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Mitrogiannis L, Mitrogiannis G, Melaki K, Karamitros A, Karantanas A, Paxinos O. An Early Functional Unsupervised Rehabilitation Protocol Allows Safe Return to Function After Achilles Tendon Repair. Cureus 2024; 16:e52477. [PMID: 38371156 PMCID: PMC10873818 DOI: 10.7759/cureus.52477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
PURPOSE Acute Achilles tendon tears in young active individuals are often treated surgically with prolonged rehabilitation, with the leg initially immobilized in plantar flexion in serial non-weight bearing casts and gradually progressing to full weight bearing. This study aimed to evaluate the safety of an early functional unsupervised rehabilitation protocol. METHODS The medical records of 25 patients treated with open repair were available for follow-up. In 10 patients, an early functional unsupervised rehabilitation protocol was used with a removable cast, active range of motion exercises of the ankle from the first postoperative day, and full weight bearing in a walking boot with the foot plantigrade after the second week. Another 15 patients who followed the classic rehabilitation protocol were used as controls. The patients were evaluated with the Victorian Institute of Sports Assessment-Achilles (VISA-A) and an ultrasound examination-based score. A Wilcoxon test was used to compare the scores between the groups. RESULTS The mean VISA-A score was 90.1 (SD = 9.87) for the early functional rehabilitation protocol group, while it was 83.8 (SD = 17.06, p = 0.624) for the control group. The mean ultrasound score was 7.75 (SD = 1.71) for the early functional rehabilitation protocol group, while it was 7.60 (SD = 3.05, p = 0.414) for the control group. There were no intra- or early postoperative complications in the groups, and all patients were satisfied with the results of their operation. CONCLUSIONS An early unsupervised functional rehabilitation protocol after open Achilles repair may allow for safe early mobilization and minimize the need for physiotherapy. The small number of participants is a limitation of this study, and further evaluation with more patients is necessary to document the efficacy.
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Affiliation(s)
| | - George Mitrogiannis
- Orthopedics Department, 251 Hellenic Air Force General Hospital, Athens, GRC
| | - Kalliopi Melaki
- Radiology Department, General Hospital of Piraeus "Tzaneio", Athens, GRC
| | | | | | - Odysseas Paxinos
- Orthopedics Department, 251 Hellenic Air Force General Hospital, Athens, GRC
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Ko PY, Hsu CH, Hong CK, Hung MT, Su WR, Jou IM, Wu PT, Su FC. Jigless Knotless Internal Brace Versus Other Minimal Invasive Achilles Tendon Repair Techniques in Biomechanical Testing Simulating the Progressive Rehabilitation Protocol. J Foot Ankle Surg 2022; 62:61-67. [PMID: 35477848 DOI: 10.1053/j.jfas.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/22/2022] [Accepted: 03/26/2022] [Indexed: 02/03/2023]
Abstract
The jigless knotless internal brace surgery (JKIB), an alternative method for minimal invasive surgery (MIS) repair of acute Achilles tendon rupture, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as previous clinical research demonstrates. However, no comparative study on the biomechanical performance between JKIB and other MIS techniques has been reported until now. In this study, 50 fresh porcine Achilles tendons were used to compare the JKIB with open surgery (two-stranded Krachow suture) with other MIS techniques, including Percutaneus Achilles Repair System (PARS), Speedbridge (SB), and Achillon Achilles Tendon Suture System (ACH), using a biomechanical testing with cyclic loading at 1 Hz. This test was used to simulate a progressive rehabilitation protocol where 20 to 100 N was applied in the first 250 cycles, followed by 20 to 190 N in the second 250 cycles, and then 20 to 369 N in the third 250 cycles. The cyclic displacement after 10, 100 and 250 cycles were recorded. The survived cycles were defined as a sudden drop in measured load. In survived cycles, the JKIB group (552.3 ± 72.8) had significantly higher cycles than the open, PARS, and ACH groups (204.3 ± 33.3, 395.9 ± 96.0, and 397.1 ± 80.9, respectively, p < .01) as analyzed by post hoc analysis, but no significant difference as compared with the SB group (641.6 ± 48.7). In cyclic displacement after 250 cyclic loadings, the JKIB group (11.29 ± 1.29) showed no significant difference as compared with PARS, SB, and ACH groups (12.21 ± 1.18, 9.80 ± 0.80, and 11.57 ± 1.10 mm, respectively) and significant less displacement than the open group (14.50 ± 1.85, p < .01). These findings suggest that JKIB could be an option for acute Achilles tendon repair in the MIS fashion due to no larger cyclic elongation compared with other MIS techniques.
