Technique

Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach.

Eccentric exercise is more effective than other exercises in the treatment of mid-portion Achilles tendinopathy: systematic review and meta-analysis

Achilles tendinopathy (AT) is one of the most frequent overuse injuries in the ankle. The evidence base for its conservative management AT continues to evolve, but there is still a gap in the evidence for the efficacy of any modality of treatment in high-quality studies. This systematic review and meta-analysis investigated the efficacy of EE in improving pain and function in adult patients with mid-portion Achilles tendinopathy compared to other forms of exercise. A search was performed in PubMed, BIREME, SportDiscus, Cinahl, Web of Science and PEDro, in November 2022. The methodological quality was evaluated using the Risk of Bias 2 tool (RoB2) of the Cochrane collaboration, and the meta-analysis was performed using the Review Manager 5.1 program. 2024 articles were identified and eight fulfilled the inclusion criteria. RoB2 presented a final score with 62.5% of the studies presented "some concerns", and 37.5% (five and three articles, respectively) presenting "high risk" of bias. EE was effective for the managment of AT. The only variable for which a meta-analysis was possible was pain (five articles), analysed with the visual analogue scale/numerical visual scale. The mean difference (MD) in treatment effect using EE was - 1.21 (- 2.72 to - 0.30) with a 95% of confidence interval (CI), thus identifying a significant positive effect for the improvement of pain in patients with AT in whom EE was used. EE is effective in the management of AT. The meta-analysis shows the need for appropriately powered randomized controlled trials with better design, the use of standard outcome measures and well-planned protocols for conservative management of AT.Level of evidence: Level 1.Registration: CRD42018118016.

Rerupture outcome of conservative versus open repair versus minimally invasive repair of acute Achilles tendon ruptures: A systematic review and meta-analysis

OBJECTIVE

To compare the rerupture rate after conservative treatment, open repair, and minimally invasive surgery management of acute Achilles tendon ruptures.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to August 2022.

METHODS

Randomised controlled trials involving different treatments for Achilles tendon rupture were included. The primary outcome was rerupture. Bayesian network meta-analysis with random effects was used to assess pooled relative risks (RRs) and 95% confidence intervals. We evaluated the heterogeneity and publication bias.

RESULTS

Thirteen trials with 1465 patients were included. In direct comparison, there was no difference between open repair and minimally invasive surgery for rerupture rate (RR, 0.72, 95% CI 0.10-4.4; I2 = 0%; Table 2). Compared to the conservative treatment, the RR was 0.27 (95% CI 0.10-0.62, I2 = 0%) for open repair and 0.14 (95% CI 0.01-0.88, I2 = 0%) for minimally invasive surgery. The network meta-analysis had obtained the similar results as the direct comparison.

CONCLUSION

Both open repair and minimally invasive surgery were associated with a significant reduction in rerupture rate compared with conservative management, but no difference in rerupture rate was found comparing open repair and minimally invasive surgery.

Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair

Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.

The joint Orthoplastic management of an Achilles tendon avulsion: A rare case report

Rupture of the Achilles tendon typically occurs at the mid-substance, and less commonly at the distal insertion or proximal musculotendinous junction. We report the case of a 60-year-old multi-morbid patient presenting with an avulsion of the Achilles tendon from the gastrocnemius-soleus complex - a variant of injury previously unrecorded in the literature. Initial Orthoplastic management involved debridement and primary fixation of the avulsed tendon to the muscle with a concurrent lateral rotational flap. Flap failure and loss of tendon viability necessitated further debridement and eventual split-skin grafting (SSG). A residual dorsiflexion deformity will undoubtedly require further operative intervention. Here, we report the management of this unreported variant of Achilles tendon injury and discuss alternatives to our initial management that could have resulted in fewer procedures and improved long-term functional outcomes.

Novel classification of Achilles tendon ruptures

In the literature, the treatment of patients with Achilles tendon ruptures begins with diagnosis and diagnosis. Depending on the classification of Achilles tendon rupture, treatment tactics are determined. From our point of view, the existing classification of Achilles tendon ruptures does not sufficiently reflect and systematize the approach to surgical treatment, which served as a more detailed study and addition to the existing classification of Achilles tendon ruptures.

