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Wang R, Huang L, Jiang S, You G, Zhou X, Wang G, Zhang L. Immediate mobilization after repair of Achilles tendon rupture may increase the incidence of re-rupture: a systematic review and meta-analysis of randomized controlled trials. Int J Surg 2024; 110:3888-3899. [PMID: 38477123 PMCID: PMC11175757 DOI: 10.1097/js9.0000000000001305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/23/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Achilles tendon rupture (ATR) is a significant injury that can require surgery and can have the risk of re-rupture even after successful treatment. Consequently, to minimize this risk, it is important to have a thorough understanding of the rehabilitation protocol and the impact of different rehabilitation approaches on preventing re-rupture. MATERIALS AND METHODS Two independent team members searched several databases (PubMed, EMBASE, Web of Science, Cochrane Library, and CINAHL) to identify randomized controlled trials (RCTs) on operative treatment of ATR. We included articles that covered open or minimally invasive surgery for ATR, with a detailed rehabilitation protocol and reports of re-rupture. The study protocol has been registered at PROSPERO and has been reported in the line with PRISMA Guidelines, Supplemental Digital Content 1, http://links.lww.com/JS9/C85 , Supplemental Digital Content 2, http://links.lww.com/JS9/C86 and assessed using AMSTAR Tool, Supplemental Digital Content 3, http://links.lww.com/JS9/C87 . RESULTS A total of 43 RCTs were eligible for the meta-analysis, encompassing a combined cohort of 2553 patients. Overall, the postoperative incidence of ATR patients developing re-rupture was 3.15% (95% CI: 2.26-4.17; I2 =44.48%). Early immobilization group patients who had ATR had a 4.07% (95% CI: 1.76-7.27; I2 =51.20%) postoperative incidence of re-rupture; Early immobilization + active range of motion (AROM) group had an incidence of 5.95% (95% CI: 2.91-9.99; I2 =0.00%); Early immobilization + weight-bearing group had an incidence of 3.49% (95% CI: 1.96-5.43; I2 =20.06%); Early weight-bearing + AROM group had an incidence of 3.61% (95% CI: 1.00-7.73; I2 =64.60%); Accelerated rehabilitation (immobilization) group had an incidence of 2.18% (95% CI: 1.11-3.59; I2 =21.56%); Accelerated rehabilitation (non-immobilization) group had a rate of 1.36% (95% CI: 0.12-3.90; I2 =0.00%). Additionally, patients in the immediate AROM group had a postoperative re-rupture incidence of 3.92% (95% CI: 1.76-6.89; I2 =33.24%); Non-immediate AROM group had an incidence of 2.45% (95% CI: 1.25-4.03; I2 =22.09%). CONCLUSIONS This meta-analysis suggests the use of accelerated rehabilitation intervention in early postoperative rehabilitation of the Achilles tendon. However, for early ankle joint mobilization, it is recommended to apply after one to two weeks of immobilization.
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Affiliation(s)
- Ruihan Wang
- School of Physical Education, Southwest Medical University
- Department of Rehabilitation, Yibin Integrated Traditional Chinese and Western Medicine Hospital, Yibin, China
| | - Lei Huang
- School of Physical Education, Southwest Medical University
| | - Songtao Jiang
- School of Clinical Medicine, Southwest Medical University
| | - Guixuan You
- School of Physical Education, Southwest Medical University
| | - Xin Zhou
- Department of Orthopedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Center for Orthopedic Diseases Research, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Luzhou Key Laboratory of Orthopedic Disorders, Luzhou
| | - Guoyou Wang
- Department of Orthopedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Center for Orthopedic Diseases Research, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Luzhou Key Laboratory of Orthopedic Disorders, Luzhou
| | - Lei Zhang
- Department of Orthopedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Center for Orthopedic Diseases Research, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Luzhou Key Laboratory of Orthopedic Disorders, Luzhou
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Bak BM, Seow D, Teo YZE, Hasan MY, Pearce CJ. Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2024; 63:420-429. [PMID: 38296023 DOI: 10.1053/j.jfas.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/19/2023] [Accepted: 12/18/2023] [Indexed: 02/12/2024]
Abstract
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.
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Affiliation(s)
| | - Dexter Seow
- National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | | | | | - Christopher J Pearce
- National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Wu H, Dong J, Dong D, Wei S, Zheng B, Kong C, Xu F, Hou W. Correlation between the Coaptation and Regeneration of Tendon Stumps in Endoscopic Assisted Achilles Tendon Rupture Repair. Orthop Surg 2023; 15:2627-2637. [PMID: 37649315 PMCID: PMC10549866 DOI: 10.1111/os.13850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVE When the endoscopic Achilles tendon repair technique is utilized, direct stitching of the ruptured site is challenging due to the frayed tendon stumps. To explore whether undesirable coaptation of the tendon stumps influences the generation of the tendons. METHODS This study is a retrospective analysis of 46 patients who underwent a modified endoscopic Achilles tendon rupture repair from October 2018 to June 2020. Patients were divided into two groups according to the coaptation of tendon stumps on postoperative ultrasonography. Group 1 included 17 cases with undesirable coaptation (<50%), and Group 2 included 29 cases with appropriate coaptation (≥50%). Magnetic resonance imaging (MRI) was obtained postoperatively at 3, 6, and 12 months to evaluate the tendon morphological construction. Clinical evaluations were performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score, the Achilles Tendon Total Rupture Score (ATRS), muscle power, and the Achilles tendon resting angle at the final follow-up. Complications were also encountered. The Student's t-test and the Mann-Whitney U-test were used to assess differences among both groups. RESULTS The mean follow-up time was 37.5 ± 10.6 months in Group 1 and 39.0 ± 11.6 months in Group 2, respectively. The average age in Group 1 is slightly older than in Group 2 (37.3 ± 6.1 vs. 32.7 ± 6.3, p = 0.021). The tendon cross-section areas and thickness increased initially and decreased later on postoperative MRI evaluation. It also showed a significantly higher signal/noise quotient (SNQ) in Group 1 at postoperative 3 months. At postoperative 6 and 12 months, the SNQ between both groups was similar. The AOFAS score (95.9 ± 5.1 vs. 96.2 ± 4.9, p = 0.832), ATRS score (97.0 ± 3.6 vs. 97.7 ± 3.3, p = 0.527), and muscle power (21.38 vs. 24.74, p = 0.287) were not significantly different between both groups. However, the resting angle of Group 1 was significantly larger than that of Group 2 (4.6 ± 2.4 vs. 2.4 ± 2.3, p = 0.004). There was no difference in the complications (p = 0.628). CONCLUSION Although complete regeneration can be finally achieved, the early stage of tendon stump regeneration can be prolonged due to undesirable coaptation when endoscopic Achilles tendon repair technique is applied. The prolonged high signal duration on MRI indicates the less-than-ideal regeneration of the tendon, which might lead to elongation of the tendon.
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Affiliation(s)
- Helin Wu
- Department of OrthopaedicsGeneral Hospital of Central Theater CommandWuhanChina
- The First Clinical Medical School of Southern Medical UniversityGuangzhouChina
| | - Jingxian Dong
- School of Life Science and TechnologyHuazhong University of Science and TechnologyWuhanChina
| | - Dandan Dong
- Department of OrthopaedicsGeneral Hospital of Central Theater CommandWuhanChina
| | - Shijun Wei
- Department of OrthopaedicsGeneral Hospital of Central Theater CommandWuhanChina
- The First Clinical Medical School of Southern Medical UniversityGuangzhouChina
- Wuhan University of Science and TechnologyWuhanChina
| | - Boyu Zheng
- Department of OrthopaedicsGeneral Hospital of Central Theater CommandWuhanChina
- Wuhan University of Science and TechnologyWuhanChina
| | - Changwang Kong
- Department of OrthopaedicsGeneral Hospital of Central Theater CommandWuhanChina
| | - Feng Xu
- Department of OrthopaedicsGeneral Hospital of Central Theater CommandWuhanChina
- The First Clinical Medical School of Southern Medical UniversityGuangzhouChina
| | - Wenguang Hou
- School of Life Science and TechnologyHuazhong University of Science and TechnologyWuhanChina
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Pearsall C, Arciero E, Czerwonka N, Gupta P, Vosseller JT, Trofa DP. A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures. Foot Ankle Surg 2023; 29:317-323. [PMID: 37098457 DOI: 10.1016/j.fas.2023.04.004] [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: 10/02/2022] [Revised: 02/04/2023] [Accepted: 04/08/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context. METHODS A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review. RESULTS Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study. CONCLUSION Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context. LEVEL OF EVIDENCE Level IV; Systematic Review.
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Affiliation(s)
- Christian Pearsall
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Emily Arciero
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Natalia Czerwonka
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Puneet Gupta
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | | | - David P Trofa
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA.