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Affiliation(s)
- Po-Yen Ko
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chieh-Hsiang Hsu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | | | - Wei-Ren Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - I-Ming Jou
- Departments of Orthopedic Surgery and Pathology, E-Da Hospital, I-Shou University, Yen-Chao District, Kaohsiung, Taiwan; GEG Orthopedic Clinic, Tainan, Taiwan
| | - Po-Ting Wu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Fong-Chin Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
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Resistance Exercises in Early Functional Rehabilitation for Achilles Tendon Ruptures Are Poorly Described: A Scoping Review. J Orthop Sports Phys Ther 2020; 50:681-690. [PMID: 33094667 PMCID: PMC8168134 DOI: 10.2519/jospt.2020.9463] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To (1) describe which resistance exercises are used in the first 8 weeks of treatment for acute Achilles tendon rupture and (2) assess the completeness of reporting of the exercise descriptions. DESIGN Scoping review. LITERATURE SEARCH We searched the MEDLINE, Embase, CINAHL, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases. STUDY SELECTION CRITERIA Randomized controlled trials, cohort studies, and case series (10 or more participants) that reported using resistance exercise in the immobilization period in the first 8 weeks of treatment for acute Achilles tendon rupture were included. DATA SYNTHESIS Completeness of exercise description was assessed with the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier exercise descriptor framework. RESULTS Thirty-eight studies were included. Fifty-one resistance exercises were extracted and categorized as isometric exercises (n = 20), heel raises (n = 6), strengthening with external resistance (n = 13), or unspecified (n = 12). A median of 8 (interquartile range, 6-10) of a possible 19 CERT items was reported. The amount of items described of the 13 Toigo and and Boutellier exercise descriptors ranged from 0 to 11. CONCLUSION A variety of resistance exercises targeted at the ankle plantar flexors were used as part of early functional rehabilitation after Achilles tendon rupture. However, most studies provided inadequate description of resistance exercise interventions. J Orthop Sports Phys Ther 2020;50(12):681-691. Epub 23 Oct 2020. doi:10.2519/jospt.2020.9463.
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Walker J, Nicholson G, Jongerius N, Parelkar P, Harris N, Bissas A. Commonly reported isokinetic parameters do not reveal long-term strength deficits of the Triceps surae complex following operative treatment of Achilles tendon rupture. J Biomech 2020; 101:109630. [DOI: 10.1016/j.jbiomech.2020.109630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/04/2020] [Accepted: 01/12/2020] [Indexed: 10/25/2022]
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Bąkowski P, Ciemniewska-Gorzela K, Talaśka K, Górecki J, Wojtkowiak D, Kerkhoffs GMMJ, Piontek T. Minimally invasive reconstruction technique for chronic Achilles tendon tears allows rapid return to walking and leads to good functional recovery. Knee Surg Sports Traumatol Arthrosc 2020; 28:305-311. [PMID: 31606762 PMCID: PMC6970963 DOI: 10.1007/s00167-019-05723-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 08/22/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE Chronic Achilles tendon tears, including chronic ruptures with end gap over 6 cm making end-to-end suturing impossible, can be treated with autologous hamstring graft reconstruction. The primary goal of this study was to present the biomechanical and long-term clinical results of recently developed minimally invasive Achilles tendon reconstruction technique. METHODS Minimally invasive Achilles tendon reconstruction was applied to 8 foot and ankle cadaveric specimens as well as 18 patients with chronic Achilles tendon tears. Repaired cadavers were subjected to the biomechanical testing using a cyclic loading protocol. Patients with reconstructed Achilles tendon were subjected to the clinical, functional and isokinetic tests at 12 months after the treatment. RESULTS All of tested Achilles cadaveric specimens survived 2 loading blocks (250 cycles of 10-100 N load followed by additional 250 cycles of 10-200 N load). With three specimens, it was possible to perform the third cyclic loading block with 20-300 N load and two specimens survived the fourth block with 20-400 N load. Therefore, a mean number of 838 cycles (±178) within the range of 509-1000 was recorded. Two specimens which survived all 1000 cycles were pulled to failure at 25 mm/s rate. The results obtained in the load to failure testing were as follows: 398 N and 608 N of maximum load. The results of functional heel rise endurance test and single leg hop for distance test indicated a decrease in the endurance and strength of the injured limb. However, the results of the weight-bearing lunge tests indicated no tendency for elongation of the Achilles tendon. A comparative analysis of the isokinetic test results for the non-injured and injured limb was revealed no statistically significant differences for every isokinetic test (n. s.), with significant difference for isometric strength parameters (p = 0.0006). CONCLUSIONS The results of the biomechanical tests as well as 1-year extensive functional, clinical and isokinetic results of the minimally invasive technique for chronic Achilles tendon tears are encouraging. Patients returned to their normal physical activity, including sport pre-injury level in most cases. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Paweł Bąkowski
