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Lee M, Lee Y, Choi JH, Kim H, Jeong D, Park K, Kim J, Park J, Jang WY, Seo J, Lee J. Postoperative Long-Term Monitoring of Mechanical Characteristics in Reconstructed Soft Tissues Using Biocompatible, Immune-Tolerant, and Wireless Electronic Sutures. ACS NANO 2024; 18:12210-12224. [PMID: 38695533 DOI: 10.1021/acsnano.4c00396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
Accurate postoperative assessment of varying mechanical properties is crucial for customizing patient-specific treatments and optimizing rehabilitation strategies following Achilles tendon (AT) rupture and reconstruction surgery. This study introduces a wireless, chip-less, and immune-tolerant in vivo strain-sensing suture designed to continuously monitor mechanical stiffness variations in the reconstructed AT throughout the healing process. This innovative sensing suture integrates a standard medical suturing thread with a wireless fiber strain-sensing system, which incorporates a fiber strain sensor and a double-layered inductive coil for wireless readout. The winding design of Au nanoparticle-based fiber electrodes and a hollow core contribute to the fiber strain sensor's high sensitivity (factor of 6.2 and 15.1 pF for revised sensitivity), negligible hysteresis, and durability over 10,000 stretching cycles. To ensure biocompatibility and immune tolerance during extended in vivo periods, an antibiofouling lubricant layer was applied to the sensing suture. Using this sensing system, we successfully monitored the strain responses of the reconstructed AT in an in vivo porcine model. This facilitated the postoperative assessment of mechanical stiffness variations through a well-established analytical model during the healing period.
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Affiliation(s)
- Mugeun Lee
- Department of Robotics and Mechatronics Engineering, DGIST Daegu 42988, Republic of Korea
| | - Yeontaek Lee
- School of Electrical and Electronic Engineering, Yonsei University Seoul 03722, Republic of Korea
| | - Ji Hye Choi
- Department of Orthopedic Surgery, Korea University College of Medicine Seoul 02841, Republic of Korea
- Institute of Nanobiomarker-Based Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Hwajoong Kim
- Department of Robotics and Mechatronics Engineering, DGIST Daegu 42988, Republic of Korea
| | - Daun Jeong
- Department of Orthopedic Surgery, Korea University College of Medicine Seoul 02841, Republic of Korea
- Institute of Nanobiomarker-Based Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Kijun Park
- School of Electrical and Electronic Engineering, Yonsei University Seoul 03722, Republic of Korea
| | - Jinho Kim
- Department of Robotics and Mechatronics Engineering, DGIST Daegu 42988, Republic of Korea
| | - Jae Park
- School of Electrical and Electronic Engineering, Yonsei University Seoul 03722, Republic of Korea
| | - Woo Young Jang
- Department of Orthopedic Surgery, Korea University College of Medicine Seoul 02841, Republic of Korea
- Institute of Nanobiomarker-Based Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Jungmok Seo
- School of Electrical and Electronic Engineering, Yonsei University Seoul 03722, Republic of Korea
| | - Jaehong Lee
- Department of Robotics and Mechatronics Engineering, DGIST Daegu 42988, Republic of Korea
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El Aissaoui T, Lawan A, Lachkar A, Abdeljaouad N, Yacoubi H. Achilles Tendon Tear Following an Unusual Pattern of Open Pure Ankle Dislocation: A Case Report. Cureus 2024; 16:e53814. [PMID: 38465081 PMCID: PMC10924186 DOI: 10.7759/cureus.53814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
We present a rare case of concurrent open Achilles tendon tear and pure subtalar dislocation in a 20-year-old male following a motorcycle accident, highlighting the complexity of managing such unique musculoskeletal injuries. The patient was initially admitted with an open and deformed left ankle, underwent prompt primary debridement, and received immediate medical intervention. Despite unsuccessful attempts to reduce the dislocation through external maneuvers, subsequent radiographic evaluation revealed a subtalar dislocation associated with a 90° rotation of the talus. A direct reduction was achieved in the operating room, uncovering a complete tear of the Achilles tendon and a section of the posterior tibial artery during more intensive debridement. The vascular surgery team repaired the posterior tibial artery, followed by Achilles tendon repair using a Kessler suture technique. Postoperative care involved immobilization and adapted rehabilitation, resulting in the patient regaining full range of motion without complications. To the best of our knowledge, this case represents the first reported open lateral subtalar dislocation associated with an open Achilles tendon tear. The detailed treatment strategies and outcomes offer valuable insights for clinicians facing similar challenges and inspire further research on rare musculoskeletal injuries.
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Affiliation(s)
- Taha El Aissaoui
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
| | | | - Adnane Lachkar
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
| | - Najib Abdeljaouad
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
| | - Hicham Yacoubi
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, Mohammed Ist University, Oujda, MAR
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Mitrogiannis L, Mitrogiannis G, Melaki K, Karamitros A, Karantanas A, Paxinos O. An Early Functional Unsupervised Rehabilitation Protocol Allows Safe Return to Function After Achilles Tendon Repair. Cureus 2024; 16:e52477. [PMID: 38371156 PMCID: PMC10873818 DOI: 10.7759/cureus.52477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
PURPOSE Acute Achilles tendon tears in young active individuals are often treated surgically with prolonged rehabilitation, with the leg initially immobilized in plantar flexion in serial non-weight bearing casts and gradually progressing to full weight bearing. This study aimed to evaluate the safety of an early functional unsupervised rehabilitation protocol. METHODS The medical records of 25 patients treated with open repair were available for follow-up. In 10 patients, an early functional unsupervised rehabilitation protocol was used with a removable cast, active range of motion exercises of the ankle from the first postoperative day, and full weight bearing in a walking boot with the foot plantigrade after the second week. Another 15 patients who followed the classic rehabilitation protocol were used as controls. The patients were evaluated with the Victorian Institute of Sports Assessment-Achilles (VISA-A) and an ultrasound examination-based score. A Wilcoxon test was used to compare the scores between the groups. RESULTS The mean VISA-A score was 90.1 (SD = 9.87) for the early functional rehabilitation protocol group, while it was 83.8 (SD = 17.06, p = 0.624) for the control group. The mean ultrasound score was 7.75 (SD = 1.71) for the early functional rehabilitation protocol group, while it was 7.60 (SD = 3.05, p = 0.414) for the control group. There were no intra- or early postoperative complications in the groups, and all patients were satisfied with the results of their operation. CONCLUSIONS An early unsupervised functional rehabilitation protocol after open Achilles repair may allow for safe early mobilization and minimize the need for physiotherapy. The small number of participants is a limitation of this study, and further evaluation with more patients is necessary to document the efficacy.
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Affiliation(s)
| | - George Mitrogiannis
- Orthopedics Department, 251 Hellenic Air Force General Hospital, Athens, GRC
| | - Kalliopi Melaki
- Radiology Department, General Hospital of Piraeus "Tzaneio", Athens, GRC
| | | | | | - Odysseas Paxinos
- Orthopedics Department, 251 Hellenic Air Force General Hospital, Athens, GRC
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Li Z, Sun X, Shen C, Deng Z, Tang K, Xie Y, Chen L, Nie M. Dynamic Tensile Stress Promotes Regeneration of Achilles Tendon in a Panda Rope Bridge Technique Mice Model. Ann Biomed Eng 2023; 51:2735-2748. [PMID: 37482574 DOI: 10.1007/s10439-023-03320-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Abstract
Regeneration of ruptured Achilles tendon remains a clinical challenge owing to its limited regenerative capacity. Dynamic tensile stress plays a positive role in the regeneration of tendon, although the specific underlying mechanisms remain unclear. In this study, the Achilles tendon defect-regeneration model was created in male C57BL/6 mice aged 8 weeks. The animals were randomly assigned to four groups-repair, non-repair, repair with fixation, and non-repair with fixation. The repair group and repair with fixation group adopted the panda rope bridge technique (PRBT) repair method. Our results demonstrated the presence of more densely aligned and mature collagen fibers, as well as more tendon-related makers, in the repair group at both 2- and 4-week post-surgery. Furthermore, the biomechanical strength of the regenerated tendon in the repair group was highly improved. Most importantly, the expressions of integrin αv and its downstream and the phosphorylation levels of FAK and ERK were remarkably higher in the repair group than in the other groups. Furthermore, blocking FAK or ERK with selective inhibitors PF573228 and U0126 resulted in obvious adverse effects on the histological structure of the regenerated Achilles tendon. In summary, this study demonstrated that dynamic tensile stress based on the PRBT could effectively promote the regeneration of the Achilles tendon, suggesting that dynamic tensile stress enhances the cell proliferation and tenogenic differentiation via the activation of the integrin/FAK/ERK signaling pathway.
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Affiliation(s)
- Zhi Li
- Department of Orthopedic, Center for Joint Surgery, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Department of Wound Repair and Rehabilitation, Daping Hospital, Trauma Center, Research Institute of Surgery, Army Medical University, Chongqing, China
| | - Xianding Sun
- Department of Orthopedic, Center for Joint Surgery, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Chen Shen
- Department of Orthopedic, Center for Joint Surgery, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Zhibo Deng
- Department of Orthopedic, Center for Joint Surgery, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Kaiying Tang
- Department of Orthopedic, Center for Joint Surgery, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China
| | - Yangli Xie
- State Key Laboratory of Trauma, Burns and Combined Injury, Department of Wound Repair and Rehabilitation, Daping Hospital, Trauma Center, Research Institute of Surgery, Army Medical University, Chongqing, China.
| | - Lin Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Department of Wound Repair and Rehabilitation, Daping Hospital, Trauma Center, Research Institute of Surgery, Army Medical University, Chongqing, China.
| | - Mao Nie
- Department of Orthopedic, Center for Joint Surgery, The Second Affiliated Hospital of Chongqing Medical University, Linjiang Road No.76, Yuzhong District, Chongqing, 400010, China.