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Deng Z, Li Z, Shen C, Sun X, Wang T, Nie M, Tang K. Outcomes of early versus late functional weight-bearing after the acute Achilles tendon rupture repair with minimally invasive surgery: a randomized controlled trial. Arch Orthop Trauma Surg 2023; 143:2047-2053. [PMID: 35767039 DOI: 10.1007/s00402-022-04535-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/19/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Optimal postoperative rehabilitation regimen for acute Achilles tendon rupture (AATR) remains unclear. It is important to evaluate whether early functional weight-bearing rehabilitation program after minimally invasive repair results in an earlier return to pre-injury activity but increases the risk of re-rupture. MATERIALS AND METHODS This was a prospective randomized controlled trial involving 68 AATR patients undergoing minimally invasive surgery. 34 patients were enrolled in early weight‑bearing mobilization accelerated rehabilitation group (AR group); 34 patients were enrolled in the traditional rehabilitation (TR) group. Outcomes measures included American Orthopaedic Foot and Ankle Society Score (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS) score before surgery and 3, 6, and 12 months after surgery, incidence rate of Achilles tendon re-rupture and total complications, length of hospital stay, time return to work and sports. RESULTS There was no significant difference in preoperative basic data between the two groups. However, AOFAS score and ATRS score were better in AR group than TR group at 3 months postoperatively (92.4 ± 3.5 vs 88.3 ± 4.5, P < 0.01; 91.1 ± 4.4 vs 88.9 ± 3.4, P = 0.03, respectively), the mean length of hospital stay (4.7 ± 1.5 vs 7.6 ± 2.0 days, P < 0.01) and time return to work (4.5 ± 1.0 vs 7.5 ± 1.6 weeks, P < 0.01) were shorter in AR group than in TR group. No statistical significance was calculated in patient-reported outcomes during the rest of the follow-up time and complications. CONCLUSION Early accelerated rehabilitation with weight-bearing in patients with AATR after minimally invasive surgery results in better early functional outcomes and shows similar security and feasibility. REGISTRATION NO ChiCTR2100043398.
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Affiliation(s)
- Zhibo Deng
- Center for Joint Surgery, Department of Orthopedic, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Zhi Li
- Center for Joint Surgery, Department of Orthopedic, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Chen Shen
- Center for Joint Surgery, Department of Orthopedic, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Xianding Sun
- Center for Joint Surgery, Department of Orthopedic, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Ting Wang
- Center for Joint Surgery, Department of Orthopedic, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Mao Nie
- Center for Joint Surgery, Department of Orthopedic, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Kaiying Tang
- Center for Joint Surgery, Department of Orthopedic, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China.
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Massen FK, Shoap S, Vosseller JT, Fan W, Usseglio J, Boecker W, Baumbach SF, Polzer H. Rehabilitation following operative treatment of acute Achilles tendon ruptures: a systematic review and meta-analysis. EFORT Open Rev 2022; 7:680-691. [PMID: 36287109 PMCID: PMC9619394 DOI: 10.1530/eor-22-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose Methods Results Conclusion
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Affiliation(s)
- Felix Kurt Massen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany,Correspondence should be addressed to F K Massen;
| | - Seth Shoap
- Trauma Training Center, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - J Turner Vosseller
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Weija Fan
- Mailman School of Public Health, Department of Biostatistics, Columbia University, New York, New York, USA
| | - John Usseglio
- Augustus C. Long Health Sciences Library, Columbia University Irving Medical Center, New York, New York, USA
| | - Wolfgang Boecker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Felix Baumbach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Hans Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
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Rendek Z, Bon Beckman L, Schepull T, Dånmark I, Aspenberg P, Schilcher J, Eliasson P. Early Tensile Loading in Nonsurgically Treated Achilles Tendon Ruptures Leads to a Larger Tendon Callus and a Lower Elastic Modulus: A Randomized Controlled Trial. Am J Sports Med 2022; 50:3286-3298. [PMID: 36005394 PMCID: PMC9527451 DOI: 10.1177/03635465221117780] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early tensile loading improves material properties of healing Achilles tendon ruptures in animal models and in surgically treated human ruptures. However, the effect of such rehabilitation in patients who are nonsurgically treated remains unknown. HYPOTHESIS In nonsurgically treated Achilles tendon ruptures, early tensile loading would lead to higher elastic modulus 19 weeks after the injury compared with controls. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS Between October 2015 and November 2018, a total of 40 nonsurgically treated patients with acute Achilles tendon rupture were randomized to an early tensile loading (loaded group) or control group. Tantalum bead markers were inserted percutaneously into the tendon stumps 2 weeks after the injury to allow high-precision measurements of callus deformation under mechanical testing. The loaded group used a training pedal twice daily to produce a gradual increase in tensile load during the following 5 weeks. Both groups were allowed full weightbearing in an ankle orthosis and unloaded range of motion exercises. Patients were followed clinically and via roentgen stereophotogrammetric analysis and computed tomography at 7, 19, and 52 weeks after the injury. RESULTS The mean ± standard deviation elastic modulus at 19 weeks was 95.6 ± 38.2 MPa in the loaded group and 108 ± 45.2 MPa in controls (P = .37). The elastic modulus increased in both groups, although it was lower in the loaded group at all time points. Tendon cross-sectional area increased from 7 weeks to 19 weeks, from 231 ± 99.5 to 388 ± 142 mm2 in the loaded group and from 188 ± 65.4 to 335 ± 87.2 mm2 in controls (P < .001 for the effect of time). Cross-sectional area for the loaded group versus controls at 52 weeks was 302 ± 62.4 mm2 versus 252 ± 49.2 mm2, respectively (P = .03). Gap elongation was 7.35 ± 13.9 mm in the loaded group versus 2.86 ± 5.52 mm in controls (P = .27). CONCLUSION Early tensile loading in nonsurgically treated Achilles tendon ruptures did not lead to higher elastic modulus in the healing tendon but altered the structural properties of the tendon via an increased tendon thickness. REGISTRATION NCT0280575 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Zlatica Rendek
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Leo Bon Beckman
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Thorsten Schepull
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Ida Dånmark
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Per Aspenberg
- Author deceased,Orthopedic Department, Linköping University Hospital, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Pernilla Eliasson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden,Pernilla Eliasson, MSc, PhD, Department of Biomedical and Clinical Sciences, Division of Cell Biology, Linköping University, Cell Biology Building Floor 10, Linköping, SE-58183, Sweden ()
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8
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Current Progress of CAR-NK Therapy in Cancer Treatment. Cancers (Basel) 2022; 14:cancers14174318. [PMID: 36077853 PMCID: PMC9454439 DOI: 10.3390/cancers14174318] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Chimeric antigen receptor (CAR)-T and -natural killer (NK) therapies are promising in cancer treatment. CAR-NK therapy gains great attention due to the lack of adverse effects observed in CAR-T therapies and to the NK cells’ unique mechanisms of recognizing target cells. Off-the-shelf products are in urgent need, not only for good yields, but also for lower cost and shorter preparation time. The current progress of CAR-NK therapy is discussed. Abstract CD8+ T cells and natural killer (NK) cells eliminate target cells through the release of lytic granules and Fas ligand (FasL)-induced target cell apoptosis. The introduction of chimeric antigen receptor (CAR) makes these two types of cells selective and effective in killing cancer cells. The success of CAR-T therapy in the treatment of acute lymphoblastic leukemia (ALL) and other types of blood cancers proved that the immunotherapy is an effective approach in fighting against cancers, yet adverse effects, such as graft versus host disease (GvHD) and cytokine release syndrome (CRS), cannot be ignored for the CAR-T therapy. CAR-NK therapy, then, has its advantage in lacking these adverse effects and works as effective as CAR-T in terms of killing. Despite these, NK cells are known to be hard to transduce, expand in vitro, and sustain shorter in vivo comparing to infiltrated T cells. Moreover, CAR-NK therapy faces challenges as CAR-T therapy does, e.g., the time, the cost, and the potential biohazard due to the use of animal-derived products. Thus, enormous efforts are needed to develop safe, effective, and large-scalable protocols for obtaining CAR-NK cells. Here, we reviewed current progress of CAR-NK therapy, including its biological properties, CAR compositions, preparation of CAR-NK cells, and clinical progresses. We also discussed safety issues raised from genetic engineering. We hope this review is instructive to the research community and a broad range of readers.