- Department of Orthopedic Surgery, Rehasport Clinic, Poznan, Poland
| | | | - Krzysztof Talaśka
- Department of Basics Machine Design, Poznan University of Technology, Poznan, Poland
| | - Jan Górecki
- Department of Basics Machine Design, Poznan University of Technology, Poznan, Poland
| | - Dominik Wojtkowiak
- Department of Basics Machine Design, Poznan University of Technology, Poznan, Poland
| | | | - Tomasz Piontek
- Department of Orthopedic Surgery, Rehasport Clinic, Poznan, Poland
- Department of Spine Disorders and Pediatric Orthopedics, University of Medical Sciences Poznan, Poznan, Poland
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Ko PY, Huang MT, Li CL, Su WR, Jou IM, Wu PT. Jigless knotless internal brace technique for acute Achilles tendon rupture: a case series study. J Orthop Surg Res 2019; 14:415. [PMID: 31806034 PMCID: PMC6896394 DOI: 10.1186/s13018-019-1471-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/13/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose To mitigate the risk of poor wound healing and of infection associated with the open repair of Achilles tendon midsubstance ruptures, minimally invasive techniques have been developed. We report our preliminary results after reviewing our “jigless knotless internal brace technique.” Methods Patients were placed in prone position and a transverse 3-cm incision was made proximal to the palpable ruptured end. The proximal ruptured end was pulled out, gently debrided, and sutured using Krackow locking loops. Percutaneous sutures were crisscrossed through the distal tendon stump and looped around the Krackow sutures over the proximal stump. The ipsilateral Krackow sutures and the contralateral crisscrossed sutures were subcutaneously passed through two mini-incisions over the posterior calcaneus tuberosity and seated at the tuberosity with two 4.5-mm knotless suture anchors. All patients underwent the same post-operative rehabilitation protocol and regular follow-ups for at least 1 year. Results We recruited 10 patients (mean age, 37.3 years) who scored 100 points on the American Orthopaedic Foot and Ankle Society (AOFAS) scale, and who returned to their preoperative exercise levels 1-year post-operatively with no complications. Conclusion Our method is simple, effective, and requires no special tools. It might be a reliable option for Achilles tendon repair. Level of evidence III
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Affiliation(s)
- Po-Yen Ko
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liu Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Tung Huang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Lung Li
- Department of Orthopedics, National Cheng Kung University Hospital Dou-Liu Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, College of Medicine, National Cheng Kung University, 1 University Road, East District, Tainan City, 701, Taiwan
| | - I-Ming Jou
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Po-Ting Wu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liu Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, College of Medicine, National Cheng Kung University, 1 University Road, East District, Tainan City, 701, Taiwan. .,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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Yeung P, Man LP, Ho WHA. Twelve-years’ experience in minimal invasive Achilles tendon repair using a suture-guiding device. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2019. [DOI: 10.1177/2210491719837815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Minimal invasive Achilles tendon repair is becoming more and more popular recently. We have evaluated our results in Achilles tendon repair using minimally invasive method by a suture-guiding device. Methods: This is a retrospective review of patients with acute Achilles tendon rupture, which was repaired using minimally invasive method namely the suture-guiding device, that was performed during 2003 to 2015 in our department. Outcome parameters were the incidence of re-rupture, other complications, and the functional outcome. Results: There were 36 men (90%) and 4 women (10%) in this study. Mechanisms of injury were basketball (28%), football (15%), squash (15%), and trauma (13%). The mean operating time was 59 min (range 30–90 min). The mean follow-up time was 8 months (range 3–35 months). The mean duration with casting was 7 weeks. The mean range of movement at 3 months was 8° dorsiflexion and 33° plantar flexion. There was no major complication necessitating surgical re-interventions such as re-ruptures and infections. No patient suffered from dysfunction of the sural nerve or delay wound healing. Conclusion: Minimally invasive Achilles tendon repair using suture-guiding device is a safe and quick procedure with a low rate of re-rupture and a satisfactory short-term and long-term recovery. Level of evidence: IV.