Effect of Myofascial Release (MFR) on Tendo Achilles (TA) Flexibility in Nurses: A Review

Increased muscle stiffness can result in a reduced range of motion (ROM) and impaired function. An increased ankle injury risk has been associated with reduced ankle dorsiflexion ROM. Although self-myofascial release (SMFR) is commonly used in clinical and sporting settings, little is known about its impact on gastrocnemius and Achilles tendon (AT) stiffness. As a result, we investigated how SMFR using a foam roller (FR) affects gastrocnemius-AT complex stiffness and ankle dorsiflexion ROM. According to these results, self-myofascial relaxation of the gastrocnemius and an improvement in ankle dorsiflexion ROM can be accomplished by rolling an FR along the calf. Myofascial release (MFR) is a type of manual therapy that involves stretching the myofascial complex with a light load and for a long duration in order to restore optimal length, relieve pain, and improve function. Viscoelastic deformation is the rapid increase in muscle length following stretching.

A Natural Hydrogel with Prohealing Properties Enhances Tendon Regeneration

Tendon regeneration and reduction of peritendinous adhesion remain major clinical challenges. This study addresses these challenges by adopting a unique hydrogel derived from the skin secretion of Andrias davidianus (SSAD) and taking advantage of its biological effects, adhesiveness, and controllable microstructures. The SSAD-derived hydrogel contains many cytokines, which could promote tendon healing. In vitro, leach liquid of SSAD powder could promote tendon stem/progenitor cells migration. In vivo, the SSAD-derived hydrogel featuring double layers possesses strong adhesiveness and could reconnect ruptured Achilles tendons of Sprague-Dawley rats without suturing. The intimal SSAD-derived hydrogel, with a pore size of 241.7 ± 21.0 µm, forms the first layer of the hydrogel to promote tendon healing, and the outer layer SSAD-derived hydrogel, with a pore size of 3.3 ± 1.4 µm, reducing peritendinous adhesion by serving as a dense barrier. Additionally, the SSAD-derived hydrogel exhibits antioxidant and antibacterial characteristics, which further contribute to the reduction of peritendinous adhesion. In vivo studies suggest that the SSAD-derived hydrogel reduces peritendinous adhesion, increases collagen fiber deposition, promotes cell proliferation, and improves the biomechanical properties of the regenerated tendons, indicating better functional restoration. The SSAD-derived bilayer hydrogel may be a feasible biomaterial for tendon repair in the future.

Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play

PURPOSE OF REVIEW

Achilles tendon ruptures (ATR) are detrimental to sports performance, and optimal treatment strategy and guidelines on return to play (RTP) remain controversial. This current review investigates the recent literature surrounding nonoperative versus operative management of ATR, clinical outcomes, and operative techniques to allow the athlete a successful return to their respective sport.

RECENT FINDINGS

The Achilles tendon (AT) is crucial to the athlete, as it is essential for explosive activities such as running and jumping. Athletes that sustain an ATR play in fewer games and perform at a lower level of play compared to age-matched controls. Recent studies also theorize that ATRs occur due to elongation of the tendon with fatigue failure. Biomechanical studies have focused on comparing modes of fixation under dynamic loading to recreate this mechanism. ATRs can be career-ending injuries. Fortunately, the recent incorporation of early weight-bearing and functional rehabilitation programming for non-operative and operative patients alike proves to be beneficial. Especially for those treated nonoperatively, with the incorporation of functional rehabilitation, the risk of re-rupture among non-operative patients is beginning to approach the historical lower risk of re-rupture observed among patients treated operatively. Despite this progress in decreasing risk of re-rupture particularly among non-operative patients, operative managements are associated with unique benefits that may be of particular interest for athletes and active individuals. Recent studies demonstrate that operative intervention improves strength and functional outcomes with more efficacy compared to nonoperative management with rehabilitation. The current literature supports operative intervention in elite athletes to improve performance and shorten the duration to RTP. However, we acknowledge that surgical intervention does have inherent risks. Ultimately, most if not all young and/or high-level athletes with an ATR benefit from surgical repair, but it is crucial to take a stepwise algorithmic approach and consider other factors, which may lead towards nonoperative intervention. These factors include age, chronicity of injury, gap of ATR, social factors, and medical history amongst others in this review.