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Amendola F, Barbasse L, Carbonaro R, Alessandri-Bonetti M, Cottone G, Riccio M, De Francesco F, Vaienti L, Serror K. The Acute Achilles Tendon Rupture: An Evidence-Based Approach from the Diagnosis to the Treatment. Medicina (B Aires) 2022; 58:medicina58091195. [PMID: 36143872 PMCID: PMC9500605 DOI: 10.3390/medicina58091195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objective: Acute Achilles tendon rupture (AATR) is a common injury with a significant impact on daily living. Although various systematic reviews and meta-analyses have been written on the topic, no actual consensus exists on the best treatment. We aimed to collect the highest quality of evidence on the subject and to produce a document to which to refer, from the diagnosis to the final treatment. Material and Methods: Inclusion criteria were systematic reviews discussing Achilles tendon rupture, concerning either diagnostic criteria, classification, or treatment; English language; clearly stated inclusion and exclusion criteria for patients’ selection. Results: Thirteen systematic reviews were included in the study. A strong consensus exists about the higher risk of re-rupture associated with non-operative treatment and a higher risk of complications associated with surgical repair. Conclusions: The combination of minimally invasive repair and accelerated functional rehabilitation seems to offer the best results in the treatment of Achilles tendon rupture.
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Affiliation(s)
- Francesco Amendola
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Léa Barbasse
- Plastic and Reconstructive Department, AP-HP, Hôpital Saint-Louis, 75010 Paris, France
| | - Riccardo Carbonaro
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Mario Alessandri-Bonetti
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Giuseppe Cottone
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Michele Riccio
- Hand Surgery Unit, Department of Plastic and Reconstructive Surgery, Azienda “Ospedali Riuniti”, Via Conca 21, 60126 Ancona, Italy
| | - Francesco De Francesco
- Hand Surgery Unit, Department of Plastic and Reconstructive Surgery, Azienda “Ospedali Riuniti”, Via Conca 21, 60126 Ancona, Italy
- Correspondence: ; Tel.: +39-0715963945
| | - Luca Vaienti
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Kevin Serror
- Plastic and Reconstructive Department, AP-HP, Hôpital Saint-Louis, 75010 Paris, France
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Mosconi M, Pasta G, Annunziata S, Guerrieri V, Ghiara M, Perelli S, Torriani C, Grassi FA, Jannelli E. Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison. Diagnostics (Basel) 2022; 12:1824. [PMID: 36010175 PMCID: PMC9406849 DOI: 10.3390/diagnostics12081824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy. METHODS 33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery. RESULTS At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups. CONCLUSIONS fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.
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Affiliation(s)
- Mario Mosconi
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Specialization School in Orthopaedics and Traumatology, University of Pavia, 27100 Pavia, Italy
| | - Gianluigi Pasta
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
| | - Salvatore Annunziata
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Specialization School in Orthopaedics and Traumatology, University of Pavia, 27100 Pavia, Italy
| | - Viviana Guerrieri
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Specialization School in Orthopaedics and Traumatology, University of Pavia, 27100 Pavia, Italy
| | - Matteo Ghiara
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
| | - Simone Perelli
- Institut CAtalá de Traumatologia i Medicina de l’Esport (ICATME)—Hospital Universitari Dexeus, Universitat Autonoma de Barcelona, 08028 Barcelona, Spain;
- Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Hospital Del Mar, Universitat Autonoma de Barcelona, 08003 Barcelona, Spain
| | - Camilla Torriani
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
| | - Federico Alberto Grassi
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Specialization School in Orthopaedics and Traumatology, University of Pavia, 27100 Pavia, Italy
| | - Eugenio Jannelli
- Orthopedics and Traumatology Clinic, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy; (M.M.); (G.P.); (V.G.); (M.G.); (C.T.); (F.A.G.); (E.J.)
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
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11
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Hoeffner R, Svensson RB, Bjerregaard N, Kjær M, Magnusson SP. Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review. TRANSLATIONAL SPORTS MEDICINE 2022; 2022:7445398. [PMID: 38655161 PMCID: PMC11022787 DOI: 10.1155/2022/7445398] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/03/2022] [Accepted: 06/15/2022] [Indexed: 04/26/2024]
Abstract
Persistent muscle weakness, tendon elongation, and incomplete return to preinjury level are frequent sequelae after acute Achilles tendon rupture, and evidence-based knowledge of how to best rehabilitate the injury is largely absent in the literature. The objective of this review is to illuminate and discuss to what extent an Achilles tendon rupture affects muscle, tendon, and function when assessed with the Achilles tendon total rupture score (ATRS), muscle strength, muscle cross-sectional area, tendon length, and the heel-rise test. The patient-reported outcome measures (PROM) data in the literature suggest that the recovery takes longer than 6 months (ATRS, 70 out of 100), that one-year postinjury, the ATRS only reaches 82, and that this does not appear to noticeably improve thereafter. Loss of muscle mass, strength, and function can in some cases be permanent. Over the first 6 months postinjury, the tendon undergoes elongation, which appears to be negatively correlated to heel-rise function. More recently, there has been some interest in how muscle length and excursion is related to the reduced function. The available literature indicates that further research is highly warranted and that efforts to restore normal tendon length may improve the likelihood of returning to preinjury level after an Achilles tendon rupture.
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Affiliation(s)
- Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Rene B. Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai Bjerregaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Michael Kjær
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stig Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
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12
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Saxena A, Giai Via A, Grävare Silbernagel K, Walther M, Anderson R, Gerdesmeyer L, Maffulli N. Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the "GAIT" Study Group. J Foot Ankle Surg 2022; 61:855-861. [PMID: 35120805 DOI: 10.1053/j.jfas.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Abstract
Surgical repair of acute mid-substance Achilles tendon ruptures is performed in active patients, but the postoperative rehabilitation program is often based on the experience of the surgeon or therapist, rather than on evidence-based protocols. The aim of the study is to establish an evidence-based protocol for rehabilitation. This study is a consensus statement. The "GAIT" study group (German, American, and Italian Tendon), an informal collection of 4 experienced foot and ankle surgeons, met to address the question of what items they felt were important relative to rehabilitate a surgically repaired Achilles tendon acute rupture. Thirty-three statements were formulated. A value of 100% agreement by all the members was set to produce a proposed consensus statement. A value of 80% consensus was set to produce "strong recommendation." A systematic review of the literature was also performed. The GAIT group reach 100% agreement on the average postoperative non-weightbearing for 2.3 weeks, the foot in plantarflexion for the first 4 weeks, avoiding ROM exercises beyond neutral, and both stretching and eccentric exercise, not started before 12 weeks. Concentric bilateral heel raises should be performed after 6 weeks, and the average return to initiate sports, was 24.4 weeks. The use of a 1/8th-1/4th inch heel cushions in daily shoes after 8 weeks, the use of an antigravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended. Given lack of established verified protocols, the recommendations by our experienced panel should be considered. These proposed consensus statements could be used as a basis for larger controlled trials, and develop best practices.
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Affiliation(s)
- Amol Saxena
- Department of Sports Medicine, Sutter-PAMF, Palo Alto, CA.
| | - Alessio Giai Via
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy
| | - Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware, STAR Health Sciences Complex Campus, Newark, DE
| | - Markus Walther
- Schön Klinik München Harlaching - FIFA Medical Centre of Excellence, München, Germany
| | | | - Ludger Gerdesmeyer
- Department of Orthopaedic Surgery & Traumatology, Public Health Clinic, Kiel, Germany
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, England; School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, England
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13
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Supervised Physiotherapy Improves Three-Dimensional (3D) Gait Parameters in Patients after Surgical Suturing of the Achilles Tendon Using an Open Method (SSATOM). J Clin Med 2022; 11:jcm11123335. [PMID: 35743407 PMCID: PMC9225029 DOI: 10.3390/jcm11123335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the effectiveness of 38 supervised postoperative physiotherapy (SVPh) visits conducted between 1 and 20 weeks after SSATOM on the values of 3D gait parameters measured at 10 and 20 weeks after surgery. MATERIAL Group I comprised male patients (n = 22) after SSATOM (SVPh x = 38 visits) and Group II comprised male patients (n = 22) from the control group. METHODS A non-randomized, open-label, controlled clinical trial was performed in the two groups to obtain the following values: Step length (cm), stride length (cm), step width (cm), next stance phase (%), swing phase (%), double support (%), gait velocity (m/s), and walking frequency (step/min). The measurements were carried out using the BTS SMART system (Italy). RESULTS Orthopedic examination showed no pain, a negative result of Thompson and Matles tests, and proper healing of Achilles tendon (ultrasound image). In Group I, between 10 and 20 weeks after SSATOM, there was a statistically significant improvement in all tested gait parameter values (p ≤ 0.001 to 0.009). CONCLUSIONS Conducting 38 SVPh visits significantly improved the values of the analyzed kinematic and spatiotemporal gait parameters in patients in the twentieth week after SSATOM, which were mostly close to the non-operated side and the results of the control group. However, the gait speed and stride length were not close to the results of the control group.
