Nonoperative, dynamic treatment of acute achilles tendon rupture: influence of early weightbearing on biomechanical properties of the plantar flexor muscle-tendon complex-a blinded, randomized, controlled trial

Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis

Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.

Socioeconomic Status and Race Are Rarely Reported in Randomized Controlled Trials for Achilles Tendon Pathology in the Top 10 Orthopaedic Journals: A Systematic Review

Background

Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals.

Methods

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high-impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details.

Results

Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA.

Conclusion

This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results.

Case study: The influence of Achilles tendon rupture on knee joint stress during counter-movement jump - Combining musculoskeletal modeling and finite element analysis

BACKGROUND

Presently, the current research concerning Achilles tendon rupture repair (ATR) is predominantly centered on the ankle joint, with a paucity of evidence regarding its impact on the knee joint. ATR has the potential to significantly impede athletic performance and increase tibiofemoral contact forces in athletes. The purpose of this study was to prognosticate the distribution of stress within the knee joint during a countermovement jump through the use of a simulation method that amalgamated a musculoskeletal model of a patient who underwent Achilles tendon rupture repair with a finite element model of the knee joint.

METHODS

A male elite badminton player who had suffered an acute Achilles tendon rupture in his right leg one year prior was selected as our study subject. In order to analyze his biomechanical data, we employed both the OpenSim musculoskeletal model and finite element model to compute various parameters such as joint angles, joint moments, joint contact forces, and the distribution of knee joint stress.

RESULTS

During the jumping phase, a significantly lower knee extension angle (p < 0.001), ankle dorsiflexion angle (p = 0.002), peak vertical ground reaction force (p < 0.001), and peak tibiofemoral contact force (p = 0.009) were observed on the injured side than on the uninjured side. During the landing phase, the ankle range of motion (ROM) was significantly lower on the injured side than on the uninjured side (p = 0.009), and higher peak vertical ground reaction forces were observed (p = 0.012). Additionally, it is logical that an injured person will put higher load on the uninjured limb, but the finite element analysis indicated that the stresses on the injured side of medial meniscus and medial cartilage were significantly greater than the uninjured side.

CONCLUSIONS

An Achilles tendon rupture can limit ankle range of motion and lead to greater joint stress on the affected area during countermovement jumps, especially during the landing phase. This increased joint stress may also transfer more stress to the soft tissues of the medial knee, thereby increasing the risk of knee injury. It is worth noting that this study only involves the average knee flexion angle and load after ATR in one athlete. Caution should be exercised when applying the conclusions, and in the future, more participants should be recruited to establish personalized knee finite element models to validate the results.

1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment

PURPOSE

The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics.

METHODS

The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control.

RESULTS

The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg.

CONCLUSION

The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain.

LEVEL OF EVIDENCE

II.

CLINICAL TRIALS IDENTIFIER

NCT02760784.

Panda rope bridge technique versus open repair of acute Achilles tendon rupture: A comparative clinical study

PURPOSE

The treatment options of acute Achilles tendon rupture (AATR) remain controversial. This article aims to compare the efficacy of a new surgical procedure, the panda rope bridge technique (PRBT) with open surgery of AATR.

METHODS

Ninety-eight patients with AATR were recruited, 53 underwent the PBRT, and 45 underwent open surgery. The operation time, postoperative American Orthopaedic Foot and Ankle Score, Achilles Tendon Rupture Score, complications and time to return to work and restore exercise were documented.

RESULTS

The average operation time, intraoperative blood loss and complication rate were 35.1 min, 18.2 ml and 3.8%, respectively, in the PRBT group, which were significantly lower than those of the open surgery group (P<0.001). The post-operative American Orthopaedic Foot and Ankle Score of 99.6 and the Achilles Tendon Rupture Score of 97.5 in the PRBT group were significantly higher than that of the open surgery group (P<0.001). The time to return to work and return to exercise were shorter in the PRBT group (P<0.001).

