Acute Achilles Tendon Ruptures

Video analysis of Achilles tendon ruptures in professional male football (soccer) reveals underlying injury patterns and provides strategies for injury prevention

PURPOSE

In professional football (soccer), Achilles tendon ruptures are severe injuries. Video analysis promotes a better understanding of the underlying situational and biomechanical patterns, and provides a roadmap for future research to improve the management and prevention of Achilles tendon ruptures. The purpose of this study was to identify injury patterns contributing to acute Achilles tendon ruptures in professional male football players.

METHODS

Professional male football players with an acute Achilles tendon rupture were identified using an online database. For every in-competition injury, the corresponding football match was detected. Video footage of the injury was accessed using Wyscout.com or publicly available video databases. Situational patterns and injury biomechanics of the injury frame were independently analysed by two reviewers using a standardised checklist and a motion analysis software. Finally, consensus was reached to describe the main injury patterns of Achilles tendon ruptures in professional male football players.

RESULTS

The search identified video footage of 80 Achilles tendon ruptures in 78 players. Most injuries (94%) occurred through indirect or non-contact mechanisms. The kinematic analysis revealed characteristic joint positions at the time of injury consisting of hip extension, knee extension, ankle dorsiflexion, foot abduction, and foot pronation in most cases. The underlying direction of movement was from flexion to extension (knee) and from plantarflexion to dorsiflexion (ankle). Player actions identified as main injury patterns were stepping back (26%), landing (20%), running/sprinting (18%), jumping (13%), and starting (10%).

CONCLUSION

Most Achilles tendon ruptures in professional male football players are closed-chain indirect or non-contact injuries. Sudden loading to the plantarflexor musculotendinous unit remains to be the main component for most cases. By achieving a better understanding of underlying injury mechanisms, this study provides new strategies for the prevention of Achilles tendon ruptures.

LEVEL OF EVIDENCE

Level IV.

Improving the regenerative microenvironment during tendon healing by using nanostructured fibrin/agarose-based hydrogels in a rat Achilles tendon injury model

AIMS

Achilles tendon injuries are a frequent problem in orthopaedic surgery due to their limited healing capacity and the controversy surrounding surgical treatment. In recent years, tissue engineering research has focused on the development of biomaterials to improve this healing process. The aim of this study was to analyze the effect of tendon augmentation with a nanostructured fibrin-agarose hydrogel (NFAH) or genipin cross-linked nanostructured fibrin-agarose hydrogel (GP-NFAH), on the healing process of the Achilles tendon in rats.

METHODS

NFAH, GP-NFAH, and MatriDerm (control) scaffolds were generated (five in each group). A biomechanical and cell-biomaterial-interaction characterization of these biomaterials was then performed: Live/Dead Cell Viability Assay, water-soluble tetrazolium salt-1 (WST-1) assay, and DNA-released after 48 hours. Additionally, a complete section of the left Achilles tendon was made in 24 Wistar rats. Animals were separated into four treatment groups (six in each group): direct repair (Control), tendon repair with MatriDerm, or NFAH, or GP-NFAH. Animals were euthanized for further histological analyses after four or eight weeks post-surgery. The Achilles tendons were harvested and a histopathological analysis was performed.

RESULTS

Tensile test revealed that NFAH and GP-NFAH had significantly higher overall biomechanical properties compared with MatriDerm. Moreover, biological studies confirmed a high cell viability in all biomaterials, especially in NFAH. In addition, in vivo evaluation of repaired tendons using biomaterials (NFAH, GP-NFAH, and MatriDerm) resulted in better organization of the collagen fibres and cell alignment without clinical complications than direct repair, with a better histological score in GP-NFAH.

CONCLUSION

In this animal model we demonstrated that NFAH and GP-NFAH had the potential to improve tendon healing following a surgical repair. However, future studies are needed to determine the clinical usefulness of these engineered strategies. Cite this article: Bone Joint J 2020;102-B(8):1095-1106.

Cost-effectiveness of Operative Versus Non-operative Management of Acute Achilles Tendon Ruptures

BACKGROUND

The management of acute Achilles tendon ruptures is controversial, and most injuries are treated with surgery in the USA. The cost utility of operative versus non-operative treatment of acute Achilles tendon injury is unclear.

QUESTIONS/PURPOSES

The purpose of this study was to compare the cost-effectiveness of operative versus functional non-operative treatment of acute Achilles tendon ruptures.

METHODS

A Markov cost-utility analysis was conducted from the societal perspective using a 2-year time horizon. Hospital costs were derived from New York State billing data, and physician and rehabilitation costs were derived from the Medicare physician fee schedule. Indirect costs of missed work were calculated using estimates from the US Bureau of Labor Statistics. Rates of re-rupture, major and minor complications, and the associated costs were obtained from the literature. Effectiveness was expressed in quality-adjusted life years (QALYs). For the base-case analysis, operative and non-operative patients were assumed to have the same utilities (quality of life) following surgery. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of model assumptions.