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Choi JY, Lee SS, Song TH, Suh JS. A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients. Arch Orthop Trauma Surg 2023; 143:6513-6520. [PMID: 37341805 DOI: 10.1007/s00402-023-04945-4] [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: 03/25/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION Achilles tendon sleeve avulsion (ATSA) is a rare injury that often results from pre-existing insertional Achilles tendinopathy and occurs when a tendon avulses from the insertion as a continuous sleeve. To date, outcomes of operative treatment for ATSA in older patients have not been reported. Therefore, this study aims to compare the characteristics and outcomes of Achilles tendon (AT) reattachment with or without tendon lengthening for ATSA between older and younger patients. MATERIALS AND METHODS This study enrolled 25 consecutive patients who underwent operative treatment following a diagnosis of ATSA between January 2006 and June 2020. The inclusion criterion was a minimum follow-up duration of one year. The enrolled patients were divided into two groups according to their age at operation: ≥ 65 years (group 1, 13 patients) and < 65 years (group 2, 12 patients). AT reattachment was performed in all patients using two 5.0-mm suture anchors after an inflamed distal stump resection in the 30° plantar-flexed ankle position. RESULTS The degree of active dorsiflexion and plantar flexion, mean visual analog scale score, and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were not significantly different between the two groups (P > 0.05 each). The rate of satisfactory clinical outcomes (defined as fair or greater) was 84.6% and 91.7% in groups 1 and 2, respectively. CONCLUSION We observed that comparable clinical outcomes could be achieved after AT reattachment with or without lengthening for ATSA between older and younger patients.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Sung Sahn Lee
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Tae Hun Song
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
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Seow D, Islam W, Randall GW, Azam MT, Duenes ML, Hui J, Pearce CJ, Kennedy JG. Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07411-1. [PMID: 37115231 DOI: 10.1007/s00167-023-07411-1] [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: 01/06/2023] [Accepted: 03/30/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR. METHODS Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance. RESULTS There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3-5%) versus conservative treatment (3.9-13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5-10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation. CONCLUSION This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Dexter Seow
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wasif Islam
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Grace W Randall
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Mohammad T Azam
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - Matthew L Duenes
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA
| | - James Hui
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christopher J Pearce
- National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - John G Kennedy
- NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA.
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Shoap S, Backer HC, Freibott CE, Ferrer XE, Polzer H, Turner Vosseller J. Rerupture and wound complications following Achilles tendon repair: A systematic review. J Orthop Res 2023; 41:845-851. [PMID: 35864743 DOI: 10.1002/jor.25419] [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: 03/15/2022] [Revised: 07/06/2022] [Accepted: 07/16/2022] [Indexed: 02/04/2023]
Abstract
Despite the relatively high frequency of Achilles ruptures, there is no general consensus on the optimal treatment method. A general trend toward more patients being treated nonoperatively has emerged recently with the advent of functional rehabilitation. However, much of the recent data on this subject has been highly variable. This systematic review focused on Achilles tendon rupture (ATR) treatment outcomes, with a focus on rerupture and complication rates. This systematic review specifically focused on articles regarding ATR treatment that also included rerupture and complication rates. Treatments were divided into three categories: open minimally invasive, open standard, and nonoperative. Bivariate analyses were performed to compare complication and rerupture rates among pairs of treatment options, as well as between early weight bearing versus immobilization. There was significantly higher complications for minimally invasive compared to nonoperative treatment (risk ratio [RR] = 4.4154; p < 0.05), lower complication rates for minimally invasive compared to open treatment (RR = 0.3231; p < 0.05), and higher complications for open standard compared to nonoperative treatment (RR = 5.6350; p < 0.001). There were significantly lower rerupture rates in minimally invasive compared to nonoperative treatment (RR = 0.4085; p < 0.001), a significantly lower rerupture rate in nonoperative treatment compared to open treatment (RR = 0.2282; p < 0.001), and no significant difference in rerupture rates when comparing minimally invasive to open standard treatment. We found that operative treatment is associated with fewer reruptures and more complications than a nonoperative approach. Minimally invasive surgery appears to be associated with a lower rate of complications than open operative treatment.
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Affiliation(s)
- Seth Shoap
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida, USA
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Henrik C Backer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Christina E Freibott
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Xavier E Ferrer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Hans Polzer
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - James Turner Vosseller
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, USA
- Jacksonville Orthopaedic Institute, Jacksonville, Florida, USA
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Ko PY, Hsu CH, Hong CK, Hung MT, Su WR, Jou IM, Wu PT, Su FC. Jigless Knotless Internal Brace Versus Other Minimal Invasive Achilles Tendon Repair Techniques in Biomechanical Testing Simulating the Progressive Rehabilitation Protocol. J Foot Ankle Surg 2022; 62:61-67. [PMID: 35477848 DOI: 10.1053/j.jfas.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/22/2022] [Accepted: 03/26/2022] [Indexed: 02/03/2023]
Abstract
The jigless knotless internal brace surgery (JKIB), an alternative method for minimal invasive surgery (MIS) repair of acute Achilles tendon rupture, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as previous clinical research demonstrates. However, no comparative study on the biomechanical performance between JKIB and other MIS techniques has been reported until now. In this study, 50 fresh porcine Achilles tendons were used to compare the JKIB with open surgery (two-stranded Krachow suture) with other MIS techniques, including Percutaneus Achilles Repair System (PARS), Speedbridge (SB), and Achillon Achilles Tendon Suture System (ACH), using a biomechanical testing with cyclic loading at 1 Hz. This test was used to simulate a progressive rehabilitation protocol where 20 to 100 N was applied in the first 250 cycles, followed by 20 to 190 N in the second 250 cycles, and then 20 to 369 N in the third 250 cycles. The cyclic displacement after 10, 100 and 250 cycles were recorded. The survived cycles were defined as a sudden drop in measured load. In survived cycles, the JKIB group (552.3 ± 72.8) had significantly higher cycles than the open, PARS, and ACH groups (204.3 ± 33.3, 395.9 ± 96.0, and 397.1 ± 80.9, respectively, p < .01) as analyzed by post hoc analysis, but no significant difference as compared with the SB group (641.6 ± 48.7). In cyclic displacement after 250 cyclic loadings, the JKIB group (11.29 ± 1.29) showed no significant difference as compared with PARS, SB, and ACH groups (12.21 ± 1.18, 9.80 ± 0.80, and 11.57 ± 1.10 mm, respectively) and significant less displacement than the open group (14.50 ± 1.85, p < .01). These findings suggest that JKIB could be an option for acute Achilles tendon repair in the MIS fashion due to no larger cyclic elongation compared with other MIS techniques.
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Affiliation(s)
- Po-Yen Ko
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chieh-Hsiang Hsu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | | | - Wei-Ren Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - I-Ming Jou
- Departments of Orthopedic Surgery and Pathology, E-Da Hospital, I-Shou University, Yen-Chao District, Kaohsiung, Taiwan; GEG Orthopedic Clinic, Tainan, Taiwan
| | - Po-Ting Wu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedics, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Fong-Chin Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
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Aufwerber S, Silbernagel KG, Ackermann PW, Naili JE. Comparable Recovery and Compensatory Strategies in Heel-Rise Performance After a Surgically Repaired Acute Achilles Tendon Rupture: An In Vivo Kinematic Analysis Comparing Early Functional Mobilization and Standard Treatment. Am J Sports Med 2022; 50:3856-3865. [PMID: 36322396 DOI: 10.1177/03635465221129284] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND Deficits in calf muscle function and heel-rise performance are common after an Achilles tendon rupture (ATR) and are related to tendon elongation and calf muscle atrophy. Whether early functional mobilization (EFM) can improve calf muscle function compared with standard treatment (ST) with 2 weeks of immobilization and unloading in a plaster cast is unknown. HYPOTHESIS EFM would lead to superior recovery of heel-rise performance, as demonstrated by more symmetrical side-to-side ankle and knee joint kinematics, compared with ST. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS In total, 47 patients with an ATR were prospectively included and treated with open surgical repair and randomized 2:1 postoperatively to either EFM or ST. Overall, 29 patients were treated with a dynamic orthosis (EFM), and 18 underwent ST. At 8 weeks and 6 months after ATR repair, 3-dimensional motion analysis of heel-rise performance was conducted. At 6 months, tendon length and muscle volume were assessed with ultrasound imaging, calf muscle function with the heel-rise test, and patient-reported outcomes with the Achilles tendon Total Rupture Score. RESULTS At 8 weeks and 6 months, there were no significant group differences between the EFM and ST groups in heel-rise performance, but significant side-to-side differences in ankle and knee kinematics were detected. At 8 weeks and 6 months, both the EFM and ST groups showed a significantly decreased peak ankle plantarflexion angle and increased knee flexion angle on the injured limb compared with the uninjured limb during bilateral heel raises. Linear regression demonstrated that greater atrophy of the medial gastrocnemius muscle (P = .008) and higher body weight (P < .001) were predictors of a decreased maximum peak ankle plantarflexion angle on the injured limb at 6 months. CONCLUSION EFM after an ATR repair did not lead to superior recovery of calf muscle function, as assessed by heel-rise performance, compared with ST. Increased knee flexion seemed to be a compensatory strategy for decreased ankle plantarflexion. Medial gastrocnemius atrophy and increased body weight were additional factors associated with a decreased ankle plantarflexion angle. REGISTRATION NCT02318472 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Women's Health and Allied Health Professionals Theme, Medical Unit of Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | | | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Josefine E Naili
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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10
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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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11
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Aufwerber S, Naili JE, Grävare Silbernagel K, Ackermann PW. No effects of early functional mobilization on gait patterns after acute Achilles tendon rupture repair. J Orthop Res 2022; 40:1932-1942. [PMID: 34674300 DOI: 10.1002/jor.25199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/06/2021] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
This study aimed to compare recovery of gait patterns in patients treated with early functional mobilization (EFM) or standard treatment (ST) after Achilles tendon rupture repair. Second, this study aimed to explore associations between gait patterns and tendon elongation and calf muscle atrophy, respectively. Forty-seven patients (12 females), mean age 38.7 (7.3) years, were included. Patients were postoperatively randomized to EFM (n = 29), including immediate weightbearing and ankle motion for 6 weeks, or ST (n = 18), with 2 weeks of unloading in a plaster cast followed by 4 weeks of weightbearing in an orthosis. Three-dimensional gait analyses were performed at 8 weeks and 6 months postoperatively to evaluate ankle and knee kinematics and kinetics. Ultrasound imaging was performed to assess tendon length and calf muscle atrophy. At 8 weeks, there were no significant group differences in ankle and knee kinematics and kinetics, while side-to-side differences between injured and uninjured side were present within both groups. At 6 months, the ST group exhibited higher generating ankle power and greater peak moments in ankle and knee compared to the EFM group. In both groups, peak ankle dorsiflexion angle was greater on the injured side compared to the uninjured side. No correlations were found between ankle joint gait deviations and degree of tendon elongation or muscle atrophy. Clinical significance: The accelerated rehabilitation regimen with EFM did not result in a more symmetrical gait pattern. The gait pattern deviations in the ankle joint were not related to the degree of muscle atrophy or tendon elongation.