CONCLUSION

Compared to open surgery, PRBT is a better approach to the management of AATR. PRBT offers accelerated recovery, lower occurrence of post-operative complications and improved recovery of ankle joint function.

Early functional rehabilitation compared with traditional immobilization for acute Achilles tendon ruptures : a meta-analysis

AIMS

The aim of this meta-analysis was to assess the prognosis after early functional rehabilitation or traditional immobilization in patients who underwent operative or nonoperative treatment for rupture of the Achilles tendon.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched for randomized controlled trials (RCTs) from their inception to 3 June 2020, using keywords related to rupture of the Achilles tendon and rehabilitation. Data extraction was undertaken by independent reviewers and subgroup analyses were performed based on the form of treatment. Risk ratios (RRs) and weighted mean differences (WMDs) (with 95% confidence intervals (CIs)) were used as summary association measures.

RESULTS

We included 19 trials with a total of 1,758 patients. There was no difference between the re-rupture rate (RR 0.84 (95% CI 0.56 to 1.28); p = 0.423), time to return to work (WMD -1.29 (95% CI -2.63 to 0.05); p = 0.060), and sporting activity (WMD -1.50 (95% CI -4.36 to 1.37); p = 0.306) between the early functional rehabilitation and the traditional immobilization treatment strategies. Early rehabilitation up to 12 weeks yielded significantly better Achilles tendon Total Rupture Scores ((ATRS) WMD 5.11 (95% CI 2.10 to 8.12); p < 0.001). Patients who underwent functional rehabilitation had significantly lower limb symmetry index of heel-rise work ((HRW) WMD -4.19 (95% CI -8.20 to 0.17); p = 0.041) at one year.

CONCLUSION

Early functional rehabilitation is safe and provides better early function and the same functional outcome in the longer term. Cite this article: Bone Joint J 2021;103-B(6):1021-1030.

Plaster cast versus functional bracing for Achilles tendon rupture: the UKSTAR RCT

BACKGROUND

Achilles tendon rupture affects > 11,000 people each year in the UK, leading to prolonged periods away from work, sports and social activities. Traditionally, the ruptured tendon is held still in a plaster cast for ≥ 8 weeks. Functional bracing is an alternative treatment that allows patients to mobilise earlier, but there is little evidence about how bracing affects patients' recovery.

OBJECTIVES

To measure the Achilles Tendon Rupture Score, quality of life, complications and resource use of patients receiving non-operative treatment for an Achilles tendon rupture treated with plaster cast compared with those treated with functional bracing.

DESIGN

This was a multicentre, randomised, pragmatic, two-group superiority trial.

SETTING

The setting was 39 NHS hospitals.

PARTICIPANTS

A total of 540 adult patients treated non-operatively for Achilles tendon rupture were randomised from July 2016 to May 2018. Exclusion criteria included presenting after 14 days, having had previous rupture and being unable to complete questionnaires.

INTERVENTIONS

A total of 266 participants had a plaster cast applied, with their toes initially pointing to the floor. The cast was changed over 8 weeks to bring the foot into a walking position. A total of 274 patients had a functional brace that facilitated immediate weight-bearing. The foot position was adjusted within the brace over the same 8-week period.

MAIN OUTCOME MEASURES

Achilles Tendon Rupture Score is patient reported and assesses symptoms and physical activity related to the Achilles tendon (score 0-100, with 100 being the best possible outcome). The secondary outcomes were quality of life, complications and resource use at 8 weeks and at 3, 6 and 9 months.

RESULTS

Participants had a mean age of 48.7 years, were predominantly male (79%) and had ruptured their tendon during sports (70%). Over 93% of participants completed follow-up. There was no statistically significant difference in Achilles Tendon Rupture Score at 9 months post injury (-1.38, 95% confidence interval -4.9 to 2.1). There was a statistically significant difference in Achilles Tendon Rupture Score at 8 weeks post injury in favour of the functional brace group (5.53, 95% confidence interval 2.0 to 9.1), but not at 3 or 6 months post injury. Quality of life showed the same pattern, with a statistically significant difference at 8 weeks post injury but not at later time points. Complication profiles were similar in both groups. Re-rupture of the tendon occurred 17 times in the plaster cast group and 13 times in the functional brace group. There was no difference in resource use.