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Affiliation(s)
- Prisca Yeung
- Department of Orthopaedics and Traumatology, Caritas Medical Centre, Hong Kong
| | - Lok Pong Man
- Department of Orthopaedics and Traumatology, Caritas Medical Centre, Hong Kong
| | - Wing Hang Angela Ho
- Department of Orthopaedics and Traumatology, Caritas Medical Centre, Hong Kong
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Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG. Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119884071. [PMID: 31803789 PMCID: PMC6878623 DOI: 10.1177/2325967119884071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines. PURPOSE To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture. RESULTS A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53). CONCLUSION Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.
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Affiliation(s)
- Jennifer A. Zellers
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marianne Christensen
- Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Inge Lunding Kjær
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
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Abstract
The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.
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Affiliation(s)
- Henrik C Bäcker
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Adrian J Yenchak
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - David P Trofa
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - J Turner Vosseller
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
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Abstract
Objectives The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development. Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2.
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Affiliation(s)
- X Yang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - H Meng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Q Quan
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - J Peng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - S Lu
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - A Wang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
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Sun T, Lu B, Cao X, Chen H, Xu X, Cui X. [Preliminary effectiveness of laminated bevel suturing technique for treating acute closed Achilles tendon rupture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:1447-1451. [PMID: 29806385 PMCID: PMC8498275 DOI: 10.7507/1002-1892.201704117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 10/24/2017] [Indexed: 11/03/2022]
Abstract
Objective To introduce a modified technique for treating acute closed Achilles tendon rupture and evaluate the preliminary effectiveness. Methods Between March 2011 and September 2015, 8 cases (8 sides) with acute closed Achilles tendon rupture were repaired with the laminated bevel suturing technique. All of the patients were male with an average age of 39.3 years (range, 22-58 years), injured in nonprofessional sports. The diagnosis was confirmed by typical signs of positive heel-lift test and Thompson test; the complete rupture of Achilles tendon was determined by color Doppler ultrasound or MRI, and the distance between the stump and calcaneus was 2-5 cm (mean, 3.3 cm). The time from injury to operation was 2-12 days (mean, 4.1 days). With the patient in prone position, a posterior longitudinal incision medial to the tendon was made, the broken stumps of Achilles tendon were divided into 3 layers on the coronal plane, fibers made into strips. The strips were staggered and stacked, stitched side to side with absorbable suture. The ankle joint at the plantar flexion position was fixed with plaster, and early rehabilitation exercise was carried out. Results The operation time was 70-135 minutes (mean, 99 minutes); the intraoperative blood loss was 5-30 mL (mean, 15.6 mL). All the incisions healed by first intention without infection, except for 1 case who need dressing exchange because of partial delayed healing. All the patients were followed up 6-50 months (mean, 30.5 months). There was no complication of surgical site infection, sural nerve injury, or deep vein thrombosis. The patients could walk normally with powerful raising heels and return to previous sports, without complication of re-rupture. Compared with the contralateral side, the activity of ankle joint dorsiflexion reduced 0-6° (mean, 3°); plantar flexion reduced 1-5° (mean, 2°). At last follow-up, according to Arner-Lindholm score, the surgical results were excellent in 7 cases and good in 1 case, with an excellent and good rate of 100%. Conclusion Laminated bevel suturing technique is simple for repairing acute closed Achilles tendon rupture without the need of special surgical instruments. It provides enough tensile strength for early rehabilitation exercise to rapid and good recovery.