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Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Women's Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Stockholm, Sweden
| | - Josefine E Naili
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
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12
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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:diagnostics12081824. [PMID: 36010175 PMCID: PMC9406849 DOI: 10.3390/diagnostics12081824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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13
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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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14
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Won Lee K, Bae JY, Ho BC, Kim JH, Seo DK. Immediate Weightbearing and Ankle Motion Exercise After Acute Achilles Tendon Rupture Repair. J Foot Ankle Surg 2022; 61:604-608. [PMID: 34785129 DOI: 10.1053/j.jfas.2021.10.021] [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: 06/21/2018] [Revised: 09/29/2018] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
The incidence of Achilles tendon rupture is increasing. Postoperative rehabilitation after repairing acute Achilles tendon rupture is very important because the choice of treatment during the rehabilitation period can influence the results. Moreover, the method of functional rehabilitation varies and is developing steadily. Recent studies recommend a functional rehabilitation protocol, and this approach is accepted widely. This study aimed to introduce our most accelerated functional rehabilitation protocol following surgery for acute Achilles tendon rupture and to review the results retrospectively. From July 2014 to July 2016, 67 patients underwent surgery for acute Achilles tendon rupture by one surgeon. Age, sex, body mass index, injury mechanism, rehabilitation method and progress, time to return to previous physical activity, and complications were evaluated. The mean time to be able to squat fully was 10 ± 4.7 (4-20) weeks. Full squatting was possible in 92.8% (52 patients). The mean time to perform a single-limb heel rise and repetitive single-limb heel rise was 12.6 ± 3.9 (6-24) and 23.3 ± 7.7 (8-40) weeks, respectively. The mean time to return to sports was 20.6 ± 5.2 (12-32) weeks. The major complication rate was 3.5% (one re-rupture and one tendon elongation). The mean pre- and postoperative Achilles Tendon Total Rupture Score was 29.5 ± 3.7 (20-38) and 79.3 ± 18.5 (20-98) points, respectively. The increase was significant (p < .01). In conclusion, immediate full weightbearing and ankle motion exercise after repair of acute Achilles tendon rupture can provide a good rehabilitation option with a low re-rupture rate and satisfactory functional results.
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Affiliation(s)
- Ki Won Lee
- Department of Orthopedic Surgery, GangNeung Asan Hospital, University of Ulsan, College of Medicine, GangNeung-si, South Korea
| | - Joo-Yul Bae
- Department of Orthopedic Surgery, GangNeung Asan Hospital, University of Ulsan, College of Medicine, GangNeung-si, South Korea
| | - Byeong Cheol Ho
- Department of Orthopedic Surgery, GangNeung Asan Hospital, University of Ulsan, College of Medicine, GangNeung-si, South Korea
| | - Joon Hee Kim
- Department of Orthopedic Surgery, GangNeung Asan Hospital, University of Ulsan, College of Medicine, GangNeung-si, South Korea
| | - Dong-Kyo Seo
- Department of Orthopedic Surgery, GangNeung Asan Hospital, University of Ulsan, College of Medicine, GangNeung-si, South Korea.
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15
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Patients with chronic Achilles tendon rupture have persistent limitations in patient-reported function and calf muscle function one year after surgical treatment - a case series. J Exp Orthop 2022; 9:15. [PMID: 35141849 PMCID: PMC8828811 DOI: 10.1186/s40634-022-00451-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/27/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose Evaluate the one-year postoperative outcomes in patients with Chronic Achilles tendon rupture. Methods Patients surgically treated for Chronic Achilles tendon rupture (n = 22, 14 males and 8 females, mean age 61 ± 15) were evaluated by Achilles tendon Total Rupture Score, The Physical Activity Scale, The Foot and Ankle Outcome Score, Calf muscle endurance test, counter movement jump, Hopping, ultrasound measurement of tendon length, Achilles Tendon Resting Angle, dorsi flexion range of motion and calf muscle circumference. Muscle function and tendon length outcomes on the injured side were compared with the healthy side. Results The patients scored a mean of 62 ± 26 on the Achilles tendon Total Rupture Score. Median scores on the injured compared with the healthy side were lower in heel-rise repetitions (20 vs 24 cm, p = 0.004), hel-rise height (8 vs 10 cm, p < 0.001), heel-rise total work (872 vs 1590 joule, p < 0.001) and hopping ratio (0.37 vs 0.48, p = 0.005). Median calf circumference was smaller (37 vs 38 cm, p = 0.001) and the mean tendon elongation greater on the injured side; Achilles tendon resting angle (55 vs 50°, p < 0.001) and ultrasound (22.4 vs 20.5 cm, p = 0.006). Conclusions At one year postoperatively, patients with chronic Achilles tendon rupture reported persistent limitations in subjective foot and ankle function. Heel-rise height and total work as well as hopping ratio were not recovered, and there was an elongation of the injured Achilles tendon compared with the healthy tendon. Level of evidence IV
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16
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Wenning M, Mauch M, Heitner A, Streicher P, Ritzmann R, Paul J. Midterm functional performance following open surgical repair of acute Achilles tendon rupture. Arch Orthop Trauma Surg 2022; 142:1337-1349. [PMID: 33484315 PMCID: PMC9217896 DOI: 10.1007/s00402-020-03746-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/19/2020] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Various impairments such as soleus atrophy and consecutive functional deficits in end-range plantarflexion have been described in surgical repair of acute Achilles tendon rupture. The aim of this study was to assess the functional performance at midterm following open surgical repair. MATERIALS AND METHODS This cross-sectional study includes n = 52 patients which were tested on average 3.5 ± 1.4 years postoperatively using three different functional performance tests and patient-reported outcome measures. Two different surgical techniques (anatomical repair = AR vs. conventional repair = CR) were compared in a subanalysis. The testing included isokinetic strength testing, a novel setup of heel-rise testing using a marker-based 3D motion analysis system and a gait analysis. RESULTS At an average 3.5 years post-surgery, there is a persisting deficit in plantarflexion strength of 10.2%. Moreover, analysis of maximum peak torque angle and strength deficits according to the plantarflexion angle revealed that these deficits are not equally distributed across the range of motion. AR results in a significantly smaller deficit at 10° of plantarflexion compared to CR (13.9 vs. 29.9%, p < 0.05). This reflects into the functional performance during different modalities (static vs. dynamic) in this novel method of heel-rise testing. CONCLUSION In summary, there are persisting functional deficits at > 3 years following Achilles tendon repair which range from strength deficits to specific impairments of functional performance e.g. during heel rise. Anatomical reconstruction is associated with an improved functional performance potentially due to a more symmetric strength during end-range plantarflexion which transfers into a higher satisfaction during athletic activities. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Markus Wenning
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland
- Department of Orthopedic and Trauma Surgery, University Medical Center Freiburg, Faculty of Medicine, Albert-Ludwigs University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Marlene Mauch
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland
| | - Albrecht Heitner
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland
| | - Paul Streicher
- Department of Sport and Sport Science, University of Freiburg, Freiburg, Germany
| | - Ramona Ritzmann
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland
| | - Jochen Paul
- Rennbahnklinik, Kriegackerstr. 100, CH-4132, Muttenz, Baselland, Switzerland.
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Secretome from In Vitro Mechanically Loaded Myoblasts Induces Tenocyte Migration, Transition to a Fibroblastic Phenotype and Suppression of Collagen Production. Int J Mol Sci 2021; 22:ijms222313089. [PMID: 34884895 PMCID: PMC8657858 DOI: 10.3390/ijms222313089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
It is known that mechanical loading of muscles increases the strength of healing tendon tissue, but the mechanism involved remains elusive. We hypothesized that the secretome from myoblasts in co-culture with tenocytes affects tenocyte migration, cell phenotype, and collagen (Col) production and that the effect is dependent on different types of mechanical loading of myoblasts. To test this, we used an in vitro indirect transwell co-culture system. Myoblasts were mechanically loaded using the FlexCell® Tension system. Tenocyte cell migration, proliferation, apoptosis, collagen production, and several tenocyte markers were measured. The secretome from myoblasts decreased the Col I/III ratio and increased the expression of tenocyte specific markers as compared with tenocytes cultured alone. The secretome from statically loaded myoblasts significantly enhanced tenocyte migration and Col I/III ratio as compared with dynamic loading and controls. In addition, the secretome from statically loaded myoblasts induced tenocytes towards a myofibroblast-like phenotype. Taken together, these results demonstrate that the secretome from statically loaded myoblasts has a profound influence on tenocytes, affecting parameters that are related to the tendon healing process.