Gene electrotransfer of FGF2 enhances collagen scaffold biocompatibility

Tendon injuries are a common athletic injury that have been increasing in prevalence. While there are current clinical treatments for tendon injuries, they have relatively long recovery times and often do not restore native function of the tendon. In the current study, gene electrotransfer (GET) parameters for delivery to the skin were optimized with monophasic and biphasic pulses with reporter and effector genes towards optimizing underlying tendon healing. Tissue twitching and damage, as well as gene expression and distribution were evaluated. Bioprinted collagen scaffolds, mimicking healthy tendon structure were then implanted subcutaneously for biocompatibility and angiogenesis analyses when combined with GET to accelerate healing. GET of human fibroblast FGF2 significantly increased angiogenesis and biocompatibility of the bioprinted implants when compared to implant only sites. The combination of bioprinted collagen fibers and angiogenic GET therapy may lead to better graft biocompatibility in tendon repair.

Treatment of partial injury of the calcaneus tendon with heterologous fibrin biopolymer and/or photobiomodulation in rats

The present study aimed to evaluate the new heterologous fibrin biopolymer associated, or not, with photobiomodulation therapy for application in tendon injuries, considered a serious and common orthopedic problem. Thus, 84 Rattus norvegicus had partial transection of the calcaneus tendon (PTCT) and were randomly divided into: control (CG); heterologous fibrin biopolymer (HFB); photobiomodulation (PBM); heterologous fibrin biopolymer + photobiomodulation (HFB + PBM). The animals received HFB immediately after PTCT, while PBM (660 nm, 40 mW, 0.23 J) started 24 h post injury and followed every 24 h for 7, 14, and 21 days. The results of the edema volume showed that after 24 h of PTCT, there was no statistical difference among the groups. After 7, 14, and 21 days, it was observed that the treatment groups were effective in reducing edema when compared to the control. The HFB had the highest edema volume reduction after 21 days of treatment. The treatment groups did not induce tissue necrosis or infections on the histopathological analysis. Tenocyte proliferation, granulation tissue, and collagen formation were observed in the PTCT area in the HFB and HFB + PBM groups, which culminated a better repair process when compared to the CG in the 3 experimental periods. Interestingly, the PBM group revealed, in histological analysis, major tendon injury after 7 days; however, in the periods of 14 and 21 days, the PBM had a better repair process compared to the CG. In the quantification of collagen, there was no statistical difference between the groups in the 3 experimental periods. The findings suggest that the HFB and PBM treatments, isolated or associated, were effective in reducing the volume of the edema, stimulating the repair process. However, the use of HFB alone was more effective in promoting the tendon repair process. Thus, the present study consolidates previous studies of tendon repair with this new HFB. Future clinical trials will be needed to validate this proposal.

Insertional versus non-insertional tendoachilles tears: a comparative analysis of various predisposing factors and outcome following a repair

BACKGROUND

Association of tendon degeneration, pre-existing posterior heel pain, Haglund's bump, retrocalcaneal spur, and mode of injury varies for the insertional and non-insertional type of tendoachilles tears (TA).

PURPOSE

The study compares the various predisposing factors that determine the distinct type of TA tear and the outcome following a repair.

METHODS

This is a retrospective study of the patients who underwent tendoachilles repair during January 2012-June 2018. Patients above 18 years with a minimum follow-up of two years were included. Patients with calcaneal tuberosity avulsions, prior surgeries, and open injuries were excluded. Patients were divided into groups 1 (insertional tears (IT)) and 2 (non-insertional tears (NIT)), and further subdivided based on the tendon degeneration (as D-degenerative and N-normal sub types) from ultrasound findings. AOFAS score and predisposing factors like degeneration, posterior heel pain, Haglund's bump, spur, and mechanism of injury were compared between the groups.