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Doyle TR, Davey MS, Hurley ET. Statistical Findings Reported in Randomized Control Trials for the Management of Acute Achilles Tendon Ruptures are at High Risk of Fragility: A Systematic Review. J ISAKOS 2022; 7:72-81. [DOI: 10.1016/j.jisako.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/18/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
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15
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Sikorski Ł, Czamara A. Ground Reaction Forces during Vertical Hops Are Correlated with the Number of Supervised Physiotherapy Visits after Achilles Tendon Surgery. J Clin Med 2021; 10:jcm10225299. [PMID: 34830581 PMCID: PMC8620226 DOI: 10.3390/jcm10225299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 12/26/2022] Open
Abstract
The objective of this study was to assess the effectiveness of, and the correlation between, an average of 42 supervised physiotherapy (SVPh) visits for the vertical ground reaction forces component (vGRF) using ankle hops during two- and one-legged vertical hops (TLH and OLH, respectively), six months after the surgical suturing of the Achilles tendon using the open method (SSATOM) via Keesler’s technique. Hypothesis: Six months of supervised physiotherapy with a higher number of visits (SPHNVs) was positively correlated with higher vGRF values during TLH and OLH. Group I comprised male patients (n = 23) after SSATOM (SVPh x = 42 visits), and Group II comprised males (n = 23) without Achilles tendon injuries. In the study groups, vGRF was measured during TLH and OLH in the landing phase using two force plates. The vGRF was normalized to the body mass. The limb symmetry index (LSI) of vGRF values was calculated. The ranges of motion of the foot and circumferences of the ankle joint and shin were measured. Then, 10 m unassisted walking, the Thompson test, and pain were assessed. A parametric test for dependent and independent samples, ANOVA and Tukey’s test for between-group comparisons, and linear Pearson’s correlation coefficient calculations were performed. Group I revealed significantly lower vGRF values during TLH and OLH for the operated limb and LSI values compared with the right and left legs in Group II (p ≤ 0.001). A larger number of visits correlates with higher vGRF values for the operated limb during TLH (r = 0.503; p = 0.014) and OLH (r = 0.505; p = 0.014). An average of 42 SVPh visits in 6 months was insufficient to obtain similar values of relative vGRF and their LSI during TLH and OLH, but the hypothesis was confirmed that SPHNVs correlate with higher relative vGRF values during TLH and OLH in the landing phase.
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Affiliation(s)
- Łukasz Sikorski
- Department of Physiotherapy, College of Physiotherapy in Wrocław, 50-038 Wrocław, Poland;
- Correspondence: ; Tel.: +48-601-911-013
| | - Andrzej Czamara
- Department of Physiotherapy, College of Physiotherapy in Wrocław, 50-038 Wrocław, Poland;
- Center of Rehabilitation and Medical Education, 50-038 Wrocław, Poland
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16
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Seow D, Yasui Y, Calder JDF, Kennedy JG, Pearce CJ. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. Am J Sports Med 2021; 49:3728-3748. [PMID: 33783229 DOI: 10.1177/0363546521998284] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling. PURPOSE To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 1. METHODS Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I2 < 25%) and by random-effects models if heterogeneity was moderate to high (I2≥ 25%). RESULTS Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications. CONCLUSION This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.
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Affiliation(s)
- Dexter Seow
- National University Health System, Singapore
| | - Youichi Yasui
- Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, Japan
| | - James D F Calder
- Fortius Clinic, London, UK.,Department of Bioengineering, Imperial College London, London, UK
| | - John G Kennedy
- NYU Langone Orthopedic Hospital, New York, New York, USA
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Shi F, Wu S, Cai W, Zhao Y. Multiple comparisons of the efficacy and safety for six treatments in Acute Achilles Tendon Rupture patients: A systematic review and network meta-analysis. Foot Ankle Surg 2021; 27:468-479. [PMID: 32732151 DOI: 10.1016/j.fas.2020.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/21/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The choice of the best therapeutic regimen for Acute Achilles Tendon Rupture (AATR) remains controversial. Our study aims to evaluate the efficacy and safety of therapeutic regimens in AATR patients using a network meta-analysis of data from clinical randomized controlled trials. MATERIAL/METHODS The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA). RESULTS 38 randomized controlled trials involving 2480 participants were included. The studies were published between 1981 and 2019. A total of 6 therapeutic regimens -open repair (OR), minimally invasive repair (MIR) and nonoperative treatment (non) combined with traditional standard rehabilitation (TSR) and accelerated functional rehabilitation (AFR) - were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the re-rupture rate, the therapeutic regimens were ranked as follows: OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR. In terms of the wound-related complication, the therapeutic regimens were ranked as follows: MIR&AFR, nonoperative treatment &AFR, MIR&TSR, nonoperative treatment &TSR, OR&AFR and OR&TSR. In terms of the sural nerve injury, the therapeutic regimens were ranked as follows: non, OR and MIR. In terms of the deep venous thrombosis, the therapeutic regimens were ranked as follows: MIR&AFR, OR&AFR, nonoperative treatment &AFR, OR&TSR, MIR&TSR and nonoperative treatment &TSR. In terms of the returning back to sport, the therapeutic regimens were ranked as follows: MIR&TSR, OR&AFR, OR&TSR, nonoperative treatment &AFR, nonoperative treatment &TSR and MIR&AFR. CONCLUSIONS MIR can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications. AFR is superior to TSR without increasing the risk of rerupture. MIR&AFR is the best therapeutic regime for AATR. More RCTs focused on AATR are needed to further indicate this conclusion.
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Affiliation(s)
- Fangling Shi
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shiyuan Wu
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Cai
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Youming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China.
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18
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Röell AE, Timmers TK, van der Ven DJC, van Olden GDJ. Rehabilitation After Surgical Repair of Acute Achilles Tendon Rupture: Functional Outcome With a Minimum Follow-Up of 6 Months. J Foot Ankle Surg 2021; 60:482-488. [PMID: 33546991 DOI: 10.1053/j.jfas.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 05/02/2020] [Accepted: 09/03/2020] [Indexed: 02/03/2023]
Abstract
The best treatment and rehabilitation of Achilles tendon ruptures remains controversial. Current literature focuses mainly on objective outcomes despite possible incongruity with patient-reported functional outcomes. Therefore, we aimed to identify the course of patient-reported symptoms, function and quality of life during the early rehabilitation period. In this prospective cohort study, 33 patients with an acute Achilles tendon rupture treated with minimally invasive tendon repair were included in this study. They were followed up at 6, 12, 18 and 24 weeks after surgery with the Foot and Ankle Outcome Score questionnaire. At 6 weeks, patient-reported outcomes were poor regarding quality of life and sports. They however were quite high in the domains activities of daily living, symptoms and pain. All scores improved over the course of 6 months (symptoms (p = .03), activities of daily living (p = .001), sports (p = .002) and quality of life (p = .001). Pain did not improve significantly (p = .12), but patients had good pain scores from the start. There were no significant differences between patients with or without physical therapy. There were 3 minor complications and no re-ruptures in this cohort. In conclusion, patient-reported outcomes improve significantly during the first 6 months after surgery, except for pain. Scores for sports and quality of life remain suboptimal.
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Affiliation(s)
- Anna E Röell
- Junior Doctor, Department of Surgery, Meander Medical Center Amersfoort, Amersfoort, the Netherlands; Junior Doctor, Department of Intensive Care, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Tim K Timmers
- Trauma Surgeon, Department of Surgery, Meander Medical Center Amersfoort, Amersfoort, the Netherlands
| | - Denise J C van der Ven
- Surgical Resident, Department of Surgery, Meander Medical Center Amersfoort, Amersfoort, the Netherlands
| | - Ger D J van Olden
- Trauma Surgeon, Department of Surgery, Meander Medical Center Amersfoort, Amersfoort, the Netherlands
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Postoperative Rehabilitation Following Achilles Tendon Repair: A Systematic Review. Sports Med Arthrosc Rev 2021; 29:130-145. [PMID: 33972490 DOI: 10.1097/jsa.0000000000000309] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The optimal postoperative management of Achilles tendon (AT) rupture remains unknown. The past 2 decades have witnessed a trend toward less rigid immobilization, earlier weightbearing, and accelerated functional rehabilitation postoperatively. The objective of this study was to identify all high-quality studies pertaining to rehabilitation after AT repair and characterize the various rehabilitation protocols that have been described. A systematic review of the English-language literature was performed according to PRISMA guidelines. All included studies represented level 1, 2, or 3 evidence and examined postoperative rehabilitation protocols following the repair of an acute AT rupture. A total of 1187 subjects were included. Surgical technique, rehabilitation protocol, and outcome assessment varied widely between studies. Early postoperative weightbearing with less rigid immobilization appears to accelerate short-term functional recovery. An aggressive rehabilitation program may also be advantageous in the short term, but further studies are needed to determine the long-term effects of these accelerated physical therapy and return-to-play protocols.