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18
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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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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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Roopnarinesingh R, Kenyon R, Turley L, Feeley A, Bayer T, Merghani K. Achilles' tendon rupture dancing the 'Jerusalema' - A case series. Int J Surg Case Rep 2021; 87:106368. [PMID: 34537526 PMCID: PMC8455660 DOI: 10.1016/j.ijscr.2021.106368] [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: 07/31/2021] [Revised: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 11/06/2022] Open
Abstract
Introduction and importance The weekend warrior has long been prey to musculoskeletal injuries as a result of intermittent, high intensity activity. The Achilles tendon is known to be particularly vulnerable in this population cohort but during the COVID-19 lockdowns in Ireland and all over the world there has been a certain level of detraining and deconditioning among all age groups and populations. Throughout the worldwide restrictions, viral internet challenges and dances have encapsulated the spirit of a global community with the ‘Jerusalema’ dance being no exception. The rise of this particular viral sensation was at the detriment of the Achilles tendons of three middle aged gentlemen on who we base our case series. Presentation of cases Over the space of ten days three cases of Achilles tendon rupture repair presented to the emergency department in Midlands Regional Hospital Tullamore (MRHT) with the mechanism of tendon rupture being through the ‘Jerusalema’ dance. These patients were surgically managed in line with local institution practice and postoperative outcomes were good with no complications noted. Follow up is ongoing. Clinical discussion This retrospective case series is based on the impact of the ‘Jerusalema Dance’ on presentations of Achilles tendon rupture to the Emergency Department in a single regional hospital from January to March 2021. We used these cases in conjunction with a review of current literature to highlight the benefit of an integrated Achilles Tendon rehabilitation programme in this at-risk patient cohort. Conclusion This paper highlights the dangers inherent when well intentioned, but physically deconditioned individuals endeavour to perform a physical exercise which is deceptively demanding. Going forward, viral challenges such as the ‘Jerusalema’ may contribute to new and interesting mechanisms of injuries in our ‘weekend warrior’ cohort. In addition to this, given the global deconditioning seen due to the COVID 19 pandemic and subsequent lockdowns we may see a higher rate of Achilles tendon injuries in the near future across a multitude of patient cohorts. Level one evidence suggests that conservative treatment is just as effective as surgical treatments in the majority of patients with an Achilles tendon rupture, as long as a protocol of rehabilitation with early weightbearing is performed. Our accelerated rehabilitation programme in MRHT is in line with others however internal audit and new literature in the future may enable us to refine it further. Achilles Tendon Rupture is common amongst the conditioned and deconditioned population. Surgical and conservative management options are widely explored in the literature. Viral dance challenges such as the Jerusalema offer new and interesting patterns of injury. An early weightbearing rehabilitation programme after TA rupture shows lower re-rupture rates.
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Affiliation(s)
- Ryan Roopnarinesingh
- Midland Regional Hospital Tullamore, Orthopaedic Department, Tullamore, Co. Offaly R35 NY51, Ireland.
| | - Robert Kenyon
- Midland Regional Hospital Tullamore, Orthopaedic Department, Tullamore, Co. Offaly R35 NY51, Ireland
| | - Luke Turley
- Midland Regional Hospital Tullamore, Orthopaedic Department, Tullamore, Co. Offaly R35 NY51, Ireland
| | - Aoife Feeley
- Midland Regional Hospital Tullamore, Orthopaedic Department, Tullamore, Co. Offaly R35 NY51, Ireland
| | - Thomas Bayer
- Midland Regional Hospital Tullamore, Orthopaedic Department, Tullamore, Co. Offaly R35 NY51, Ireland
| | - Khalid Merghani
- Midland Regional Hospital Tullamore, Orthopaedic Department, Tullamore, Co. Offaly R35 NY51, Ireland
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21
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Chauhan A, Stotts J, Ayeni OR, Khan M. Return to play, performance, and value of National Basketball Association players following Achilles tendon rupture. PHYSICIAN SPORTSMED 2021; 49:271-277. [PMID: 34010095 DOI: 10.1080/00913847.2021.1932634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Achilles tendon ruptures are devastating injuries for National Basketball Association (NBA) players: prior studies have demonstrated decreased performance following return-to-play, but none have evaluated the effect of injury on rate-adjusted contextual statistics to assess the true change in performance. Additionally, there exists a paucity of data on the independent impact on defensive performance following return.Hypothesis: Compared to both control-matched peers and preoperative careers, we hypothesize that player production based on rate-adjusted contextual statistics will significantly decline following Achilles tendon rupture.Study design: Retrospective Cohort StudyMethods: Publicly available NBA injury data on Achilles tendon rupture were reviewed from the 1996 -1997 to the 2016-2017 seasons. Controls were matched based on height, position, age, and rate-adjusted statistics. Extracted data included Value over Replacement Player Rating, Box Plus-Minus, Win Shares, offensive rating, defensive rating, and time to return-to-play, and was collected for the season before and two seasons following injury.Results: Twenty-five NBA players with surgically treated complete Achilles ruptures met inclusion and exclusion criteria. The return-to-play rate from Achilles tendon ruptures from 1996-1997 to 2016-2017 was 80%, with a mean recovery period of 311.0 ± 100.9 days. After 2 years, performance significantly declined for Value over Replacement Player Rating, Box Plus-Minus, and offensive rating compared to controls and cases. However, there was no significant effect on defensive rating (P = 0.38). After two seasons, returning players had a Value over Replacement Player Rating that was 24.1% below pre-injury levels, contributed 1.4 fewer points per 100 possessions by Box Plus-Minus, and yielded 2.4 fewer wins by Win Shares.Conclusions: Achilles tendon rupture results in significant decreases in offensive production and career longevity. The injury does not have a significant impact on defensive production.Clinical relevance: Achilles tendon ruptures significantly affect basketball players ability to return-to-play, and their in-game performance.Level of evidence: 3.
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Affiliation(s)
- Avinash Chauhan
- Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeff Stotts
- Department of Athletic Training, St Vincent Health System, Little Rock, Arkansas, United States
| | - Olufemi R Ayeni
- Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Moin Khan
- Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
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22
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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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23
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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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24
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Reddy AK, Anderson JM, Gray HM, Fishbeck K, Vassar M. Clinical Trial Registry Use in Orthopaedic Surgery Systematic Reviews. J Bone Joint Surg Am 2021; 103:e41. [PMID: 33983151 DOI: 10.2106/jbjs.20.01743] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Results from systematic reviews and meta-analyses, which have the highest level of evidence (Level I), often drive clinical decision-making and health policy. Often, unpublished trial data are omitted from systematic reviews, raising concerns about the extent of the reliability and validity of results that have been drawn from systematic reviews. We aimed to determine the extent to which systematic review authors include searches of clinical trial registries for unpublished data when conducting systematic reviews in orthopaedic surgery. METHODS Systematic reviews and/or meta-analyses were gathered from the top 5 orthopaedic surgery journals based on the h5-index from Google Scholar Metrics. Systematic reviews that had been published in the Cochrane Database of Systematic Reviews, which requires the inclusion of a clinical trial registry search, served as controls. For the primary outcome, each systematic review from the top 5 orthopaedic journals was screened to determine whether the authors of each study searched for unpublished data in clinical trial registries. We then compared the rate of registry searches with those in the control group. For the secondary analysis, a search of ClinicalTrials.gov was performed for unpublished trial data for 100 randomized systematic reviews. RESULTS All 38 of the Cochrane systematic reviews (100%) included clinical trial registry searches, while the top 5 orthopaedic journals had only 31 of 480 studies (6.5%) that looked at clinical trial registries. The secondary analysis yielded 59 of 100 systematic review articles (59.0%) that could have included unpublished clinical trial data from ≥1 studies to their sample. CONCLUSIONS Systematic reviews that have been published in the top orthopaedic surgery journals seldom included a search for unpublished clinical trial data. CLINICAL RELEVANCE The exclusion of clinical trial registry searches potentially contributes to publication bias within the orthopaedic literature. Moving forward, systematic review authors should include clinical trial registry searches for unpublished clinical trial data to provide the most accurate representation of the available evidence for systematic reviews and meta-analyses.
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Affiliation(s)
- Arjun K Reddy
- Office of Medical Student Research (A.K.R., J.M.A., H.M.G., and M.V.) and Department of Psychiatry and Behavioral Sciences (M.V.), Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma
| | - J Michael Anderson
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Harrison M Gray
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Keith Fishbeck
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
| | - Matt Vassar
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma
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25
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Bravo-Sánchez A, Abián P, Jimenez F, Abián-Vicén J. Structural and mechanical properties of the Achilles tendon in senior badminton players: Operated vs. non-injured tendons. Clin Biomech (Bristol, Avon) 2021; 85:105366. [PMID: 33915493 DOI: 10.1016/j.clinbiomech.2021.105366] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 04/01/2021] [Accepted: 04/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to describe the differences in structural and mechanical properties between operated and non-injured Achilles tendons in senior badminton players who had had Achilles tendon surgery and had returned to play. METHODS Eighteen players (age = 48.9(10.0)years), assigned to the unilateral Achilles tendon rupture group and 177 non-injured players (age = 55.4(9.4)years), assigned to the control group. A Logiq®S8 ultrasound was used to study tendon structure and elastography index values and a Myoton®PRO hand-held myotonometer was used to record the stiffness of the Achilles tendon. FINDINGS In Achilles tendon rupture group, operated tendons showed higher values than non-injured ones in thickness (Operated = 9.03(2.67)mm vs. non-injured = 5.88(0.88)mm; P < 0.001), width (Operated = 18.44(3.20)mm vs. non-injured = 16.80(1.97)mm; P = 0.039), cross sectional area (Operated = 140.33(60.29)mm2 vs. non-injured = 74.40(17.09)mm2; P < 0.001) and elastography index (Operated = 2.05(1.35)A.U. vs. non-injured = 1.47(0.62)A.U.; P = 0.025). The bilateral differences shown by the Achilles tendon rupture group were greater than the bilateral differences shown by the control group for thickness (P < 0.001), width (P = 0.001), cross sectional area (P < 0.001), tone (P = 0.006) and dynamic stiffness (Achilles tendon rupture group = 10.85(23.90)N∙m-1. vs. control group = 0.18(18.83)N∙m-1; P = 0.031). INTERPRETATION Surgery on the Achilles tendon and adaptation to the mobilisation and strength training during rehabilitation could provoke structural and mechanical differences compared to the non-injured tendon. Furthermore, the differences between both Achilles tendons in the Achilles tendon rupture group was higher than the asymmetry observed between dominant and non-dominant Achilles tendons in the control group. In addition, the higher logarithmic decrement values showed by non-injured tendons in the Achilles tendon rupture group could be a tendinous injury risk factor.