RESULTS

The study included N = 146 with a mean age of 51.6 years and mean follow-up of 38.6 (range 24 to 96) months. IT associated with degeneration (IT-D) had a trivial fall as the predominant mechanism (P < 0.001). All patients had significant postoperative improvement of scores with no significant difference between the groups (P = 0.59) and subgroups (P = 0.27).75.34% had degenerative tendon, of which 64.5% were in the IT group and the rest in the NIT group (P = 0.02). 51.4% patients had a Haglund bump in the IT group and n.s. (P = 0.9). Forty-seven percent of patients had pre-existing posterior heel pain, 68% in IT and 32% in NIT (P = 0.04). Subgroup analysis revealed 65% of patients were in the IT-D subgroup (P < 0.001).

CONCLUSION

Predisposing factors like posterior heel pain, tendon degeneration, and trivial trauma have a strong propensity for insertional TA tear. In contrast, the prominence of Haglund's bump does not predispose to a distinct type of TA tears. The outcome following a surgical repair-yields good results with no difference between the two groups.

[Method of surgical treatment of patients with a chronic rupture of the Achilles tendon]

OBJECTIVE

To improve treatment outcomes in patients with long-standing Achilles tendon ruptures with severe diastasis and dysfunction of the calf muscle via the use of a new method of surgical treatment.

MATERIAL AND METHODS

The authors proposed a new method of Achilles tendon repair for diastasis from 5 to 10 cm. This technique consists in elimination of diastasis with a tendon of the long peroneal muscle on the distal base. Surgical stages are described. The authors also report a patient with long-standing Achilles tendon rupture. Surgical treatment and postoperative outcomes are described.

RESULTS

Postoperative outcomes were assessed in 23 patients. The control group consisted of 21 patients who underwent reconstruction according to Chernavsky's and Krasnov's methods. Assessment was carried out using clinical and biomechanical methods. The authors analyzed gait asymmetry and functional myography data. Their data indicate the advantage of treatment in the main group.

Muscular and Tendon Degeneration after Achilles Rupture: New Insights into Future Repair Strategies

Achilles tendon rupture is a frequent injury with an increasing incidence. After clinical surgical repair, aimed at suturing the tendon stumps back into their original position, the repaired Achilles tendon is often plastically deformed and mechanically less strong than the pre-injured tissue, with muscle fatty degeneration contributing to function loss. Despite clinical outcomes, pre-clinical research has mainly focused on tendon structural repair, with a lack of knowledge regarding injury progression from tendon to muscle and its consequences on muscle degenerative/regenerative processes and function. Here, we characterize the morphological changes in the tendon, the myotendinous junction and muscle belly in a mouse model of Achilles tendon complete rupture, finding cellular and fatty infiltration, fibrotic tissue accumulation, muscle stem cell decline and collagen fiber disorganization. We use novel imaging technologies to accurately relate structural alterations in tendon fibers to pathological changes, which further explain the loss of muscle mechanical function after tendon rupture. The treatment of tendon injuries remains a challenge for orthopedics. Thus, the main goal of this study is to bridge the gap between clinicians’ knowledge and research to address the underlying pathophysiology of ruptured Achilles tendon and its consequences in the gastrocnemius. Such studies are necessary if current practices in regenerative medicine for Achilles tendon ruptures are to be improved.

Reconstruction of Achilles region defects: A single-centre experience

BACKGROUND

Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes.

METHOD

In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre.

RESULTS

Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting.

CONCLUSION

Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.

Tendon Tissue Repair in Prospective of Drug Delivery, Regenerative Medicines, and Innovative Bioscaffolds

The natural healing capacity of the tendon tissue is limited due to the hypovascular and cellular nature of this tissue. So far, several conventional approaches have been tested for tendon repair to accelerate the healing process, but all these approaches have their own advantages and limitations. Regenerative medicine and tissue engineering are interdisciplinary fields that aspire to develop novel medical devices, innovative bioscaffold, and nanomedicine, by combining different cell sources, biodegradable materials, immune modulators, and nanoparticles for tendon tissue repair. Different studies supported the idea that bioscaffolds can provide an alternative for tendon augmentation with an enormous therapeutic potentiality. However, available data are lacking to allow definitive conclusion on the use of bioscaffolds for tendon regeneration and repairing. In this review, we provide an overview of the current basic understanding and material science in the field of bioscaffolds, nanomedicine, and tissue engineering for tendon repair.