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20
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Liu X, Dai TJ, Li BL, Li C, Zheng ZY, Liu Y. Early functional rehabilitation compared with traditional immobilization for acute Achilles tendon ruptures : a meta-analysis. Bone Joint J 2021; 103-B:1021-1030. [PMID: 34058871 DOI: 10.1302/0301-620x.103b6.bjj-2020-1890.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this meta-analysis was to assess the prognosis after early functional rehabilitation or traditional immobilization in patients who underwent operative or nonoperative treatment for rupture of the Achilles tendon. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched for randomized controlled trials (RCTs) from their inception to 3 June 2020, using keywords related to rupture of the Achilles tendon and rehabilitation. Data extraction was undertaken by independent reviewers and subgroup analyses were performed based on the form of treatment. Risk ratios (RRs) and weighted mean differences (WMDs) (with 95% confidence intervals (CIs)) were used as summary association measures. RESULTS We included 19 trials with a total of 1,758 patients. There was no difference between the re-rupture rate (RR 0.84 (95% CI 0.56 to 1.28); p = 0.423), time to return to work (WMD -1.29 (95% CI -2.63 to 0.05); p = 0.060), and sporting activity (WMD -1.50 (95% CI -4.36 to 1.37); p = 0.306) between the early functional rehabilitation and the traditional immobilization treatment strategies. Early rehabilitation up to 12 weeks yielded significantly better Achilles tendon Total Rupture Scores ((ATRS) WMD 5.11 (95% CI 2.10 to 8.12); p < 0.001). Patients who underwent functional rehabilitation had significantly lower limb symmetry index of heel-rise work ((HRW) WMD -4.19 (95% CI -8.20 to 0.17); p = 0.041) at one year. CONCLUSION Early functional rehabilitation is safe and provides better early function and the same functional outcome in the longer term. Cite this article: Bone Joint J 2021;103-B(6):1021-1030.
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Affiliation(s)
- Xuan Liu
- Beijing Sport University, Beijing, China
| | - Tian-Jiao Dai
- Beijing Sport University, Beijing, China.,Jiangsu College of Nursing, Jiangsu, China
| | - Bao-Lin Li
- Beijing Sport University, Beijing, China
| | - Chen Li
- Beijing Sport University, Beijing, China
| | | | - Ye Liu
- Beijing Sport University, Beijing, China
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21
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Baxter JR, Corrigan P, Hullfish TJ, O'Rourke P, Silbernagel KG. Exercise Progression to Incrementally Load the Achilles Tendon. Med Sci Sports Exerc 2021; 53:124-130. [PMID: 32658037 DOI: 10.1249/mss.0000000000002459] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE The purposes of our study were to evaluate Achilles tendon loading profiles of various exercises and to develop guidelines to incrementally increase the rate and magnitude of Achilles tendon loading during rehabilitation. METHODS Eight healthy young adults completed a battery of rehabilitation exercises. During each exercise, we collected three-dimensional motion capture and ground reaction force data to estimate Achilles tendon loading biomechanics. Using these loading estimates, we developed an exercise progression that incrementally increases Achilles tendon loading based on the magnitude, duration, and rate of tendon loading. RESULTS We found that Achilles tendon loading could be incrementally increased using a set of either isolated ankle movements or multijoint movements. Peak Achilles tendon loads varied more than 12-fold, from 0.5 bodyweights during a seated heel raise to 7.3 bodyweights during a forward single-leg hop. Asymmetric stepping movements like lunges, step ups, and step downs provide additional flexibility for prescribing tendon loading on a side-specific manner. CONCLUSION By establishing progressions for Achilles tendon loading, rehabilitative care can be tailored to address the specific needs of each patient. Our comprehensive data set also provides clinicians and researchers guidelines on how to alter magnitude, duration, and rate of loading to design new exercises and exercise progressions based on the clinical need.
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Affiliation(s)
- Josh R Baxter
- Department of Orthopaedic Surgery, Pearlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Patrick Corrigan
- Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston, MA
| | - Todd J Hullfish
- Department of Orthopaedic Surgery, Pearlman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Patrick O'Rourke
- Department of Physical Therapy, University of Delaware, Wilmington, DE
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22
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Venturini S, Garbett M, Houchen-Wolloff L, Mangwani J. Unusual Presentation of a Swelling in the Achilles Tendon After an Acute Rupture: A Case Report. J Orthop Case Rep 2020; 10:88-91. [PMID: 32953665 PMCID: PMC7476688 DOI: 10.13107/jocr.2020.v10.i02.1712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Achilles tendon rupture is common and most cases heal with appropriate treatment. However, complications in the treatment of this condition can be debilitating, especially for young, active individuals. Case Report We present the case of a 37-year-old man who presented with ongoing pain on weight-bearing and swelling in the left Achilles tendon area8 months after acute rupture treated with functional bracing and early rehabilitation. Magnetic resonance imaging showed intrasubstance thickening of the tendon with a large swelling. Successful decompression of the swelling was achieved using an arthroscopic technique and the patient returned to normal activities. Conclusion Physiotherapy and return to normal activities were limited in our patient due to high levels of discomfort and pain. Prolonged immobility following tendon rupture has been shown to cause increased scar tissue proliferation. This may have hindered functional rehabilitation progress and negatively impacted on the reparative process.
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Affiliation(s)
- Sara Venturini
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Marie Garbett
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Linzy Houchen-Wolloff
- Department of Physiotherapy, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Jitendra Mangwani
- Department of Orthopaedic surgery Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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23
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Maempel JF, Clement ND, Duckworth AD, Keenan OJF, White TO, Biant LC. A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures. Am J Sports Med 2020; 48:2755-2764. [PMID: 32816521 DOI: 10.1177/0363546520944905] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been a shift toward functional nonoperative rehabilitation in the treatment of Achilles tendon rupture (ATR) despite a shortage of studies directly comparing nonoperative functional rehabilitation with traditional nonoperative immobilization. PURPOSE To compare patient-reported outcome measures and functional outcomes for nonoperatively treated ATR with traditional cast immobilization or functional rehabilitation in a walking boot. STUDY DESIGN Randomized controlled clinical trial; Level of evidence, 2. METHODS In a single-center nonblinded study, 140 patients were randomized to compare treatment for acute ATR in (1) an immobilizing cast in reducing degrees of equinus over a 10-week period with 8 weeks of nonweightbearing mobilization or (2) a walking boot for 8 weeks with reducing equinus and immediate full weightbearing. Exclusion criteria were delayed presentation >2 weeks after injury, tendon reruptures, and latex allergy. Analysis was undertaken on an intention-to-treat basis. RESULTS A total of 69 patients (median age, 41 years [interquartile range, 33-50.5 years]) were randomized to walking boot treatment and 71 patients (41 [32-49]) to cast treatment. At 6 months, patients treated in a walking boot reported better Short Musculoskeletal Function Assessment (SMFA) dysfunction index (6.62 [2.21-12.50] vs 10.66 [4.96-13.42]; P = .050), SMFA bother index (7.29 [2.08-14.58] vs 10.42 [5.73-19.27]; P = .04), Achilles Tendon Total Rupture Score (71.5 [53.50-84.25] vs 54.0 [37-76]; P = .01), and Foot and Ankle Questionnaire core score (91 [81.89-97.55] vs 85 [78.25-92.09]; P = .04). At 1 year, there was no difference in SMFA dysfunction index (2.21 [0.74-5.88] vs 2.94 [1.47-6.62]; P = .25), SMFA bother index (2.08 [0-9.38] vs 5.21 [0.52-11.98]; P = .25), Achilles Tendon Total Rupture Score (92 [72.50-96] vs 87.5 [66.0-94.75]; P = .21), or Foot and Ankle Questionnaire core score (97.75 [89.46-99.00] vs 95.50 [90.88-97.50]; P = .18). Rerupture occurred in 5 and 11 patients (P = .075) and venous thromboembolism in 2 and 3 patients (P = .67) in the boot and cast groups, respectively. Fifteen patients in the boot group but none in the cast group had skin problems (P < .001). Patients treated in a boot returned to driving at a median 12 weeks (vs 13 weeks for cast; P = .045), but there was no difference in time to return to work (P = .48). CONCLUSION Functional rehabilitation with early weightbearing is a safe alternative to traditional immobilizing treatment for ATR, giving better early functional outcomes, albeit with a higher incidence of transient minor skin complications. REGISTRATION NCT02598843 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Julian F Maempel
- Royal Prince Alfred Hospital, Sydney, Australia.,University of Malta Medical School, Msida, Malta
| | | | - Andrew D Duckworth
- Royal Infirmary of Edinburgh, Edinburgh, UK.,University of Edinburgh, Edinburgh, UK
| | | | - Tim O White
- Royal Infirmary of Edinburgh, Edinburgh, UK.,University of Edinburgh, Edinburgh, UK
| | - Leela C Biant
- University of Manchester Medical School, Manchester, UK.,Manchester Orthopaedic Centre, Manchester University NHS Foundation Trust, Manchester, UK
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24
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Hansen MS, Nilsson Helander K, Karlsson J, Barfod KW. Performance of the Achilles Tendon Total Rupture Score Over Time in a Large National Database: Development of an Instruction Manual for Accurate Use. Am J Sports Med 2020; 48:1423-1429. [PMID: 32255669 DOI: 10.1177/0363546520912222] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Achilles tendon Total Rupture Score (ATRS) is a commonly used patient-reported outcome measure for patients with an acute Achilles tendon rupture. The score consists of 10 questions, the last 3 of which include activities that some patients cannot or do not do. No instruction manual has been developed for the ATRS. HYPOTHESIS/PURPOSE The purpose was to evaluate the ATRS at 4, 12, and 24 months after a rupture. The hypothesis was that the results at 4 months would be inconsistent when compared with the results at 1 year and 2 years. We also aimed to develop a manual that explains how to use the ATRS. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 3. METHODS This was a mixed-methods study. The first section was a registry study, where prospectively collected data were analyzed. Data were collected 4, 12, and 24 months after rupture. The original score based on 10 items was compared with a score based on the first 7 items adjusted to the same scale as the original score. Density plots and scatterplots were made and differences between the scores were tested using the Mann-Whitney U test. The second section of the study consisted of discussions among the authors, which resulted in a manual for the ATRS. RESULTS In total, 2790 complete ATRSs were included. The 7-item score significantly overestimated the value of the 10-item score at all time points (P < .001), but only at 4 months was the difference clinically relevant (9.7 points). CONCLUSION When the ATRS is used for short-term evaluation, there is a risk of results being inconsistent because of the last 3 questions. A manual explaining how to use the ATRS was therefore developed. We recommend that the full ATRS together with the manual should be used in future research rather than eliminating the 3 last questions.