CONCLUSIONS

This trial provides strong evidence that early weight-bearing in a functional brace provides similar outcomes to traditional plaster casting and is safe for patients receiving non-operative treatment of Achilles tendon rupture. The probability that functional bracing is cost-effective exceeds 95% for the base-case imputed analysis, assuming a cost-effectiveness threshold of £20,000 per quality-adjusted life-year. On average, functional brace is associated with lower costs (-£103, 95% confidence interval -£290 to £84) and more quality-adjusted life-years (0.015, 95% confidence interval -0.0013 to 0.030) than plaster cast.

LIMITATIONS

Some patients declined to participate in the trial, but only a small proportion of these declined because they had a preference for one treatment or another. Overall, 58% of eligible patients agreed to participate, so the participants are broadly representative of the population under investigation.

FUTURE WORK

Although the UK Study of Tendo Achilles Rehabilitation provides guidance with regard to early management, rehabilitation following Achilles tendon rupture is prolonged and further research is required to define the optimal mode of rehabilitation after the initial cast/brace has been removed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN62639639.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 8. See the NIHR Journals Library website for further project information.

Does size of tendon gap affect patient-reported outcome following Achilles tendon rupture treated with functional rehabilitation?

AIMS

Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation.

METHODS

Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included.

RESULTS

In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson's correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%).

CONCLUSION

Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535-1541.

A Pilot Study of Musculoskeletal Abnormalities in Patients in Recovery from a Unilateral Rupture-Repaired Achilles Tendon

The purpose of this study was to compare the inter-limb joint kinematics, joint moments, muscle forces, and joint reaction forces in patients after an Achilles tendon rupture (ATR) via subject-specific musculoskeletal modeling. Six patients recovering from a surgically repaired unilateral ATR were included in this study. The bilateral Achilles tendon (AT) lengths were evaluated using ultrasound imaging. The three-dimensional marker trajectories, ground reaction forces, and surface electromyography (sEMG) were collected on both sides during self-selected speed during walking, jogging and running. Subject-specific musculoskeletal models were developed to compute joint kinematics, joint moments, muscle forces and joint reaction forces. AT lengths were significantly longer in the involved side. The side-to-side triceps surae muscle strength deficits were combined with decreased plantarflexion angles and moments in the injured leg during walking, jogging and running. However, the increased knee extensor femur muscle forces were associated with greater knee extension degrees and moments in the involved limb during all tasks. Greater knee joint moments and joint reaction forces versus decreased ankle joint moments and joint reaction forces in the involved side indicate elevated knee joint loads compared with reduced ankle joint loads that are present during normal activities after an ATR. In the frontal plane, increased subtalar eversion angles and eversion moments in the involved side were demonstrated only during jogging and running, which were regarded as an indicator for greater medial knee joint loading. It seems after an ATR, the elongated AT accompanied by decreased plantarflexion degrees and calf muscle strength deficits indicates ankle joint function impairment in the injured leg. In addition, increased knee extensor muscle strength and knee joint loads may be a possible compensatory mechanism for decreased ankle function. These data suggest patients after an ATR may suffer from increased knee overuse injury risk.

Individualized treatment for acute Achilles tendon rupture based on the Copenhagen Achilles Rupture Treatment Algorithm (CARTA): a study protocol for a multicenter randomized controlled trial

Background

An individualized treatment algorithm (Copenhagen Achilles Rupture Treatment Algorithm (CARTA)) based on the ultrasonographic appearance of an acute Achilles tendon rupture has been developed aiming to select the correct patients for operative and non-operative treatment. The objective of this study is to investigate if this individualized treatment algorithm gives a better functional outcome than treating all patients either operatively or non-operatively per default.