Ground Reaction Forces during Vertical Hops Are Correlated with the Number of Supervised Physiotherapy Visits after Achilles Tendon Surgery

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.

Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates

BACKGROUND

An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling.

PURPOSE

To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 1.

METHODS

Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I² < 25%) and by random-effects models if heterogeneity was moderate to high (I²≥ 25%).

RESULTS

Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications.

CONCLUSION

This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.

Validation of PROMIS Physical Function for Evaluating Outcome After Acute Achilles Tendon Rupture

Background:

There is increased demand for valid, reliable, and responsive patient-reported outcome measures (PROMs) to evaluate treatment for Achilles tendon rupture, but not all PROMs currently in use are reliable and responsive for this condition.

Purpose:

To evaluate the measurement properties of the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) compared with other PROMs used after treatment for acute Achilles tendon rupture.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

A retrospective cohort study with a follow-up questionnaire was performed. All adult patients with an acute Achilles tendon rupture between June 2016 and June 2018 with a minimum 12-month follow-up were eligible for inclusion. Functional outcome was assessed using the PROMIS PF computerized adaptive test (CAT), Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL), FAAM–Sports, and Achilles Tendon Total Rupture Score (ATRS). Pearson correlation (r) was used to assess the correlations between PROMs. Absolute and relative floor and ceiling effects were calculated.

Results:

In total, 103 patients were included (mean age, 44.7 years; 74% male); 82 patients (79.6%) underwent operative repair, while 21 patients (20.4%) underwent nonoperative management. The mean time between treatment and collection of PROMs was 25.3 months (range, 15-36 months). The mean scores were 55.4 ± 9.2 (PROMIS PF), 92.9 ± 12.2 (FAAM-ADL), 77.7 ± 22.9 (FAAM–Sports), and 83.0 ± 19.4 (ATRS). The ATRS was correlated with FAAM-ADL (r = 0.80; 95% CI, 0.72-0.86; P < .001) and FAAM–Sports (r = 0.86; 95% CI, 0.80-0.90; P < .001). The PROMIS PF was correlated with the FAAM-ADL (r = 0.66; 95% CI, 0.53-0.75; P < .001), FAAM–Sports (r = 0.65; 95% CI, 0.53-0.75; P < .001), and ATRS (r = 0.69; 95% CI, 0.58-0.78; P < .001). The PROMIS PF did not show absolute floor or ceiling effects (0%). The FAAM-ADL (35.9%), FAAM–Sports (15.8%), and ATRS (20.4%) had substantial absolute ceiling effects.

Conclusion:

The PROMIS PF, FAAM-ADL, and FAAM–Sports all showed a moderate to high mutual correlation with the ATRS. Only the PROMIS PF avoided substantial floor and ceiling effects. The results suggest that the PROMIS PF CAT is a valid, reliable, and perhaps the most responsive tool to evaluate patient outcomes after treatment for an Achilles tendon rupture.

A Self-Powered Piezo-Bioelectric Device Regulates Tendon Repair-Associated Signaling Pathways through Modulation of Mechanosensitive Ion Channels

Tendon disease constitutes an unmet clinical need and remains a critical challenge in the field of orthopaedic surgery. Innovative solutions are required to overcome the limitations of current tendon grafting approaches, and bioelectronic therapies show promise in treating musculoskeletal diseases, accelerating functional recovery through the activation of tissue regeneration-specific signaling pathways. Self-powered bioelectronic devices, particularly piezoelectric materials, represent a paradigm shift in biomedicine, negating the need for battery or external powering and complementing existing mechanotherapy to accelerate the repair processes. Here, the dynamic response of tendon cells to a piezoelectric collagen-analogue scaffold comprised of aligned nanoscale fibers made of the ferroelectric material poly(vinylidene fluoride-co-trifluoroethylene) is shown. It is demonstrated that motion-powered electromechanical stimulation of tendon tissue through piezo-bioelectric device results in ion channel modulation in vitro and regulates specific tissue regeneration signaling pathways. Finally, the potential of the piezo-bioelectronic device in modulating the progression of tendinopathy-associated processes in vivo, using a rat Achilles acute injury model is shown. This study indicates that electromechanical stimulation regulates mechanosensitive ion channel sensitivity and promotes tendon-specific over non-tenogenic tissue repair processes.