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Affiliation(s)
- Maria Swennergren Hansen
- Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.,Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | | | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
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25
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Su AW, Bogunovic L, Johnson J, Klein S, Matava MJ, McCormick J, Smith MV, Wright RW, Brophy RH. Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Pilot Economic Decision Analysis. Orthop J Sports Med 2020; 8:2325967120909918. [PMID: 32284940 PMCID: PMC7139191 DOI: 10.1177/2325967120909918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/17/2019] [Indexed: 11/15/2022] Open
Abstract
Background The operative treatment of Achilles tendon ruptures has been associated with lower rerupture rates and better function but also a risk of surgery-related complications compared with nonoperative treatment, which may provide improved outcomes with accelerated rehabilitation protocols. However, economic decision analyses integrating the updated costs of both treatment options are limited in the literature. Purpose To compare the cost-effectiveness of operative and nonoperative treatment of acute Achilles tendon tears. Study Design Economic and decision analysis; Level of evidence, 2. Methods An economic decision model was built to assess the cost-utility ratio (CUR) of open primary repair versus nonoperative treatment for acute Achilles tendon ruptures, based on direct costs from the practices of sports medicine and foot and ankle surgeons at a single tertiary academic center, with published outcome probabilities and patient utility data. Multiway sensitivity analyses were performed to reflect the range of data. Results Nonoperative treatment was more cost-effective in the average scenario (nonoperative CUR, US$520; operative CUR, US$1995), but crossover occurred during the sensitivity analysis (nonoperative CUR range, US$224-US$2079; operative CUR range, US$789-US$8380). Operative treatment cost an extra average marginal CUR of US$1475 compared with nonoperative treatment, assuming uneventful healing in both treatment arms. The sensitivity analysis demonstrated a decreased marginal CUR of operative treatment when the outcome utility was maximized, and rerupture rates were minimized compared with nonoperative treatment. Conclusion Nonoperative treatment was more cost-effective in average scenarios. Crossover indicated that open primary repair would be favorable for maximized outcome utility, such as that for young athletes or heavy laborers. The treatment decision for acute Achilles tendon ruptures should be individualized. These pilot results provide inferences for further longitudinal analyses incorporating future clinical evidence.
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Affiliation(s)
- Alvin W Su
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA.,Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Ljiljana Bogunovic
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Jeffrey Johnson
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Sandra Klein
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Jeremy McCormick
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Matthew V Smith
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Rick W Wright
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
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26
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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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27
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Lu J, Liang X, Ma Q. Early Functional Rehabilitation for Acute Achilles Tendon Ruptures: An Update Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg 2019; 58:938-945. [PMID: 31474405 DOI: 10.1053/j.jfas.2018.12.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Indexed: 02/03/2023]
Abstract
The aim of this study was to investigate the role of early functional rehabilitation in acute Achilles tendon ruptures. Eligible studies were identified from PubMed, Embase, and the Cochrane Library using the following search keywords: "Achilles tendon rupture" and "rehabilitation" or "function" or "functional" or "mobilization" and "randomized" or "random" or "blind" or "control" or "compare" or "comparative." A heterogeneity test based on I2 statistic and Cochran's Q test was conducted. The pooled risk ratio and weighted mean difference with 95% confidence interval was calculated for each outcome using the random-effect (p < .05 or I2 > 50% for significant heterogeneity) or fixed-effect (p > .05 or I2 < 50% for nonsignificant heterogeneity) model. A subgroup analysis was also performed. Fourteen randomized controlled trials were identified. Pooled data demonstrated no difference in the complication rates, time taken to return to sports, total number of patients returning to work or sports, and satisfaction rate between the early functional rehabilitation and conventional cast immobilization groups. Early functional rehabilitation significantly decreased the time taken to return to work (weighted mean difference -1.56; 95% confidence interval -3.09 to 0.04; p = .04]. Early functional rehabilitation for acute Achilles tendon ruptures appeared to be related to a shorter time taken to return to work; however, it did not affect the other variables between the groups.
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Affiliation(s)
- Jun Lu
- Surgeon, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China
| | - Xiaojun Liang
- Professor, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China
| | - Qiang Ma
- Surgeon, Foot and Ankle Surgery, Xi'an Honghui Hospital Affiliated to Xi'an Jiaotong University, Xi'an, China.
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28
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Zhao J, Guo W, Zeng X, Kan S. [Research progress of early postoperative rehabilitation for acute Achilles tendon rupture after surgical repair]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:382-386. [PMID: 30874399 PMCID: PMC8337926 DOI: 10.7507/1002-1892.201807146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/07/2019] [Indexed: 12/28/2022]
Abstract
Objective To summarize the latest research progress of early postoperative rehabilitation for acute Achilles tendon rupture after surgical repair. Methods The high-quality randomized controlled trials and systematic reviews/meta-analyses regarding early postoperative rehabilitation for acute Achilles tendon rupture in recent years were reviewed. Results There are three functional rehabilitations after acute Achilles tendon rupture surgery, including early postoperative mobilization, early weight-bearing with immobilization, and early weight-bearing combined with mobilization. The results of randomized controlled trials show that the effectiveness of early postoperative rehabilitation is similar or better than the early postoperative immobilization. The results of systematic reviews/meta-analyses show that the early postoperative rehabilitation is beneficial to the early function recovery of the Achilles tendon, can reduce the time for functional recovery, and do not adversely affect the outcomes. Conclusion Early postoperative rehabilitation is beneficial to the functional recovery, and do not increase postoperative complications. There is still no uniform protocol of early postoperative rehabilitation and the timing of weight-bearing, and further studies are needed in the future.
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Affiliation(s)
- Jiaguo Zhao
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211,
| | - Wenxuan Guo
- School of Graduates, Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, P.R.China
| | - Xiantie Zeng
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China
| | - Shilian Kan
- Department of Hand Surgery, Tianjin Hospital, Tianjin, 300211, P.R.China
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29
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Porter MD. Surgical Technique Influences Rehabilitation Regimen: Letter to the Editor. Am J Sports Med 2019; 47:NP6-NP7. [PMID: 30781984 DOI: 10.1177/0363546518810705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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30
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van Maele M, Misselyn D, Metsemakers WJ, Sermon A, Nijs S, Hoekstra H. Is open acute Achilles tendon rupture repair still justified? A single center experience and critical appraisal of the literature. Injury 2018; 49:1947-1952. [PMID: 30144965 DOI: 10.1016/j.injury.2018.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/31/2018] [Accepted: 08/14/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Acute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures. METHODS Between June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved. RESULTS We recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5-39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21-63) and 28 (IQR 15-28). Nevertheless, a difference of 10 points is considered clinically relevant. CONCLUSION The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed.