Methods/design

This study is conducted as a multicenter, three-armed randomized controlled trial. Participants are included from four hospitals in Denmark and randomized 1:1:1 to one of three parallel groups: 1) Intervention group—participants are treated according to an individualized treatment algorithm; 2) Control group A—participants are treated non-operatively; 3) Control group B—participants are treated operatively. The individualized treatment algorithm for the intervention group is based on an ultrasonographic examination; tendon overlap and elongation below 7% is to be treated non-operatively, while no tendon overlap and/or elongation above 7% will be treated operatively. Over a period of 3 years, 300 participants will be included. The primary outcome is the heel-rise work test at 12 months post-injury. Secondary outcomes are tendon elongation, the Achilles tendon Total Rupture Score (ATRS), the rate of re-ruptures, and other complications. The primary analysis will be conducted as an intention-to-treat analysis.

Discussion

This trial will indicate if treatment of acute Achilles tendon rupture can be individualized based on elongation and tendon overlap. It is hypothesized that different patients will benefit from different treatments instead of offering all the same treatment.

Trial registration

ClinicalTrials.gov, NCT03525964. Registered 16 May 2018.

Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation

BACKGROUND

Patients with Achilles tendon rupture who have non-operative treatment have traditionally been treated with immobilisation of the tendon in plaster casts for several weeks. Functional bracing is an alternative non-operative treatment that allows earlier mobilisation, but evidence on its effectiveness and safety is scarce. The aim of the UKSTAR trial was to compare functional and quality-of-life outcomes and resource use in patients treated non-operatively with plaster cast versus functional brace.

METHODS

UKSTAR was a pragmatic, superiority, multicentre, randomised controlled trial done at 39 hospitals in the UK. Patients (aged ≥16 years) who were being treated non-operatively for a primary Achilles tendon rupture at the participating centres were potentially eligible. The exclusion criteria were presenting more than 14 days after injury, previous rupture of the same Achilles tendon, or being unable to complete the questionnaires. Eligible participants were randomly assigned (1:1) to receive a plaster cast or functional brace using a centralised web-based system. Because the interventions were clearly visible, neither patients nor clinicians could be masked. Participants wore the intervention for 8 weeks. The primary outcome was patient-reported Achilles tendon rupture score (ATRS) at 9 months, analysed in the modified intention-to-treat population (all patients in the groups to which they were allocated, excluding participants who withdrew or died before providing any outcome data). The main safety outcome was the incidence of tendon re-rupture. Resource use was recorded from a health and personal social care perspective. The trial is registered with ISRCTN, ISRCTN62639639.

FINDINGS

Between Aug 15, 2016, and May 31, 2018, 1451 patients were screened, of whom 540 participants (mean age 48·7 years, 79% male) were randomly allocated to receive plaster cast (n=266) or functional brace (n=274). 527 (98%) of 540 were included in the modified intention-to-treat population, and 13 (2%) were excluded because they withdrew or died before providing any outcome data. There was no difference in ATRS at 9 months post injury (cast group n=244, mean ATRS 74∙4 [SD 19∙8]; functional brace group n=259, ATRS 72∙8 [20∙4]; adjusted mean difference -1∙38 [95% CI -4∙9 to 2∙1], p=0·44). There was no difference in the rate of re-rupture of the tendon (17 [6%] of 266 in the plaster cast group vs 13 [5%] of 274 in the functional brace group, p=0·40). The mean total health and personal social care cost was £1181 for the plaster cast group and £1078 for the functional bract group (mean between-group difference -£103 [95% CI -289 to 84]).

INTERPRETATION

Traditional plaster casting was not found to be superior to early weight-bearing in a functional brace, as measured by ATRS, in the management of patients treated non-surgically for Achilles tendon rupture. Clinicians may consider the use of early weight-bearing in a functional brace as a safe and cost-effective alternative to plaster casting.