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Affiliation(s)
- Taicun Sun
- Department of Orthopedics, Affiliated Hospital of Jiangsu University, Zhenjiang Jiangsu, 212001,
| | - Biao Lu
- Department of Orthopedics, Affiliated Hospital of Jiangsu University, Zhenjiang Jiangsu, 212001, P.R.China
| | - Xingbing Cao
- Department of Orthopedics, Affiliated Hospital of Jiangsu University, Zhenjiang Jiangsu, 212001, P.R.China
| | - Haining Chen
- Department of Orthopedics, Affiliated Hospital of Jiangsu University, Zhenjiang Jiangsu, 212001, P.R.China
| | - Xiaofeng Xu
- Department of Orthopedics, Affiliated Hospital of Jiangsu University, Zhenjiang Jiangsu, 212001, P.R.China
| | - Xuewen Cui
- Department of Orthopedics, Affiliated Hospital of Jiangsu University, Zhenjiang Jiangsu, 212001, P.R.China
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Miyamoto W, Imade S, Innami K, Kawano H, Takao M. Acute Achilles Tendon Rupture Treated by Double Side-Locking Loop Suture Technique With Early Rehabilitation. Foot Ankle Int 2017; 38:167-173. [PMID: 27765870 DOI: 10.1177/1071100716673589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although early accelerated rehabilitation is recommended for the treatment of acute Achilles tendon rupture, most traditional rehabilitation techniques require some type of brace. METHODS We retrospectively analyzed 44 feet of 44 patients (25 male and 19 female) with a mean age of 31.8 years who had an acute Achilles tendon rupture related to athletic activity. Patients had been treated by a double side-locking loop suture (SLLS) technique using double antislip knots between stumps and had undergone early accelerated rehabilitation, including active and passive range of motion exercises on the day following the operation and full weight-bearing at 4 weeks. No brace was applied postoperatively. The evaluation criteria included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS) score; active plantar flexion and dorsiflexion angles; and the intervals between surgery and the time when patients could walk normally without any support, perform double-leg heel raises, and perform 20 continuous single-leg heel raises of the operated foot. RESULTS Despite postoperative early accelerated rehabilitation, the AOFAS score and active dorsiflexion angles improved over time (6, 12, and 24 weeks and 2 years). A mean of 4.3 ± 0.6 weeks was required for patients to be able to walk normally without any support. The mean period to perform double-leg heel raises and 20 continuous single-leg heel raises of the injured foot was 8.0 ± 1.3 weeks and 10.9 ± 2.1 weeks, respectively. All patients, except one who was engaged in classical ballet, could return to their preinjury level of athletic activities, and the interval between operation and return to athletic activities was 17.1 ± 3.7 weeks. CONCLUSION The double SLLS technique with double antislip knots between stumps adjusted the tension of the sutured Achilles tendon at the ideal ankle position and provided good clinical outcomes following accelerated rehabilitation after surgery without the use of a brace. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Wataru Miyamoto
- 1 Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Shinji Imade
- 2 Department of Orthopaedic Surgery, Shimane University School of Medicine, Izumo, Japan
| | - Ken Innami
- 1 Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Hirotaka Kawano
- 1 Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Masato Takao
- 1 Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
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Abstract