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Affiliation(s)
- Alfredo Bravo-Sánchez
- Performance and Sport Rehabilitation Laboratory, Faculty of Sport Sciences, University of Castilla-La Mancha, Toledo, Spain
| | - Pablo Abián
- Faculty of Humanities and Social Sciences, Comillas Pontifical University, Madrid, Spain
| | - Fernando Jimenez
- Performance and Sport Rehabilitation Laboratory, Faculty of Sport Sciences, University of Castilla-La Mancha, Toledo, Spain
| | - Javier Abián-Vicén
- Performance and Sport Rehabilitation Laboratory, Faculty of Sport Sciences, University of Castilla-La Mancha, Toledo, Spain.
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26
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Yang YP, Chen HY, Cui GQ, Xiu XL, Liu XP, An H, Ao YF. Endoscopic Surgery for Delayed Wound Healing After Achilles Tendon Suture Repair: A Report of Three Cases. Orthop Surg 2021; 13:1126-1131. [PMID: 33829676 PMCID: PMC8126896 DOI: 10.1111/os.12995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/30/2021] [Accepted: 02/21/2021] [Indexed: 11/30/2022] Open
Abstract
Background Delayed wound healing is a potention complication after Achilles tendon suture repair and occurs for various reasons. The conventional treatment for delayed wound healing is open surgery, but patients face long recovery times and postoperative care is difficult. Case Presentation This report presents three patients who were seen at our institute from April 2008 to October 2017 due to long‐term non‐healing wounds after surgery. All three patients had undergone surgery at least 2 months previously. We performed endoscopic surgery on these patients. After the operation, patients received less antibiotics and simpler care than would be required for conventional open surgery. There is no need to keep the wound open after the operation or perform wound cleaning for multiple times at the same time, which can reduce healing time. At the last follow up, all postoperative scores among the patients were significantly improved compared to before surgery. The Achilles tendon total rupture scores were excellent and the American Orthopedic Foot and Ankle Society scores were satisfactory, indicating improvements in Achilles tendon function and movement in patients after surgery. Conclusion Our case reports demonstrate that arthroscopic treatment for delayed wound healing after Achilles tendon suture repair is satisfactory and reliable; frequent opening of the wound for cleaning is not required after the operation, thus reducing the healing time.
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Affiliation(s)
- Yu-Ping Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China.,Department of Sports Medicine, Peking University Third Hospital-Chongli, Zhangjiakou city, Hebei province, 076350, China
| | - Hong-Yu Chen
- School of Clinical Medicine, Peking University of Medical Department, Beijing, China
| | - Guo-Qing Cui
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Xiao-Lei Xiu
- Department of Hand Surgery, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, China
| | - Xiao-Peng Liu
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Hua An
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Ying-Fang Ao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
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27
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Leek CC, Soulas JM, Sullivan AL, Killian ML. Using tools in mechanobiology to repair tendons. ACTA ACUST UNITED AC 2021; 1:31-40. [PMID: 33585822 DOI: 10.1007/s43152-020-00005-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of review The purpose of this review is to describe the mechanobiological mechanisms of tendon repair as well as outline current and emerging tools in mechanobiology that might be useful for improving tendon healing and regeneration. Over 30 million musculoskeletal injuries are reported in the US per year and nearly 50% involve soft tissue injuries to tendons and ligaments. Yet current therapeutic strategies for treating tendon injuries are not always successful in regenerating and returning function of the healing tendon. Recent findings The use of rehabilitative strategies to control the motion and transmission of mechanical loads to repairing tendons following surgical reattachment is beneficial for some, but not all, tendon repairs. Scaffolds that are designed to recapitulate properties of developing tissues show potential to guide the mechanical and biological healing of tendon following rupture. The incorporation of biomaterials to control alignment and reintegration, as well as promote scar-less healing, are also promising. Improving our understanding of damage thresholds for resident cells and how these cells respond to bioelectrical cues may offer promising steps forward in the field of tendon regeneration. Summary The field of orthopaedics continues to advance and improve with the development of regenerative approaches for musculoskeletal injuries, especially for tendon, and deeper exploration in this area will lead to improved clinical outcomes.
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Affiliation(s)
- Connor C Leek
- College of Engineering, Department of Biomedical Engineering, 5 Innovation Way, Suite 200, University of Delaware, Newark, Delaware 19716
| | - Jaclyn M Soulas
- College of Engineering, Department of Biomedical Engineering, 5 Innovation Way, Suite 200, University of Delaware, Newark, Delaware 19716.,College of Agriculture and Natural Resources, Department of Animal Biosciences, 531 South College Avenue, University of Delaware, Newark, Delaware 19716
| | - Anna Lia Sullivan
- College of Engineering, Department of Biomedical Engineering, 5 Innovation Way, Suite 200, University of Delaware, Newark, Delaware 19716.,College of Agriculture and Natural Resources, Department of Animal Biosciences, 531 South College Avenue, University of Delaware, Newark, Delaware 19716
| | - Megan L Killian
- College of Engineering, Department of Biomedical Engineering, 5 Innovation Way, Suite 200, University of Delaware, Newark, Delaware 19716.,College of Medicine, Department of Orthopaedic Surgery, 109 Zina Pitcher Place, University of Michigan, Ann Arbor, Michigan 48109
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28
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Yassin M, Myatt R, Thomas W, Gupta V, Hoque T, Mahadevan D. Does size of tendon gap affect patient-reported outcome following Achilles tendon rupture treated with functional rehabilitation? Bone Joint J 2020; 102-B:1535-1541. [PMID: 33135439 DOI: 10.1302/0301-620x.102b11.bjj-2020-0908.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation. METHODS Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included. RESULTS In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson's correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%). CONCLUSION Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535-1541.
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Affiliation(s)
- Mohamed Yassin
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Richard Myatt
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - William Thomas
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Vatsal Gupta
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Tagrit Hoque
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Devendra Mahadevan
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
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Yang YP, Wang DY, Wei LW, An N, Tao LY, Jiao C, Guo QW, Hu YL. Repair of Achilles sleeve avulsion: a new transosseous suture technique. J Orthop Surg Res 2020; 15:224. [PMID: 32552910 PMCID: PMC7302392 DOI: 10.1186/s13018-020-01699-2] [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: 07/22/2019] [Accepted: 05/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Achilles sleeve avulsion usually occurs from pre-existing insertional Achilles tendinopathy, leaving a calcific spur at the insertional site. The purpose of this study was to introduce a new technique using the spur base on the insertional site to drill the suture tunnel to repair Achilles sleeve avulsion. METHODS In total, 11 patients diagnosed with Achilles sleeve avulsion underwent this new surgical technique and were followed for a mean time of 40 months. Clinical outcomes were measured using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Tegner score, and time taken to return to activities. Preoperative and postoperative MRI, the ability to perform heel rise, and complications were also evaluated. RESULTS All cases (11/11) had insertional Achilles tendinopathy with calcific spur formation on the tendon's insertion. At final follow-up, the average VAS score improved from 5.3 to 0.1, AOFAS score improved from 44.8 to 97.9, VISA-A score improved from 23.6 to 96.6, and Tegner score improved from 0.9 to 4.9. Tendinopathy symptoms were eliminated. Patients returned to daily activities, work, and sports 3.5 months, 2.8 months, and 12.3months after operation, respectively. Patients took an average of 18.1 weeks after operation to perform the single heel rise test. No severe complications such as infection and rerupture were observed. CONCLUSION Our new transosseous suture technique is a promising alternative option in treating Achilles sleeve avulsion. More cases and longer follow up are needed in order to find the best reconstructive option for this pathology. LEVELS OF EVIDENCE Level IV.
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Affiliation(s)
- Yu-Ping Yang
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China
| | - Ding-Yu Wang
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China
| | - Lin-Wei Wei
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China
| | - Ning An
- Pharmacy Department, Peking University Third Hospital, Beijing, 100191, People's Republic of China
| | - Li-Yuan Tao
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, 100191, People's Republic of China
| | - Chen Jiao
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China
| | - Qin-Wei Guo
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China
| | - Yue-Lin Hu
- Institute of Sports Medicine, Peking University Third Hospital, Beijing, 100191, People's Republic of China.
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30
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Westin O, Sjögren T, Svedman S, Horvath A, Hamrin Senorski E, Samuelsson K, Ackermann P. Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis. BMC Musculoskelet Disord 2020; 21:358. [PMID: 32513228 PMCID: PMC7282056 DOI: 10.1186/s12891-020-03320-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/28/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND While numerous clinical studies have compared the surgical and non-surgical treatment of acute Achilles tendon rupture (ATR), there are no studies that have performed a non-inferiority analysis between treatments. METHODS Data from patients who were included in five randomised controlled trials from two different centres in Sweden were used. Outcomes at 1 year after ATR consisted of the patient-reported Achilles tendon Total Rupture Score (ATRS) and the functional heel-rise tests reported as the limb symmetry index (LSI). The non-inferiority statistical 10% margin was calculated as a reflection of a clinically acceptable disadvantage in ATRS and heel-rise outcome when comparing treatments. RESULTS A total of 422 patients (350 males and 72 females) aged between 18 and 71 years, with a mean age of 40.6 (standard deviation 8.6), were included. A total of 363 (86%) patients were treated surgically. The ATRS (difference (Δ) = - 0.253 [95% confidence interval (CI); - 5.673;5.785] p = 0.36) and LSI of heel-rise height (difference = 1.43 [95% CI; - 2.43;5.59] p = 0.81), total work (difference = 0.686 [95% CI; - 4.520;6.253] p = 0.67), concentric power (difference = 2.93 [95% CI; - 6.38;11.90] p = 0.063) and repetitions (difference = - 1.30 [95% CI; - 6.32;4.13] p = 0.24) resulted in non-inferiority within a Δ - 10% margin for patients treated non-surgically. CONCLUSION The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes.