FUNDING

UK National Institute for Health Research Health Technology Assessment Programme.

Jigless knotless internal brace technique for acute Achilles tendon rupture: a case series study

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

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

Background:

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

Purpose:

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

Study Design:

Systematic review; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

Efficacy of early controlled motion of the ankle compared with immobilisation in non-operative treatment of patients with an acute Achilles tendon rupture: an assessor-blinded, randomised controlled trial

Background

Early controlled motion (ECM) of the ankle is widely used in the non-operative treatment of acute Achilles tendon rupture, although its safety and efficacy have not been investigated properly in a randomised set-up.

Purpose/Aim of the study

To investigate if ECM of the ankle was superior to immobilisation in the treatment of acute Achilles tendon rupture.

Materials and methods

This was an assessor-blinded, randomised controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients aged 18–70 years were eligible for inclusion. The ECM group performed movements of the ankle five times a day from week 3 to week 8 after rupture. The control group was immobilised for 8 weeks. The primary outcome was the Achilles tendon Total Rupture Score (ATRS) evaluated at 1-year postinjury. The secondary outcomes were heel-rise work test (HRW), Achilles tendon elongation and rate of rerupture. Analysis was conducted as intention-to-treat using inverse probability weighting.

Findings/Results

189 patients were assessed for eligibility and 130 were included from February 2014 to December 2016. There were 64 patients in the ECM group and 58 in the immobilisation group. There were no statistically significant differences (p>0.3) between the ECM and the immobilisation groups at 1 year: mean (SD) ATRS was 74 (18) and 75 (18), respectively. HRW was 60% (21) and 60% (21) of the uninjured limb, and elongation was 18 mm (13) and 16 mm (11), respectively. Correspondingly, there were six and seven reruptures.

Conclusions

ECM revealed no benefit compared with immobilisation in any of the investigated outcomes.

Trial registration number

NCT02015364

Early weight-bearing in nonoperative treatment of acute Achilles tendon rupture did not influence mid-term outcome: a blinded, randomised controlled trial

PURPOSE

Acute Achilles tendon rupture leads to impaired outcome at short term, but little is known concerning medium-term results. The aim of the present study was to investigate the influence of early weight-bearing on clinical outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture.

METHOD

The study was performed as a medium-term follow-up on patients included in a randomised controlled trial. Both groups were treated with nonoperative management and controlled early motion. The intervention group was allowed full weight-bearing from day 1, and the control group was non-weight-bearing for 6 weeks. 60 patients were randomised 1:1. Of those, 56 were eligible for inclusion in the medium-term follow-up and 37 participated (18 control, 19 intervention). The outcomes were Achilles tendon Total Rupture Score (ATRS) and heel raise work performed at an average of 4.5 years after the initial injury. Statistical analysis was performed using paired t tests and linear regression.

RESULTS

No differences were found between control and intervention groups at 4.5 years. ATRS scores consistently improved in both the intervention and the control groups from 0.5 to 1 year and from 1 to 4.5 years, ending up at 80.5 on average after 4.5 years. Heel raise height kept improving from 0.5 to 4.5 years, reaching a limb symmetry index of 82.4%. The heel raise work improvement from 0.5 to 1 year did not continue. No significant change was found from 1 to 4.5 years, ending at a limb symmetry index of 60%.

CONCLUSION

Early weight-bearing did not influence outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. The calf muscle of the injured limb performs 40% less work, when compared to the healthy limb, though lifting height recovers better.

LEVEL OF EVIDENCE

II.

CLINICAL TRIALS IDENTIFIER

NCT02760784.