Objective * These authors contributed equally to this work. To explore tendon-bundle technique for treating Achilles tendon rupture with no defects. Methods Patients with full unilateral Achilles tendon rupture with no defects were included. The Achilles tendon medial edge surgical repair approach was used, revealing horsetail-like rupture bundles. Tendon bundles were anatomically realigned and repaired end-to-end using 5-0 sutures. Patients were followed-up for 1 year, and assessed for differences between the repaired versus healthy limb. Results Out of 24 patients (18 male, 6 female; aged 19-56 years) at 1 year following surgery, mean American Orthopaedic Foot and Ankle Society score was 92.4 ± 5.9; mean differences between the surgically repaired versus contralateral side in dorsiflexion and plantarflexion angle were 3.5 ± 2.3° and 5.6 ± 3.2°, respectively; mean difference in calf circumference between the two sides was 0.9 ± 0.5 cm; and mean increase in Achilles tendon width versus the healthy side was 0.8 ± 0.2 cm. By 1 year post-surgery, there were no significant between-side differences in dorsiflexion and plantarflexion angle, or calf circumference. Conclusions Tendon-bundle surgery resulted in good ankle function restoration and low complication rates. Tendon-bundle surgery may reduce blood supply destruction and maximally preserve Achilles tendon length, and may be effective for treating Achilles tendon rupture with no defects.
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Affiliation(s)
- Chun-Guang Li
- Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bing Li
- Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yun-Feng Yang
- Department of Orthopaedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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Sarman H, Muezzinoglu US, Memisoglu K, Aydin A, Atmaca H, Baran T, Odabas Ozgur B, Ozgur T, Kantar C. Comparison of Semi-Invasive "Internal Splinting" and Open Suturing Techniques in Achilles Tendon Rupture Surgery. J Foot Ankle Surg 2016; 55:965-70. [PMID: 27338652 DOI: 10.1053/j.jfas.2016.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Indexed: 02/03/2023]
Abstract
The goal of the present study was to evaluate the semi-invasive "internal splinting" (SIIS) method for repair of Achilles tendon rupture relative to open repair with Krakow sutures. Efficacy was evaluated based on the clinical and functional outcomes, postoperative magnetic resonance imaging measurements, isokinetic results, and surgical complication rates. Functional measurements included the Thermann and American Orthopaedic Foot and Ankle Society (AOFAS) ankle scores, bilateral ankle dorsiflexion, and plantar flexion measurements. Magnetic resonance imaging was used to compare the bilateral length and thickness of each Achilles tendon. The isokinetic outcomes were evaluated using a Biodex System 3 dynamometer. Of the 45 patients meeting the inclusion criteria, 24 were treated by SIIS and 21 by the open Krackow suture technique. The mean follow-up time for all patients was 43.7 (range 6 to 116) months. In the SIIS group, patients returned to normal daily activities after 7.2 (range 6 to 8) weeks compared with 14.3 (range 12 to 15) weeks in the open surgery group. The AOFAS ankle scores were 93.5 (range 82 to 100) points in the open repair group and 96.2 (range 86 to 100) points in the SIIS group. The Thermann scores were 80.4 (range 53 to 91) points for the open repair group and 87.9 (range 81 to 100) points for the SIIS method. The mean Achilles length on the operated side measured using magnetic resonance imaging was 175.06 (range 110 to 224) mm and 177.76 (range 149 to 214) mm for the open surgery and SIIS groups, respectively. Sensory impairment in the territory of the sural nerve was identified in 1 patient immediately after SIIS surgery, although this defect had completely resolved within 12 months. SIIS yielded better outcomes relative to the open surgery group according to the isokinetic measurements. Taken together, these data indicate the SIIS method for Achilles tendon ruptures performed better in terms of both functional and objective outcomes compared with open surgery.