Effect of muscle atrophy and fatty infiltration on mid-term clinical, and functional outcomes after Achilles tendon repair

OBJECTIVES

Muscle atrophy is one of the most common problems after Achilles tendon repair. The aim of this study was to evaluate the effect of gastrosoleus muscle atrophy and fatty infiltration on clinical, and functional outcomes after Achilles tendon repair.

MATERIAL AND METHODS

A total of 46 patients (mean age = 39.3 ± 7.4 years) who underwent open Achilles tendon repair were included in the study. During the clinical evaluation of muscle atrophy, ipsilateral and contralateral calf circumference (CC), maximum heel rise (HR), and ankle range of motion measurements were recorded. Functional outcomes were assessed via The Achilles tendon Total Rupture Score (ATRS), the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Leppilahti score. Muscle volume (MV), cross-sectional area (CSA), and percent of fatty infiltration (FI) were measured via magnetic image resonance.

RESULTS

The functional outcome scores were excellent: ATRS = 98.1 ± 2.2; AOFAS = 97.3 ± 4.1; Leppilahti score = 95.8 ± 5.1. There were significant differences detected between injured and non-injured legs regarding CC, HR, MV, CSA, and FI. Additionally, there were significant negative correlations between CSA and MV loss with all functional outcome scores. FI was correlated with only the AOFAS ankle-hindfoot score.

CONCLUSIONS

Significant muscle atrophy was measured after a mean follow-up period of 7.4 (range 2.0-12.6) years post-surgery and negatively correlated with clinical outcomes. CC is an easy and cost-effective measurement method to predict MV during the follow-up of Achilles tendon repairs.

The Surgical Care Practitioner role in Achilles tendon re-rupture: A case study

The value of a Surgical Care Practitioner to an orthopaedic team is demonstrated in this case study of a patient who presented with a re-ruptured Achilles tendon. It highlights the role the practitioner plays in the patient journey and illustrates it's value throughout the clinical course from consultation through to discharge. The Surgical Care Practitioner, as a member of the extended surgical team can help to explain the diagnosis and associated treatment options, facilitate informed consent and provide expert procedural assistance to the surgeon. A Surgical Care Practitioner is ideally placed to answer patient queries and aid in rehabilitation.

Return to Play and Player Performance After Achilles Tendon Rupture in UEFA Professional Soccer Players: A Matched-Cohort Analysis of Players From 1999 to 2018

Background:

Achilles tendon rupture (ATR) is a potentially career-ending injury in professional athletes. Limited information exists regarding return to play (RTP) in professional soccer players after this injury.

Purpose:

To determine the RTP rate and time in professional soccer players after ATR and to evaluate player performance relative to matched controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We evaluated 132 professional soccer players who suffered an ATR between 1999 and 2018. These athletes were matched 2:1 to uninjured controls by position, age, season of injury, seasons played, and height. We collected information on the date of injury, the date of RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) from official team websites, public injury reports, and press releases. Changes in performance metrics for the 4 years after the season of injury were compared with metrics 1 season before injury. Univariate comparisons were performed using independent-sample, 2-group t tests and Wilcoxon rank-sum tests when normality of distributions was violated.

Results:

The mean age at ATR was 27.49 ± 4.06 years, and the mean time to RTP was 5.07 ± 2.61 months (18.19 ± 10.96 games). The RTP rate was 71% for the season after injury and 78% for return at any timepoint. Overall, 9% of the injured players experienced a rerupture during the study period. Compared with controls, the injured players played significantly less (-6.77 vs -1.81 games [P < .001] and -560.17 vs -171.17 minutes [P < .05]) and recorded fewer goals (-1.06 vs -0.29 [P < .05]) and assists (-0.76 vs -0.02 [P < .05]) during the season of their Achilles rupture. With the exception of midfielders, there were no significant differences in play time or performance metrics between injured and uninjured players at any postinjury timepoint.