Minimally Invasive Treatments of Acute Achilles Tendon Ruptures

Achilles tendon rupture is a common injury to the lower extremity that requires appropriate treatment to minimize functional deficit. Available treatments of Achilles tendon ruptures include nonoperative, open surgical repair, percutaneous repair, and minimally invasive repair. Open surgical repair obtains favorable functional outcomes with significant potential for deep soft tissue complications, calling into question the value of open repair. Percutaneous repair is an alternative option with comparable functional results and minimal soft tissue complications; however, sural nerve injury is a complication. Minimally invasive Achilles repair offers optimal results with superior functional outcomes with minimal soft tissue complications and sural nerve injury.

Gait Function and Postural Control 4.5 Years After Nonoperative Dynamic Treatment of Acute Achilles Tendon Ruptures

Background:

An Achilles tendon rupture (ATR) is known to cause persistent biomechanical deficits such as decreased muscle strength in end-range plantar flexion and reduced tendon stiffness.

Purpose/Hypothesis:

This study aimed to examine whether sustained asymmetries were present in dynamic stiffness and kinematic and kinetic variables in gait and single-leg balance at 4.5-year follow-up in conservatively treated patients recovering from an ATR. We hypothesized that patients who had recovered from ATRs exhibit a midterm increase in peak ankle dorsiflexion, a decrease in concentric work, and decreased dynamic stiffness during the stance phase of gait, along with increased single-leg standing sway in the injured leg compared with the uninjured leg.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study was a cross-sectional medium-term follow-up of conservatively treated patients recovering from ATRs. A total of 34 patients who underwent nonoperative treatment were included for testing 4.5 years after a rupture. The Achilles tendon length was measured using ultrasound. Standard instrumented 3-dimensional (3D) gait analysis and single-leg standing balance were performed using 3D motion capture. Kinematic and kinetic ankle parameters were calculated during gait, and quasi-stiffness was calculated as the moment change per the change in the degree of dorsiflexion during the second (ankle) rocker of the gait cycle. Center of pressure displacement (sway length), along with rambling and trembling, was calculated for the single-leg balance task.

Results:

Peak dorsiflexion in stance was 13.4% larger in the injured leg than the uninjured leg (16.9° ± 3.1° vs 14.9° ± 0.4°, respectively; P ≤ .001). Peak dorsiflexion was not associated with the normalized Achilles tendon length (B = 0.052; P = .775). Total positive work in the plantar flexors was 23.9% greater in the uninjured leg than the injured leg (4.71 ± 1.60 vs 3.80 ± 0.79 J/kg, respectively; P = .001). Quasi-stiffness was greater in the uninjured leg than the injured leg during the initial (0.053 ± 0.022 vs 0.046 ± 0.020 N·m/kg/deg, respectively; P = .009) and late (0.162 ± 0.110 vs 0.139 ± 0.041 N·m/kg/deg, respectively; P = .005) phases of eccentric loading. No difference was found in sway length during single-leg stance between the injured and uninjured legs (1.45 ± 0.4 vs 1.44 ± 0.4 m, respectively; P = .955).

Conclusion:

Patients treated conservatively have a small increase in peak dorsiflexion, decreased total concentric plantar flexor power, and decreased quasi-stiffness in initial and end-range dorsiflexion in the injured leg. These deviations could not be directly associated with the measured tendon elongation.

Registration:

NCT02760784 (ClinicalTrials.gov).

Quantitative comparison of three rat models of Achilles tendon injury: A multidisciplinary approach

The Achilles tendon, while the strongest and largest tendon in the body, is frequently injured. Inconclusive evidence exists regarding treatment strategies for both complete tears and partial tears. Well-characterized animal models of tendon injury are important for understanding physiological processes of tendon repair and testing potential therapeutics. Utilizing three distinct models of rat Achilles tendon injury, the objective of this study was to define and compare the effects and relative impact on tendon properties and ankle function of both tear severity (complete tear versus partial tear, both with post-operative immobilization) and immobilization after partial tear (partial tear with versus without immobilization). We hypothesized that a complete tear would cause inferior post-injury properties compared to a partial tear, and that immediate loading after partial tear would improve post-injury properties compared to immobilization. All models were reproducible and had distinct effects on measured parameters. Injury severity drastically influenced tendon healing, with complete tear causing decreased ankle mobility and tendon mechanics compared to partial tears. One week of plantarflexion immobilization had a strong effect on animals receiving a partial tear. Tendons with partial tears and immobilization failed early during fatigue cycling three weeks post-injury. Partial tear without immobilization had no effect on ankle range of motion through dorsiflexion at any time point compared to the pre-surgery value, while partial tear with immobilization demonstrated diminished function at all post-injury time points. All three models of Achilles injury could be useful for tendon healing investigations, chosen based on the prospective applications of a potential therapeutic.