RESULTS

In the base-case model, non-operative management of acute Achilles tendon ruptures dominated operative management, resulting in both lower costs and greater QALY gains. The differences in costs and effectiveness were relatively small. The benefit of non-operative treatment was 1.69 QALYs, and the benefit of operative treatment was 1.67 QALYs. Similarly, the total cost of operative and non-operative management was $13,936 versus $13,413, respectively. In sensitivity analyses, surgical costs and days of missed work were important drivers of cost-effectiveness. If hospitalization costs dropped below $2621 (compared with $3145) or the hourly wage rose above $29 (compared with $24), then operative treatment became a cost-effective strategy at the willingness-to-pay threshold of $50,000/QALY. The model results were also highly sensitive to the relative utilities for operative versus non-operative treatment. If non-operative utilities decreased relative to operative utilities by just 2%, then operative management became the dominant treatment strategy.

CONCLUSION

For acute Achilles tendon ruptures, non-operative treatment provided greater benefits and lower costs than operative management in the base case; however, surgical costs and the economic impact associated with return to work are important determinants of the preferred cost-effective strategy.

Risk factors for complications after primary repair of Achilles tendon ruptures

Purpose

To identify patient characteristics associated with adverse events in Achilles tendon rupture (ATR) surgical repair cases.

Methods

A high risk (HR) cohort group of ATR patients were compared to healthy controls in the ACSNSQIP database with multivariate regression analysis.

Results

Overall, 2% (n = 23) of the group sustained an AE postoperatively, most commonly superficial SSI (0.9%, n = 10). Multivariate analysis did not reveal any patient characteristics to be significantly associated with the occurrence of an AE or superficial SSI.

Conclusions

Obesity, diabetes and a history of smoking did not predispose patients to significantly more AEs in the 30 day postoperative period following ATR repair in this study.

Incidence and risk factors for postoperative Achilles tendon calcifications after percutaneous repair

INTRODUCTION

Numerous publications are dealing with acute Achilles tendon rupture. To our knowledge, no systematic trial has been published analyzing the incidence, risk factors and the potential clinical impact of postoperative tendon calcifications (PTC) after percutaneous Achilles tendon repair. Therefore, the aim of this study was to analyze these relevant aspects.

MATERIALS AND METHODS

Between March 2003 and November 2010, a total of 126 patients with an acute, complete Achilles tendon rupture were treated with a percutaneous technique according to Ma and Griffith at a single university-based trauma department. The follow-up included a detailed clinical and sonographic examination. To assess the functional outcome and possible impact of PTC after percutaneous Achilles tendon repair, the Thermann and AOFAS scores were used. 81 patients (65 men and 16 women) with a median age of 46 years (range 24-76) were available for a follow-up examination. The median time of follow-up was 64 months (range 15-110 months).

RESULTS

PTC occurred in nine out of 81 patients (11.1%). All patients with PTC were male with a median age of 52 years (range 26-76 years). In the group of patients with PTC, the median overall Thermann score was 94 (range 68-100) and the median overall AOFAS score was 97 (range 85-100). In the group of patients without PTC, the median overall Thermann score was 88.5 (range 60-100) and the median overall AOFAS score was 97 (range 85-100). No significant differences were detected between the group of patients with PTC and the group of patients without PTC and the clinical outcome according to the Thermann (p = 0.21) and the AOFAS scores (p = 0.37). None of the patients with PTC sustained a re-rupture. The overall re-rupture rate was 4.9%. PTC was no risk factor for wound and neurological complications.

CONCLUSION

The incidence of PTC after percutaneous Achilles tendon repair was 11.1%. Male gender and advanced age seem to be risk factors for PTC. In this study, PTC had no negative impact on the postoperative clinical outcome.

Increasing age in Achilles rupture patients over time

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III; Retrospective cohort study.

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

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

Knotless Repair of Achilles Tendon Rupture in an Elite Athlete: Return to Competition in 18 Weeks

Rupture of the Achilles tendon is an increasingly common injury, particularly in physically active males, and current evidence favors minimally invasive surgical repair. We describe the case of a 36-year-old male elite bobsled athlete with complete rupture of the Achilles tendon. He was treated with surgical repair of the ruptured tendon using an innovative, minimally invasive procedure based on an internal bracing concept and was able to undergo early mobilization and aggressive physiotherapy rehabilitation. His recovery was such that he returned to training at 13 weeks postoperatively and participated in an international competition at 18 weeks, winning a World Cup silver medal. He subsequently raced at the 2014 Winter Olympic Games at 29 weeks after surgery. At >2 years since his injury, he has experienced no complications or reinjury. This represents an exceptional recovery that far exceeds the standard expected for such injuries. The use of this technique for athletes could enable accelerated return to sporting activity and attainment of their preinjury activity levels.