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Affiliation(s)
- Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Tony Sjögren
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Svedman
- Integrative Orthopedic Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Horvath
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Paul Ackermann
- Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden
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31
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Binkley HM, Douglass D, Phillips K, Wise SL. Rehabilitation and Return to Sport After Nonsurgical Treatment of Achilles Tendon Rupture. Strength Cond J 2020. [DOI: 10.1519/ssc.0000000000000536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Michel PA, Kronenberg D, Neu G, Stolberg-Stolberg J, Frank A, Pap T, Langer M, Fehr M, Raschke MJ, Stange R. Microsurgical reconstruction affects the outcome in a translational mouse model for Achilles tendon healing. J Orthop Translat 2020; 24:1-11. [PMID: 32489862 PMCID: PMC7260609 DOI: 10.1016/j.jot.2020.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/17/2020] [Accepted: 04/08/2020] [Indexed: 01/02/2023] Open
Abstract
Background Animal models are one of the first steps in translation of basic science findings to clinical practice. For tendon healing research, transgenic mouse models are important to advance therapeutic strategies. However, the small size of the structures complicates surgical approaches, histological assessment, and biomechanical testing. In addition, available models are not standardized and difficult to compare. How surgery itself affects the healing outcome has not been investigated yet. The focus of the study was to develop a procedure that includes a transection and microsurgical reconstruction of the Achilles tendon but, unlike other models, preserves the sciatic nerve. We wanted to examine how distinct parts of the technique influenced healing. Methods For this animal model study, we used 96 wild-type male C57BL/6 mice aged 8–12 weeks. We evaluated different suture techniques and macroscopically confirmed the optimal combination of suture material and technique to minimize tendon gap formation. A key element is the detailed, step-by-step illustration of the surgery. In addition, we assessed histological (Herovici and Alcian blue staining) outcome parameters at 1–16 weeks postoperatively. Microcomputed tomography (micro-CT) was performed to measure the bone volume of heterotopic ossifications (HOs). Biomechanical analyses were carried out using a viscoelastic protocol on the biomechanical testing machine LM1. Results A modified 4-strand suture combined with a cerclage for immobilization without transection of the sciatic nerve reliably eliminated gap formation. The maximal dorsal extension of the hindlimb at the upper ankle joint from the equinus position (limited by the immobilization cerclage) increased over time postoperatively (operation: 28.8 ± 2.2°; 1 week: 54 ± 36°; 6 weeks: 80 ± 11.7°; 16 weeks: 96 ± 15.8°, p > 0.05). Histological staining revealed a maturation of collagen fibres within 6 weeks, whereas masses of cartilage were visible throughout the healing period. Micro-CT scans detected the development of HOs starting at 4 weeks and further progression at 6 and 16 weeks (bone volume, 4 weeks: 0.07604 ± 0.05286 mm3; 6 weeks: 0.50682 ± 0.68841 mm3; 16 weeks: 2.36027 ± 0.85202 mm3, p > 0.001). In-depth micro-CT analysis of the different surgical elements revealed that an injury of the tendon is a key factor for the development of HOs. Immobilization alone does not trigger HOs. Biomechanical properties of repaired tendons were greatly altered and remained inferior 6 weeks after surgery. Conclusion With this study, we demonstrated that the microsurgical technique greatly influences the short- and longer-term healing outcome. When the sciatic nerve is preserved, the best surgical reconstruction of the tendon defect is achieved by a 4-strand core suture in combination with a tibiofibular cerclage for postoperative immobilization. The cerclage promotes a gradual increase in the range of motion of the upper ankle joint, comparable with an early mobilization rehabilitation protocol. HO, as a key mechanism for poor tendon healing, is progressive and can be monitored early in the model. The translational potential of this article The study enhances the understanding of model dependent factors of healing. The described reconstruction technique provides a reproducible and translational rodent model for future Achilles tendon healing research. In combination with transgenic strains, it can be facilitated to advance therapeutic strategies to improve the clinical results of tendon injuries.
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Affiliation(s)
- Philipp A Michel
- Department of Trauma, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | - Daniel Kronenberg
- Department of Regenerative Musculoskeletal Medicine, Institute of Musculoskeletal Medicine, Westfaelische Wilhelms University Muenster, Muenster, Germany
| | - Gertje Neu
- University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Josef Stolberg-Stolberg
- Department of Trauma, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | - Andre Frank
- Department of Trauma, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | - Thomas Pap
- Institute of Musculoskeletal Medicine, Westfaelische Wilhelms University Muenster, Muenster, Germany
| | - Martin Langer
- Department of Trauma, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | - Michael Fehr
- University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Michael J Raschke
- Department of Trauma, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
| | - Richard Stange
- Department of Regenerative Musculoskeletal Medicine, Institute of Musculoskeletal Medicine, Westfaelische Wilhelms University Muenster, Muenster, Germany
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Park SH, Lee HS, Young KW, Seo SG. Treatment of Acute Achilles Tendon Rupture. Clin Orthop Surg 2020; 12:1-8. [PMID: 32117532 PMCID: PMC7031433 DOI: 10.4055/cios.2020.12.1.1] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/31/2019] [Indexed: 12/15/2022] Open
Abstract
There is no clear consensus on the optimal treatment of acute Achilles tendon rupture. Recently, studies have demonstrated the critical role of functional rehabilitation in the treatment of ruptured Achilles tendons. Hence, conservative treatment is preferred by a growing number of surgeons seeking to treat the condition without the risk of complications from surgery. However, operative treatment is still considered as a more reliable treatment option for acute Achilles tendon rupture. In this review article, we provide an overview of recent treatment strategies for acute rupture of the Achilles tendon.
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Affiliation(s)
- Seung-Hwan Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho Seong Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki Won Young
- Department of Orthopedic Surgery, Eulji Hospital, Seoul, Korea
| | - Sang Gyo Seo
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Aufwerber S, Heijne A, Edman G, Grävare Silbernagel K, Ackermann PW. Early mobilization does not reduce the risk of deep venous thrombosis after Achilles tendon rupture: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2020; 28:312-319. [PMID: 31679069 PMCID: PMC6971132 DOI: 10.1007/s00167-019-05767-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/21/2019] [Indexed: 11/06/2022]
Abstract
PURPOSE The hypothesis was that early functional mobilization would reduce the incidence of deep venous thrombosis (DVT) during leg immobilization after Achilles tendon rupture surgery. A secondary aim was to evaluate if the amount of weightbearing and daily steps influenced the risk of sustaining a DVT. METHODS One-hundred and fifty patients with Achilles tendon rupture repair were randomized to treatment with early functional mobilization, encouraging full weightbearing and ankle motion in orthosis, or treatment-as-usual, i.e., 2 weeks of unloading in plaster cast followed by 4 weeks weightbearing in orthosis. At 2 and 6 weeks postoperatively, all patients were screened for DVT using compression duplex ultrasound. During the first 2 weeks postoperatively, patient-reported loading, pain and step counts were assessed. RESULTS At 2 weeks, 28/96 (29%) of the patients in early functional mobilization group and 15/49 (31%) in the control group (n.s) had sustained a DVT. At 6 weeks, the DVT rate was 35/94 (37%) in the early functional mobilization and 14/49 (29%) in the control group (n.s). During the first postoperative week, the early functional mobilization group reported low loading and higher experience of pain vs. the control group (p = 0.001). Low patient-reported loading ≤ 50% (OR = 4.3; 95% CI 1.28-14.3) was found to be an independent risk factor for DVT, in addition to high BMI and higher age. CONCLUSIONS Early functional mobilization does not prevent the high incidence of DVT during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual. The low efficacy of early functional mobilization is mainly explained by postoperative pain and subsequent low weightbearing. To minimize the risk of DVT, patients should be encouraged to load at least 50% of body weight on the injured leg 1 week after surgery. LEVEL OF EVIDENCE Therapeutic, level 1.