Effects of immobilization angle on tendon healing after achilles rupture in a rat model

Conservative (non-operative) treatment of Achilles tendon ruptures is a common alternative to operative treatment. Following rupture, ankle immobilization in plantarflexion is thought to aid healing by restoring tendon end-to-end apposition. However, early activity may improve limb function, challenging the role of immobilization position on tendon healing, as it may affect loading across the injury site. This study investigated the effects of ankle immobilization angle in a rat model of Achilles tendon rupture. We hypothesized that manipulating the ankle from full plantarflexion into a more dorsiflexed position during the immobilization period would result in superior hindlimb function and tendon properties, but that prolonged casting in dorsiflexion would result in inferior outcomes. After Achilles tendon transection, animals were randomized into eight immobilization groups ranging from full plantarflexion (160°) to mid-point (90°) to full dorsiflexion (20°), with or without angle manipulation. Tendon properties and ankle function were influenced by ankle immobilization position and time. Tendon lengthening occurred after 1 week at 20° compared to more plantarflexed angles, and was associated with loss of propulsion force. Dorsiflexing the ankle during immobilization from 160° to 90° produced a stiffer, more aligned tendon, but did not lead to functional changes compared to immobilization at 160°. Although more dorsiflexed immobilization can enhance tissue properties and function of healing Achilles tendon following rupture, full dorsiflexion creates significant tendon elongation regardless of application time. This study suggests that the use of moderate plantarflexion and earlier return to activity can provide improved clinical outcomes. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Management of acute Achilles tendon ruptures: A review

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.

Mechanical, histological, and functional properties remain inferior in conservatively treated Achilles tendons in rodents: Long term evaluation

Conservative treatment (non-operative) of Achilles tendon ruptures is suggested to produce equivalent capacity for return to function; however, long term results and the role of return to activity (RTA) for this treatment paradigm remain unclear. Therefore, the objective of this study was to evaluate the long term response of conservatively treated Achilles tendons in rodents with varied RTA. Sprague Dawley rats (n=32) received unilateral blunt transection of the Achilles tendon followed by randomization into groups that returned to activity after 1-week (RTA1) or 3-weeks (RTA3) of limb casting in plantarflexion, before being euthanized at 16-weeks post-injury. Uninjured age-matched control animals were used as a control group (n=10). Limb function, passive joint mechanics, tendon properties (mechanical, histological), and muscle properties (histological, immunohistochemical) were evaluated. Results showed that although hindlimb ground reaction forces and range of motion returned to baseline levels by 16-weeks post-injury regardless of RTA, ankle joint stiffness remained altered. RTA1 and RTA3 groups both exhibited no differences in fatigue properties; however, the secant modulus, hysteresis, and laxity were inferior compared to uninjured age-matched control tendons. Despite these changes, tendons 16-weeks post-injury achieved secant stiffness levels of uninjured tendons. RTA1 and RTA3 groups had no differences in histological properties, but had higher cell numbers compared to control tendons. No changes in gastrocnemius fiber size or type in the superficial or deep regions were detected, except for type 2x fiber fraction. Together, this work highlights RTA-dependent deficits in limb function and tissue-level properties in long-term Achilles tendon and muscle healing.

Acute Achilles Tendon Ruptures: An Update on Treatment

Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow-derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.