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Affiliation(s)
- Margaux van Maele
- KU Leuven - University of Leuven, Faculty of Medicine, B-3000 Leuven, Belgium
| | - Dominique Misselyn
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - An Sermon
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - Stefaan Nijs
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium.
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31
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Eliasson P, Agergaard AS, Couppé C, Svensson R, Hoeffner R, Warming S, Warming N, Holm C, Jensen MH, Krogsgaard M, Kjaer M, Magnusson SP. The Ruptured Achilles Tendon Elongates for 6 Months After Surgical Repair Regardless of Early or Late Weightbearing in Combination With Ankle Mobilization: A Randomized Clinical Trial. Am J Sports Med 2018; 46:2492-2502. [PMID: 29965789 DOI: 10.1177/0363546518781826] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim of this project was to examine whether tendon elongation, mechanical properties, and functional outcomes during rehabilitation of surgically repaired acute Achilles tendon ruptures were influenced by different rehabilitation regimens during the early postsurgical period. HYPOTHESIS Restricted early weightbearing that permits only limited motion about the ankle in the early phase of tendon healing limits tendon elongation and improves functional outcome. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS 75 consecutive patients with an acute Achilles tendon rupture were included. They underwent surgical repair, and tantalum beads were placed in the distal and proximal parts of the tendon; thereafter, the patients were randomized into 3 groups. The first group was completely restricted from weightbearing until week 7. The second group was completely restricted from weightbearing until week 7 but performed ankle joint mobilization exercises. The first and second groups were allowed full weightbearing after week 8. The third group was allowed partial weightbearing from day 1 and full weightbearing from week 5. All patients received the same instructions in home exercise guidelines starting from week 9. RESULTS The rehabilitation regimen in the initial 8 weeks did not significantly influence any of the measured outcomes including tendon elongation. Achilles tendon elongation and tendon compliance continued for up to 6 months after surgery, and muscle strength, muscle endurance, and patient-reported functional scores did not reach normal values at 12 months. CONCLUSION Differences in rehabilitation loading pattern in the initial 8 weeks after the repair of an Achilles tendon rupture did not measurably alter the outcome. The time to recover full function after an Achilles tendon rupture is at least 12 months. Registration: NCT02422004 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Pernilla Eliasson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Anne-Sofie Agergaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Christian Couppé
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - René Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Susan Warming
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Nichlas Warming
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Christina Holm
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Mikkel Holm Jensen
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
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Ateschrang A, Körner D, Joisten K, Ahrend MD, Schröter S, Stöckle U, Riedmann S. Incidence and risk factors for postoperative Achilles tendon calcifications after percutaneous repair. Arch Orthop Trauma Surg 2018; 138:203-210. [PMID: 29094200 DOI: 10.1007/s00402-017-2829-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Numerous publications are dealing with acute Achilles tendon rupture. To our knowledge, no systematic trial has been published analyzing the incidence, risk factors and the potential clinical impact of postoperative tendon calcifications (PTC) after percutaneous Achilles tendon repair. Therefore, the aim of this study was to analyze these relevant aspects. MATERIALS AND METHODS Between March 2003 and November 2010, a total of 126 patients with an acute, complete Achilles tendon rupture were treated with a percutaneous technique according to Ma and Griffith at a single university-based trauma department. The follow-up included a detailed clinical and sonographic examination. To assess the functional outcome and possible impact of PTC after percutaneous Achilles tendon repair, the Thermann and AOFAS scores were used. 81 patients (65 men and 16 women) with a median age of 46 years (range 24-76) were available for a follow-up examination. The median time of follow-up was 64 months (range 15-110 months). RESULTS PTC occurred in nine out of 81 patients (11.1%). All patients with PTC were male with a median age of 52 years (range 26-76 years). In the group of patients with PTC, the median overall Thermann score was 94 (range 68-100) and the median overall AOFAS score was 97 (range 85-100). In the group of patients without PTC, the median overall Thermann score was 88.5 (range 60-100) and the median overall AOFAS score was 97 (range 85-100). No significant differences were detected between the group of patients with PTC and the group of patients without PTC and the clinical outcome according to the Thermann (p = 0.21) and the AOFAS scores (p = 0.37). None of the patients with PTC sustained a re-rupture. The overall re-rupture rate was 4.9%. PTC was no risk factor for wound and neurological complications. CONCLUSION The incidence of PTC after percutaneous Achilles tendon repair was 11.1%. Male gender and advanced age seem to be risk factors for PTC. In this study, PTC had no negative impact on the postoperative clinical outcome.
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Affiliation(s)
- Atesch Ateschrang
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Schnarrrenbergstr. 95, 72076, Tübingen, Germany
| | - Daniel Körner
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Schnarrrenbergstr. 95, 72076, Tübingen, Germany.
| | - Konrad Joisten
- Department of Oral and Maxillofacial Surgery, Marien Hospital, Stuttgart, Germany
| | - Marc-Daniel Ahrend
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Schnarrrenbergstr. 95, 72076, Tübingen, Germany
| | - Steffen Schröter
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Schnarrrenbergstr. 95, 72076, Tübingen, Germany
| | - Ulrich Stöckle
- Department of Traumatology and Reconstructive Surgery, BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Schnarrrenbergstr. 95, 72076, Tübingen, Germany
| | - Stephan Riedmann
- Orthopedic Clinic Paulinenhilfe, Diakonie Clinic, Stuttgart, Germany
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Lim CS, Lees D, Gwynne-Jones DP. Functional Outcome of Acute Achilles Tendon Rupture With and Without Operative Treatment Using Identical Functional Bracing Protocol. Foot Ankle Int 2017; 38:1331-1336. [PMID: 28891323 DOI: 10.1177/1071100717728687] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to compare the functional results of operative and nonoperative treatment of acute Achilles tendon rupture using an identical rehabilitation program of functional bracing. METHODS Over a 10-year period, 200 patients (99 operative, 101 nonoperative) aged between 18 and 65 years were treated at our institution's physiotherapy department after acute Achilles tendon rupture. There were 132 patients (62 operative, 70 nonoperative) available for a minimum 2-year follow-up (average 6.5 years; range, 2-13 years). Functional outcome was assessed using the Achilles tendon total rupture score (ATRS). RESULTS With the numbers available, no significant difference could be detected in ATRS between operative (mean 84.8, median 90) and nonoperative groups (mean 85.3, median 91; P = 0.55). No significant difference could be detected in ATRS between male and female patients however treated ( P = 0.30) or between patients younger and older than 40 years at time of injury ( P = 0.68). There was no correlation between ATRS score and age at injury in all patients (ρ = -0.0168, P = 0.85). In male patients, there was a weak trend with older patients at follow-up having better scores (ρ = 0.21, P = 0.069). However, among female patients, there was a significant negative correlation between ATRS scores and increasing age (ρ = -0.29, P = 0.03). Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS. CONCLUSIONS This study showed no significant difference detectable in ATRS between operative and nonoperative patients in the treatment of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Che Siu Lim
- 1 Whangarei Hospital, Orthopaedic Outpatients, Whangarei, New Zealand
| | - David Lees
- 2 Waikato District Health Board, Hamilton, New Zealand
| | - David P Gwynne-Jones
- 3 Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,4 Department of Orthopaedic Surgery, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand
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Ho G, Tantigate D, Kirschenbaum J, Greisberg JK, Vosseller JT. Increasing age in Achilles rupture patients over time. Injury 2017; 48:1701-1709. [PMID: 28457569 DOI: 10.1016/j.injury.2017.04.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. METHODS Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. RESULTS The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. CONCLUSION Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. LEVEL OF EVIDENCE Level III; Retrospective cohort study.
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Affiliation(s)
- Gavin Ho
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Direk Tantigate
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Josh Kirschenbaum
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Justin K Greisberg
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - J Turner Vosseller
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States.