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Affiliation(s)
- Hakan Sarman
- Assistant Professor, Department of Orthopedics and Traumatology, Abant Izzet Baysal University School of Medicine, Bolu, Turkey.
| | - Umit Sefa Muezzinoglu
- Professor, Department of Orthopedics and Traumatology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Kaya Memisoglu
- Associate Professor, Department of Orthopedics and Traumatology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | | | - Halil Atmaca
- Associate Professor, Department of Orthopedics and Traumatology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Tuncay Baran
- Surgeon, Department of Orthopedics and Traumatology, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Bahar Odabas Ozgur
- Assistant Professor, Department of Sports Management, Kocaeli University Physical Education and Sports High School, Kocaeli, Turkey
| | - Turgay Ozgur
- Associate Professor, Department of Sports Management, Kocaeli University Physical Education and Sports High School, Kocaeli, Turkey
| | - Cengizhan Kantar
- Resident Physician, Department of Orthopedics and Traumatology, Kocaeli University School of Medicine, Kocaeli, Turkey
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Spennacchio P, Vascellari A, Cucchi D, Canata GL, Randelli P. Outcome evaluation after Achilles tendon ruptures. A review of the literature. JOINTS 2016; 4:52-61. [PMID: 27386448 DOI: 10.11138/jts/2016.4.1.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The optimal treatment and the best rehabilitation protocol after an acute Achilles tendon rupture (ATR) remain a matter of controversy in orthopaedic and sports medicine. The use of validated injury-specific outcome instruments is the only way to clarify these issues, in order to ensure that patients receive the best possible treatment. This article describes the most commonly reported outcome measures used to assess patients treated for ATR. On the basis of the available evidence, the Achilles tendon Total Rupture Score (ATRS) is the most appropriate outcome measure for evaluating the management of acute ATR.
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16
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Zellers JA, Carmont MR, Grävare Silbernagel K. Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Br J Sports Med 2016; 50:1325-1332. [PMID: 27259751 DOI: 10.1136/bjsports-2016-096106] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 12/26/2022]
Abstract
AIM This systematic review and meta-analysis sought to identify return to play (RTP) rates following Achilles tendon rupture and evaluate what measures are used to determine RTP. DESIGN A systematic review and meta-analysis were performed. Studies were assessed for risk of bias and grouped based on repeatability of their measure of RTP determination. DATA SOURCES PubMed, CINAHL, Web of Science and Scopus databases were searched to identify potentially relevant articles. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies reporting RTP/sport/sport activity in acute, closed Achilles tendon rupture were included. RESULTS 108 studies encompassing 6506 patients were included for review. 85 studies included a measure for determining RTP. The rate of RTP in all studies was 80% (95% CI 75% to 85%). Studies with measures describing determination of RTP reported lower rates than studies without metrics described, with rates being significantly different between groups (p<0.001). CONCLUSIONS 80 per cent of patients returned to play following Achilles tendon rupture; however, the RTP rates are dependent on the quality of the method used to measure RTP. To further understand RTP after Achilles tendon rupture, a standardised, reliable and valid method is required.