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Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. .,Functional Area Occupational Therapy and Physiotherapy, Allied Health Professionals Function, A6:U1, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Annette Heijne
- grid.4714.60000 0004 1937 0626Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden
| | - Gunnar Edman
- R&D, Norrtälje Hospital, Tiohundra AB, Norrtälje, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Karin Grävare Silbernagel
- grid.33489.350000 0001 0454 4791Department of Physical Therapy, University of Delaware, Newark, DE USA
| | - Paul W. Ackermann
- grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Ko PY, Huang MT, Li CL, Su WR, Jou IM, Wu PT. Jigless knotless internal brace technique for acute Achilles tendon rupture: a case series study. J Orthop Surg Res 2019; 14:415. [PMID: 31806034 PMCID: PMC6896394 DOI: 10.1186/s13018-019-1471-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/13/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose To mitigate the risk of poor wound healing and of infection associated with the open repair of Achilles tendon midsubstance ruptures, minimally invasive techniques have been developed. We report our preliminary results after reviewing our “jigless knotless internal brace technique.” Methods Patients were placed in prone position and a transverse 3-cm incision was made proximal to the palpable ruptured end. The proximal ruptured end was pulled out, gently debrided, and sutured using Krackow locking loops. Percutaneous sutures were crisscrossed through the distal tendon stump and looped around the Krackow sutures over the proximal stump. The ipsilateral Krackow sutures and the contralateral crisscrossed sutures were subcutaneously passed through two mini-incisions over the posterior calcaneus tuberosity and seated at the tuberosity with two 4.5-mm knotless suture anchors. All patients underwent the same post-operative rehabilitation protocol and regular follow-ups for at least 1 year. Results We recruited 10 patients (mean age, 37.3 years) who scored 100 points on the American Orthopaedic Foot and Ankle Society (AOFAS) scale, and who returned to their preoperative exercise levels 1-year post-operatively with no complications. Conclusion Our method is simple, effective, and requires no special tools. It might be a reliable option for Achilles tendon repair. Level of evidence III
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Affiliation(s)
- Po-Yen Ko
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liu Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Tung Huang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Lung Li
- Department of Orthopedics, National Cheng Kung University Hospital Dou-Liu Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopedics, College of Medicine, National Cheng Kung University, 1 University Road, East District, Tainan City, 701, Taiwan
| | - I-Ming Jou
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Po-Ting Wu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liu Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan. .,Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Orthopedics, College of Medicine, National Cheng Kung University, 1 University Road, East District, Tainan City, 701, Taiwan. .,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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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] [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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Čretnik A, Kosanović M, Košir R. Long-Term Results With the Use of Modified Percutaneous Repair of the Ruptured Achilles Tendon Under Local Anaesthesia (15-Year Analysis With 270 Cases). J Foot Ankle Surg 2019; 58:828-836. [PMID: 31474397 DOI: 10.1053/j.jfas.2018.11.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Indexed: 02/03/2023]
Abstract
Controversy regarding the optimal treatment of fresh total Achilles tendon rupture remains. This article presents results with the use of modified percutaneous Achilles tendon repair under local anesthesia performed from January 1991 to December 2005 with a 2- to 10-year follow-up. There were 270 procedures in 247 male patients (92.51%) and 20 female patients (7.49%), mean ± SD age 38.7 ± 11.56 (range 20 to 83) years, in all consecutively treated patients within 7 days after acute total rupture; 3 patients sustained ruptures on both sides in different periods. Postoperative care consisted of wearing a cast or soft cast or functional immobilization for 6 weeks. The procedure was well tolerated in all patients. There were 3 (1.11%) complete and 5 (1.85%) partial repeat ruptures (8 [2.96%] altogether). Fourteen patients (5.18%) developed transient sural neuritis that spontaneously resolved in 2 to 10 months. One case (0.3%) of deep venous thrombosis was successfully treated. There were 25 (9.36%) major and minor complications altogether, with no cases of increased postoperative dorsiflexion, deep infection, or necrosis. Forty-four patients (16.48%) had a slightly decreased range of ankle motion, and 216 (80.89%) patients, including all high-caliber athletes, resumed all their previous activities. The mean American Orthopedic Foot and Ankle Society hindfoot-ankle score was 96.10 points. Long-term results of the analyzed modified method suggest a reasonable treatment option for acute total Achilles tendon ruptures, with a low number of complications and repeat rupture rate and return to preinjury activities comparable to those of open procedures.
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Affiliation(s)
- Andrej Čretnik
- Professor of Surgery, General and Trauma Surgeon, Department of Traumatology, University Clinical Centre Maribor, Maribor, Slovenia.
| | - Miloš Kosanović
- Orthopaedic and Trauma Surgeon, Department of Traumatology, General and Teaching Hospital Celje, Celje, Slovenia
| | - Roman Košir
- Assistant, General Surgeon, Department of Traumatology, University Clinical Centre Maribor, Maribor, Slovenia
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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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Cui J, Chen Z, Wu W. Expression of TGF-β1 and VEGF in patients with Achilles tendon rupture and the clinical efficacy. Exp Ther Med 2019; 18:3502-3508. [PMID: 31602226 PMCID: PMC6777322 DOI: 10.3892/etm.2019.7968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022] Open
Abstract
Expression of transforming growth factor-β1 (TGF-β1) and vascular endothelial growth factor (VEGF) in patients with Achilles tendon rupture, and the predictive values and significance in clinical efficacy were explored. Forty-two patients with Achilles tendon rupture, surgically treated in the First Affiliated Hospital of University of South China, were selected and the clinical efficacy was evaluated based on the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. RT-qPCR was adopted to detect the expression of serum TGF-β1 and VEGF in the patients before and after treatment, and Spearman's correlation was used to analyze the correlation of TGF-β1 and VEGF with the clinical efficacy after treatment. Patients were divided into an excellent efficacy group and a good/general efficacy group according to the predictive efficacy. In the two groups, the expression levels of TGF-β1 and VEGF before treatment were observed, and the predictive values of TGF-β1 and VEGF in clinical efficacy using the receiver operating characteristic (ROC) curves were obtained. The 42 patients showed significantly higher expression of TGF-β1 and VEGF at 3 months after treatment, and significantly decreased expression at 6 months after treatment, compared to the results before treatment (both P<0.001). After treatment, the efficacy was excellent in 11 patients, good in 25 and general in 6. Spearman's correlation analysis revealed that the expression of TGF-β1 and VEGF decreased with the improvement of efficacy after treatment (P<0.001), and the excellent efficacy group showed significantly lower expression of TGF-β1 and VEGF than that in the good/general efficacy group (P<0.01). Moreover, according to ROC curves, the areas under the curves (AUCs) of TGF-β1 and VEGF were 0.651 and 0.645, respectively. In conclusion, TGF-β1 and VEGF can be considered as observational indexes and predictors for clinical efficacy in patients with Achilles tendon rupture, before and after treatment.
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Affiliation(s)
- Juncheng Cui
- Department of Orthopaedics, First Affiliated Hospital of University of South China, Henyang, Hunan 421001, P.R. China
| | - Zhiwei Chen
- Department of Orthopaedics, First Affiliated Hospital of University of South China, Henyang, Hunan 421001, P.R. China
| | - Wente Wu
- Department of Orthopaedics, First Affiliated Hospital of University of South China, Henyang, Hunan 421001, P.R. China
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40
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Nam IH, Park YU, Cho JH, Lee DH, Min KJ. Comparison Between Early Functional Rehabilitation and Cast Immobilization After Minimally Invasive Repair for an Acute Achilles Tendon Rupture. J Foot Ankle Surg 2019; 58:628-631. [PMID: 31130480 DOI: 10.1053/j.jfas.2018.12.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Indexed: 02/03/2023]
Abstract
The purpose of the present study was to compare the outcomes of patients with Achilles tendon rupture treated with minimally invasive repair and early functional rehabilitation with the outcomes of similar patients treated with cast immobilization. After undergoing minimally invasive surgery, a below-knee splint with the foot in 30° of plantarflexion was applied to each patient for the first week. Patients were then assigned to a cast immobilization group (IG; n = 25) or a functional group (FG; n = 16). Data were collected during outpatient checks at 6 weeks, 3 months, 6 months, and 1 year. Outcomes of interest included range of motion (ROM), heel height, calf circumference, pain and functional score, return to work and light sports activity, and complications. The time interval for return to work in the FG was faster than that in the IG (p = .026). There was no clinically important difference between the 2 groups with regard to heel height, ROM, return to sports, calf circumference, visual analog scale, American Orthopaedic Foot and Ankle Society score, or Achilles tendon Total Rupture Score at every outpatient check except ROM difference at 6 weeks and heel height at 3 months. Rerupture occurred in 2 patients (1 [4%] in the IG and 1 [6.25%] in the FG). Early functional rehabilitation seemed to be as safe as traditional postoperative immobilization with a similar functional result and complications, but it was advantageous for the early phase of rehabilitation only.
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Affiliation(s)
- Il Hyun Nam
- Surgeon, Department of Orthopedic Surgery, Pohang, St. Mary's Hospital, Pohang, Gyeongsangbuk-do, Republic of Korea
| | - Young Uk Park
- Professor, Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea.
| | - Jae Ho Cho
- Professor, Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Doo Hyung Lee
- Professor, Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
| | - Kyung Jun Min
- Surgeon, Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Gyeonggi-do, Republic of Korea
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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 DOI: 10.7507/1002-1892.201807146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [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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de Cesar Netto C, Bernasconi A, Roberts L, Saito GH, Hamilton WG, O'Malley MJ. Open Re-rupture of the Achilles Tendon Following Minimally Invasive Repair: A Case Report. J Foot Ankle Surg 2019; 57:1272-1277. [PMID: 30115453 DOI: 10.1053/j.jfas.2018.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Indexed: 02/03/2023]
Abstract
In this report, we describe a rare complication of an open re-rupture of the Achilles tendon following a minimally invasive Achilles tendon repair on a healthy 29-year-old active male. The reinjury happened 19 weeks following the primary surgical repair of a spontaneous rupture, performed by minimally invasive technique with the help of a jig using partially absorbable sutures and four locking stitches. The wound of the open re-rupture was transverse, in a perpendicular orientation relative to the longitudinal approach used in the index procedure. Increased scar tissue formation, the absence of an adequate layer of paratenon overlying the primary tendon repair, and foreign-body reaction to the suture may have been involved in the occurrence of this unusual complication in the surgical treatment of Achilles tendon rupture.