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Rehabilitation of Achilles tendon ruptures: is early functional rehabilitation daily routine? Arch Orthop Trauma Surg 2017; 137:333-340. [PMID: 28097423 DOI: 10.1007/s00402-017-2627-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Ruptures of the Achilles tendon are the most common tendon injuries of the lower extremities. Besides the initial operative or non-operative treatment, rehabilitation of patients plays a crucial role for tendon healing and long-term outcome. As only limited evidence is available for optimized rehabilitation regimen and guidelines for the initial (e.g., first 6 weeks) rehabilitation are limited, this study investigated the current rehabilitation concepts after Achilles tendon rupture. MATERIALS AND METHODS We analyzed 213 written rehabilitation protocols that are provided by orthopedic and trauma surgery institutions throughout Germany in terms of recommendations for weight-bearing, range of motion (ROM), physiotherapy, and choice of orthosis. All protocols for operatively and non-operatively treated Achilles tendon ruptures were included. Descriptive analysis was carried out and statistical analysis applied where appropriate. RESULTS Of 213 institutions, 204 offered rehabilitation protocols for Achilles tendon rupture and, therefore, 243 protocols for operative and non-operative treatment could be analyzed. While the majority of protocols allowed increased weight-bearing over time, significant differences were found for durations of fixed plantar flexion between operative (o) and non-operative (n) treatments [fixed 30° (or 20)° to 15° (or 10)°: 3.6 weeks (±0.1; o) vs 4.7 weeks (±0.3; n) (p ≤ 0.0001) and fixed 15° (or 10)° to 0°: 5.8 weeks (±0.1; o) vs 6.6 weeks (±0.2; n) (p ≤ 0.001)]. The mean time of the recommended start of physiotherapy is at 2.9 weeks (±0.2; o) vs 3.3 weeks (±0.4; n), respectively. CONCLUSION Our study shows that a huge variability in rehabilitation after Achilles tendon rupture exists. This study shows different strategies in rehabilitation of Achilles tendon ruptures using a convertible vacuum brace system. To improve patient care, further clinical as well as biomechanical studies need to be conducted. This study might serve as basis for prospective randomized controlled trials to optimize rehabilitation for Achilles tendon ruptures.
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review the current literature of Achilles tendon injuries, specifically chronic tendinopathy and acute ruptures in regard to etiology, diagnosis, treatment options, and outcomes. RECENT FINDINGS The incidence of Achilles tendon injuries is increasing, but the necessity for surgical intervention is decreasing due to improved conservative therapies, which may provide comparable outcomes without the implied surgical risk. If surgery is undertaken, no difference has been noted between open and minimally invasive techniques. The majority of patients are able to return to pre-injury level of activity, with the elite athlete as an unfortunate exception. Achilles injuries can be devastating injuries, but if addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality implemented. Further research is needed into the etiology, potential preventative measures, and longer-term outcomes of the different treatment options for wide range of Achilles pathology.
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Affiliation(s)
- Anthony C Egger
- Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, 2049 E 100th St, Desk A40, Cleveland, OH, 44195, USA.
| | - Mark J Berkowitz
- Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, 2049 E 100th St, Desk A40, Cleveland, OH, 44195, USA
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Revak A, Diers K, Kernozek TW, Gheidi N, Olbrantz C. Achilles Tendon Loading During Heel-Raising and -Lowering Exercises. J Athl Train 2017; 52:89-96. [PMID: 28145739 DOI: 10.4085/1062-6050-52.1.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
CONTEXT Achilles tendinopathies are common injuries during sport participation, although men are more prone to Achilles tendon injuries than women. Heel-raising and -lowering exercises are typically suggested for Achilles tendon rehabilitation. OBJECTIVE To compare the estimated Achilles tendon loading variables and the ankle range of motion (ROM) using a musculoskeletal model during commonly performed heel-raising and -lowering exercises. DESIGN Controlled laboratory study. SETTING University biomechanics laboratory. PATIENTS OR OTHER PARTICIPANTS Twenty-one healthy men (age = 21.59 ± 1.92 years, height = 178.22 ± 8.02 cm, mass = 75.81 ± 11.24 kg). INTERVENTION(S) Each participant completed 4 exercises: seated heel raising and lowering, bilateral standing heel raising and lowering, bilateral heel raising and unilateral lowering, and unilateral heel raising and lowering. MAIN OUTCOME MEASURE(S) A repeated-measures multivariate analysis of variance (α = .05) was used to compare Achilles tendon stress, force, and strain and ankle ROM for each exercise. Kinematic data were recorded at 180 Hz with 15 motion-analysis cameras synchronized with kinetic data collected from a force platform sampled at 1800 Hz. These data were then entered in a musculoskeletal model to estimate force in the triceps surae. For each participant, we determined Achilles tendon stress by measuring cross-sectional images using ultrasound. RESULTS Peak Achilles tendon loading was lowest when performing the seated heel-raising and -lowering exercise and highest when performing the unilateral heel-raising and -lowering exercise. Loading was greater for the unilateral exercise or portions of the exercise that were performed unilaterally. CONCLUSIONS Bilateral and seated exercises with less weight-bearing force resulted in less Achilles tendon loading. These exercises may serve as progressions during the rehabilitation process before full-body weight-bearing, unilateral exercises are allowed. Ankle ROM did not follow the same order as loading and may need additional monitoring or instruction during rehabilitation.
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Affiliation(s)
- Andrew Revak
- La Crosse Institute for Movement Science, Physical Therapy Program, Department of Health Professions, University of Wisconsin-La Crosse
| | - Keith Diers
- La Crosse Institute for Movement Science, Physical Therapy Program, Department of Health Professions, University of Wisconsin-La Crosse
| | - Thomas W Kernozek
- La Crosse Institute for Movement Science, Physical Therapy Program, Department of Health Professions, University of Wisconsin-La Crosse
| | - Naghmeh Gheidi
- La Crosse Institute for Movement Science, Physical Therapy Program, Department of Health Professions, University of Wisconsin-La Crosse
| | - Christina Olbrantz
- La Crosse Institute for Movement Science, Physical Therapy Program, Department of Health Professions, University of Wisconsin-La Crosse
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De la Fuente C, Peña y Lillo R, Carreño G, Marambio H. Prospective randomized clinical trial of aggressive rehabilitation after acute Achilles tendon ruptures repaired with Dresden technique. Foot (Edinb) 2016; 26:15-22. [PMID: 26802945 DOI: 10.1016/j.foot.2015.10.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/04/2015] [Accepted: 10/07/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rupture of the Achilles tendon is a common injury during working years. Aggressive rehabilitation may provide better outcomes, but also a greater chance of re-rupture. OBJECTIVE To determine if aggressive rehabilitation has better clinical outcomes for Achilles tendon function, Triceps surae function, one-leg heel rise capacity and lower complication rate during twelve weeks after percutaneous Achilles tendon repair compared to conventional rehabilitation. DESIGN Randomized controlled trial. METHOD Thirty-nine patients were prospectively randomized. The aggressive group (n=20, 41.4 ± 8.3 years) received rehabilitation from the first day after surgery. The conventional group (n=19, 41.7 ± 10.7 years) rested for 28 days, before rehabilitation started. The statistical parameters were the Achilles tendon rupture score (ATRS), verbal pain scale, time to return to work, pain medication consumption, Achilles tendon strength, dorsiflexion range of motion (RoM), injured-leg calf circumference, calf circumference difference, one-leg heel rise repetition and difference, re-rupture rate, strength deficit rate, and other complication rates. Mixed-ANOVA and Bonferroni's post hoc test were performed for multiple comparisons. Student's t-test was performed for parameters measured on the 12th week. RESULTS The aggressive group with respect to the conventional group had a higher ATRS; lower verbal pain score; lower pain medication consumption; early return to work; higher Achilles tendon strength; higher one-leg heel rise repetitions; and lower one-leg heel rise difference. The re-rupture rate was 5% and 5%, the strength deficit rate was 42% and 5%, and other complications rate was 11% and 15% in the conventional and aggressive group, respectively. CONCLUSION Patients with Dresden repair and aggressive rehabilitation have better clinical outcomes, Achilles tendon function and one-leg heel rise capacity without increasing the postoperative complications rate after 12 weeks compared to rehabilitation with immobilization and non-weight-bearing during the first 28 days after surgery.
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Affiliation(s)
- Carlos De la Fuente
- Biomechanics Unit, Centro de Investigaciones Médicas del Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile; Carrera de Kinesiología, UDA Cs Salud, Facultad Medicina, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile; Mechanics Department, Engineer Faculty, USACH, Santiago 717835, Chile; Kinesiology and Clinical Biomechanics Program, UMCE, Santiago 7780450, Chile.
| | - Roberto Peña y Lillo
- Foot and Ankle Unit, Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile; Servicio de Kinesiterapia y Terapia Ocupacional, Instituto Traumatológico "Teodoro Gebauer Weisser", Santiago 8340220, Chile.
| | - Gabriel Carreño
- Laboratorio de Movimiento Humano, Escuela de Kinesiología, Facultad de Salud y Odontología, Universidad Diego Portales, Santiago 8370109, Chile; Facultad de Ciencias de la Salud, Universidad Iberoamericana de Ciencias y Tecnología, Santiago 8330440, Chile.
| | - Hugo Marambio
- Trauma Service, Clínica Santa María, Santiago 7520378, Chile; Exercise Science Laboratory, School of Kinesiology, Faculty of Medicine, Universidad Finis Terrae, Santiago 7501015, Chile.
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