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Affiliation(s)
- Jennifer A Zellers
- Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA
| | - Michael R Carmont
- Department of Orthopaedic Surgery, The Princess Royal Hospital, Telford, Shropshire, UK.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Grävare Silbernagel
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
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Heikkinen J, Lantto I, Flinkkilä T, Ohtonen P, Pajala A, Siira P, Leppilahti J. Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up. J Bone Joint Surg Am 2016; 98:85-92. [PMID: 26791028 DOI: 10.2106/jbjs.o.00496] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This prospective randomized trial with a mean fourteen-year follow-up compared simple end-to-end repair with fascial flap-augmented repair for acute Achilles tendon ruptures. METHODS From 1998 to 2001, sixty patients with acute Achilles tendon rupture were randomized to receive simple end-to-end repair or augmented repair; both groups were treated with postoperative bracing allowing free active plantar flexion. After a follow-up of thirteen years or more, fifty-five patients (twenty-eight in the nonaugmented-repair group and twenty-seven in the augmented-repair group) were reexamined. Outcome measures included the Leppilahti Achilles tendon score, isokinetic plantar flexion strength (peak torque and the work-displacement deficit at 10° intervals over the ankle range of motion), tendon elongation, and the RAND 36-item health survey. RESULTS After a mean of fourteen years of follow-up, the mean Leppilahti score was 87.1 points for the nonaugmented repairs and 91.5 points for the augmented repairs, with a mean difference of 4.3 points (95% confidence interval [CI], -0.1 to 8.8 points). The surgical technique did not have an impact on strength parameters, with a mean peak torque of 112.6 Nm after the nonaugmented repairs and 107.3 Nm after the augmented repairs (mean difference, 5.3 Nm [95% CI, -22.2 to 11.6 Nm]) and a median work-displacement deficit of 6.7% to 20.3% after the nonaugmented repairs and 12.8% to 18.0% after the augmented repairs (p = 0.9). Strength did not significantly change between the twelve-month and fourteen-year follow-up examinations. At a mean of fourteen years, the injured side showed a 12.2% to 18.0% median work-displacement deficit compared with the unaffected side (p < 0.001). RAND-36 scores indicated no between-group difference in health domains. CONCLUSIONS Augmented repair of total Achilles tendon ruptures provided no advantage over simple end-to-end repair. Achilles tendon ruptures result in a permanent calf muscle strength deficit, but its clinical relevance remains unclear. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Tapio Flinkkilä
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Ari Pajala
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Pertti Siira
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., T.F., P.O., A.P., and J.L.), and Department of Physical Medicine and Rehabilitation (P.S.), Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland
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Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Kangas J, Siira P, Leppilahti J. Early functional treatment versus cast immobilization in tension after achilles rupture repair: results of a prospective randomized trial with 10 or more years of follow-up. Am J Sports Med 2015; 43:2302-9. [PMID: 26229048 DOI: 10.1177/0363546515591267] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are no long-term prospective controlled trials comparing postoperative regimens after Achilles tendon rupture repair. PURPOSE To compare ≥10-year outcomes of 2 postoperative regimens after Achilles tendon rupture repair: early weightbearing with early mobilization versus early weightbearing with early immobilization in tension. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 50 patients with acute Achilles tendon ruptures were randomized postoperatively to receive either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks (group 1) or Achilles tendon immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks (group 2). Patients were assessed at 3, 6, and 14 months and 11 years postoperatively. RESULTS There were 37 patients (74%) evaluated at a mean (±SD) of 11.0 ± 0.9 years. The mean Leppilahti score was 92.9 ± 5.6 in group 1 and 93.6 ± 7.2 in group 2 (P = .68). The mean isokinetic plantar flexion peak torque deficits or average work deficits in plantar flexion showed no differences between the groups with any angular velocity. Isokinetic strength changed minimally between 1 and 11 years compared with the unaffected ankle, but a mean deficit of 5% in peak torque and mean deficit of 8% in average work were still present after 11 years. On the contrary, isometric plantar flexion strength recovered significantly, with only a 2.4% difference at 11-year follow-up. CONCLUSION After the 11-year follow-up, early mobilization and immobilization in tension after Achilles rupture repair resulted in similar clinical outcomes and isokinetic strengths. Regardless of patient satisfaction with the operative treatment, calf muscle strength did not recover normally even at 11-year follow-up.
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Affiliation(s)
- Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tapio Flinkkila
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Jarmo Kangas
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pertti Siira
- Department of Physical Medicine and Rehabilitation, Oulu University Hospital, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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