Conclusion:

Soccer players who suffered an ATR had a 78% RTP rate, with a mean RTP time of 5 months. Injured players played less and demonstrated inferior performance during the season of injury. With the exception of midfielders, players displayed no significant differences in play time or performance during any of the 4 postinjury seasons.

Return to play, performance, and value of National Basketball Association players following Achilles tendon rupture

Background: Achilles tendon ruptures are devastating injuries for National Basketball Association (NBA) players: prior studies have demonstrated decreased performance following return-to-play, but none have evaluated the effect of injury on rate-adjusted contextual statistics to assess the true change in performance. Additionally, there exists a paucity of data on the independent impact on defensive performance following return.Hypothesis: Compared to both control-matched peers and preoperative careers, we hypothesize that player production based on rate-adjusted contextual statistics will significantly decline following Achilles tendon rupture.Study design: Retrospective Cohort StudyMethods: Publicly available NBA injury data on Achilles tendon rupture were reviewed from the 1996 -1997 to the 2016-2017 seasons. Controls were matched based on height, position, age, and rate-adjusted statistics. Extracted data included Value over Replacement Player Rating, Box Plus-Minus, Win Shares, offensive rating, defensive rating, and time to return-to-play, and was collected for the season before and two seasons following injury.Results: Twenty-five NBA players with surgically treated complete Achilles ruptures met inclusion and exclusion criteria. The return-to-play rate from Achilles tendon ruptures from 1996-1997 to 2016-2017 was 80%, with a mean recovery period of 311.0 ± 100.9 days. After 2 years, performance significantly declined for Value over Replacement Player Rating, Box Plus-Minus, and offensive rating compared to controls and cases. However, there was no significant effect on defensive rating (P = 0.38). After two seasons, returning players had a Value over Replacement Player Rating that was 24.1% below pre-injury levels, contributed 1.4 fewer points per 100 possessions by Box Plus-Minus, and yielded 2.4 fewer wins by Win Shares.Conclusions: Achilles tendon rupture results in significant decreases in offensive production and career longevity. The injury does not have a significant impact on defensive production.Clinical relevance: Achilles tendon ruptures significantly affect basketball players ability to return-to-play, and their in-game performance.Level of evidence: 3.

Identification of Three Loci Associated with Achilles Tendon Injury Risk from a Genome-wide Association Study

PURPOSE

This study aimed to screen the entire genome for genetic markers associated with risk for Achilles tendon injury.

METHODS

A genome-wide association analysis was performed using data from the Kaiser Permanente Research Board and the UK Biobank. Achilles tendon injury cases were identified based on electronic health records from the Kaiser Permanente Research Board databank and the UK Biobank from individuals of European ancestry. Genome-wide association analyses from both cohorts were tested for Achilles tendon injury using a logistic regression model adjusting for sex, height, weight, and race/ethnicity using allele counts for single nucleotide polymorphisms (SNP). Previously identified genes within the literature were also tested for association with Achilles tendon injury.

RESULTS

There were a total of 12,354 cases of Achilles tendon injury and 483,080 controls within the two combined cohorts, with 67 SNP in three chromosomal loci demonstrating a genome-wide significant association with Achilles tendon injury. The first locus contains a single SNP (rs183364169) near the CDCP1 and TMEM158 genes on chromosome 3. The second locus contains 65 SNP in three independently segregating sets near the MPP7 gene on chromosome 10. The last locus contains a single SNP (rs4454832) near the SOX21 and GPR180 genes on chromosome 13. The current data were used to test 14 candidate genes previously reported to show an association with Achilles tendon injury, but none showed a significant association (all P > 0.05).

CONCLUSION

Three loci were identified as potential risk factors for Achilles tendon injury and deserve further validation and investigation of molecular mechanisms.