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Affiliation(s)
| | | | - Lauren Roberts
- Clinical Fellow, Hospital for Special Surgery, New York, NY
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Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Bosma E, van Raaij TM, Munzebrock AV, Zijlstra WP, Zwerver J, Reininga IHF. The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study. BMC Musculoskelet Disord 2019; 20:69. [PMID: 30744626 PMCID: PMC6371453 DOI: 10.1186/s12891-019-2437-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 01/28/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Achilles tendon rupture (ATR) is a common sports injury, with a rising incidence and significant impairments. Due to the lack of treatment guidelines, there is no consensus about diagnostic methods, primary treatment (non-surgical or surgical) and rehabilitation. It is hypothesized that this lack of consensus and guidelines leads to sub-optimal recovery and higher societal costs. The primary aim of this study is to give a broad insight into the recovery after ATR. Secondarily this study aims to explore factors contributing to recovery and gain insight into the cost-effectiveness of ATR management. METHODS This multicenter prospective cohort study will include all adult (≥ 18 years) patients with an ATR treated at the three main hospitals in the Northern Netherlands: University Medical Center Groningen, Martini Hospital Groningen and Medical Center Leeuwarden. All subjects will be invited for three visits at 3, 6 and 12 months post-injury. The following data will be collected: patient-reported outcome measures (PROMs), physical tests, imaging and economic questionnaires. At 3 months post-injury personal, injury, and treatment data will be collected through a baseline questionnaire and assessment of the medical file. The PROMs concern the Dutch version of the Achilles Tendon Total Rupture Score, EQ-5D-5 L, Oslo Sport Trauma Research Center Overuse Injury Questionnaire, Injury Psychological Readiness Return to Sport Scale, Tampa Scale of Kinesiophobia, Expectations, Motivation and Satisfaction questionnaire and a ranking of reasons for not returning to sport. The administered physical tests are the heel-rise test, standing dorsiflexion range of motion, resting tendon length and single leg hop for distance. Ultrasound Tissue Characterization will be used for imaging. Finally, economic data will be collected using the Productivity Cost Questionnaire and Medical Consumption Questionnaire. DISCUSSION This prospective cohort study will contribute to optimal decision making in the primary treatment and rehabilitation of ATRs by providing insight into (1) ATR recovery (2) novel imaging for monitoring recovery (3) (barriers to) return to sport and (4) cost-effectiveness of management. The analysis of these data strives to give a broad insight into the recovery after ATR as well as provide data on novel imaging and costs, contributing to individualized ATR management. TRIAL REGISTRATION Trialregister.nl. NTR6484 . 20/06/2017. 20/07/2017.
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Affiliation(s)
- Olivier C. Dams
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ron L. Diercks
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaus W. Wendt
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eelke Bosma
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Tom M. van Raaij
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Arvid V. Munzebrock
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Wierd P. Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Johannes Zwerver
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Zwerver J, Reininga IHF. Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines. Knee Surg Sports Traumatol Arthrosc 2019; 27:2754-2764. [PMID: 29971520 PMCID: PMC6706364 DOI: 10.1007/s00167-018-5049-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 06/29/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE This study aimed to describe and analyse usual care of Achilles tendon ruptures (ATRs) by orthopaedic surgeons and trauma surgeons in the Netherlands. METHODS A nationwide online survey of ATR management was sent to all consultant orthopaedic and trauma surgeons in the Netherlands, requesting participation of those involved in ATR management. Data on individual characteristics and the entire ATR management (from diagnosis to rehabilitation) were gathered. Consensus was defined as ≥ 70% agreement on an answer. RESULTS A total of 91 responses (70 orthopaedic surgeons and 21 trauma surgeons) were analysed. There was consensus on the importance of the physical examination in terms of diagnosis (> 90%) and a lack of consensus on diagnostic imaging (ultrasound/MRI). There was consensus that non-surgical treatment is preferred for sedentary and systemically diseased patients and surgery for patients who are younger and athletic and present with larger tendon gap sizes. There was consensus on most of the non-surgical methods used: initial immobilisation in plaster cast with the foot in equinus position (90%) and its gradual regression (82%) every 2 weeks (85%). Only length of immobilisation lacked consensus. Surgery was generally preferred, but there was a lack of consensus on the entire followed protocol. Orthopaedic and trauma surgeons differed significantly on their surgical (p = 0.001) and suturing techniques (p = 0.002) and methods of postoperative immobilisation (p < 0.001). Orthopaedic surgeons employed open repair and Bunnell sutures more often, whereas trauma surgeons used minimally invasive approaches and bone anchors. Rehabilitation methods and advised time until weight-bearing and return to sport varied. Orthopaedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment (p = 0.001) and surgery (p = 0.002) than trauma surgeons. CONCLUSION This is the first study to describe the entire ATR management. The results show a lack of consensus and wide variation in management of ATRs in the Netherlands. This study shows that especially the methods of the perioperative and rehabilitation phases were inconclusive and differed between orthopaedic and trauma surgeons. Further research into optimal ATR management regimens is recommended. In addition, to achieve uniformity in management more multidisciplinary collaboration between Dutch and international surgeons treating ATRs is needed. LEVEL OF EVIDENCE Cross-sectional survey, Level V.
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Affiliation(s)
- Olivier C. Dams
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands ,0000 0000 9558 4598grid.4494.dDepartment of Orthopaedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Ron L. Diercks
- 0000 0000 9558 4598grid.4494.dDepartment of Orthopaedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Klaus W. Wendt
- 0000 0000 9558 4598grid.4494.dDepartment of Trauma Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johannes Zwerver
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Inge H. F. Reininga
- 0000 0000 9558 4598grid.4494.dDepartment of Trauma Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Abstract
Objectives The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development. Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2.
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Affiliation(s)
- X Yang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - H Meng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Q Quan
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - J Peng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - S Lu
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - A Wang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
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Telleria JJM, Smith JT, Ready LV, Bluman EM. Outcomes of Limited Open Achilles Repair Using Modified Ring Forceps. Orthop J Sports Med 2018; 6:2325967118794927. [PMID: 30228992 PMCID: PMC6137553 DOI: 10.1177/2325967118794927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The optimal treatment of acute Achilles tendon ruptures remains controversial. When surgical repair is undertaken, the reported rate of infections and wound-healing complications ranges from 2% to 5%. Meta-analyses have demonstrated that minimally invasive approaches have equivalent rerupture rates, a significantly lower risk of superficial infections, and higher patient satisfaction rates compared with traditional open Achilles repair techniques. Purpose To review the clinical outcomes of acute, limited open Achilles tendon repair using modified ring forceps and to analyze functional results using foot and ankle-specific outcome measures. Study Design Case series; Level of evidence, 4. Methods The clinical records of 32 consecutive patients (mean age, 44 years) with 33 acute Achilles tendon ruptures were retrospectively reviewed. All patients underwent limited open repair with modified ring forceps through a 2- to 3-cm midline incision. Suture placement into the tendon stumps was guided using a pair of ring forceps bent 30°. Three No. 2 nonabsorbable sutures were placed in the proximal and distal segments, the tendon ends were reapproximated, and the sutures were tied to secure the tendon. Outcomes from a 10-cm visual analog scale (VAS), the Foot and Ankle Ability Measure (FAAM), and the Victorian Institute of Sport Assessment-Achilles (VISA-A) were assessed. Results At final follow-up (mean, 42.1 months [range, 6-90 months]), 31 of 32 patients (33 Achilles tendons) reported no pain in their Achilles, with a mean Achilles VAS score of 0.7 ± 4.2 of 100. The mean postoperative VISA-A score was 82.3 ± 19.5 of 100. The mean FAAM activities of daily living and sports subscores were 96.5% ± 5.2% and 85.1% ± 21.2%, respectively. Regarding current functional level, 19 of 33 tendons (57.6%) were rated as "normal," 10 (30.3%) as "nearly normal," and 4 (12.1%) as "abnormal"; none were rated as "severely abnormal." There was 1 case (3.0%) of a superficial infection; there were no cases of deep infections, sural neuritis, or reruptures. The cost of the modified ring forceps technique is 5.3 to 12.1 times less than commercially available devices. Conclusion Limited open Achilles repair with modified ring forceps provides an economical repair with excellent pain relief, favorable functional outcomes, and a very low complication rate at midterm follow-up.
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Affiliation(s)
- Jessica J M Telleria
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeremy T Smith
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren V Ready
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eric M Bluman
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Ling SKK, Slocum A, Lui TH. 5-year results of the 1.5cm incision Achilles tendon repair. Foot (Edinb) 2017; 33:35-38. [PMID: 29126040 DOI: 10.1016/j.foot.2017.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 06/02/2017] [Accepted: 06/05/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND To study a hypothesis that the cost-effective 1.5cm medial incision Achilles tendon repair technique will provide good functional outcomes which are maintained for over 5 years. METHOD Prospective study of 12 consecutive cases with a minimal 5-year follow-up were recruited from April 2008 to November 2010. Cases whom were mentally incompetent or those which required concomitant procedures were excluded. Outcomes measures included the numeric pain rating scale, motor power strength, range of motion, functional scoring using the AOFAS hindfoot score and patient's self-assessment using the Foot and Ankle Outcome Score (FAOS). RESULT No re-ruptures or sural nerve injured were identified after a minimal 5-year follow-up. Pain was minimal at 0.5/10, calf power was 5/5 and ankle range was good (plantarflexion: 38°/dorsiflexion: 21°). The AOFAS hindfoot score was 97.4 and all 5 sub-categories of the Foot and Ankle Outcome Score (FAOS) were good. CONCLUSION The 1.5cm medial incision repair of the Achilles tendon is an economically sound surgical technique, with minimal complications, which gives good medium length functional outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Samuel K K Ling
- Dept. of Orthopadics & Traumatology, North District Hospital, Hong Kong Special Administrative Region.
| | - Amanda Slocum
- Dept. of Orthopadics & Traumatology, North District Hospital, Hong Kong Special Administrative Region.
| | - T H Lui
- Dept. of Orthopadics & Traumatology, North District Hospital, Hong Kong Special Administrative Region.
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Braunstein M, Baumbach SF, Herterich V, Böcker W, Polzer H. Die akute Achillessehnenruptur. Unfallchirurg 2017; 120:1007-1014. [DOI: 10.1007/s00113-017-0420-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Wang KC, Cotter EJ, Cole BJ, Lin JL. Rehabilitation and Return to Play Following Achilles Tendon Repair. OPER TECHN SPORT MED 2017. [DOI: 10.1053/j.otsm.2017.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Temporal Healing of Achilles Tendons After Injury in Rodents Depends on Surgical Treatment and Activity. J Am Acad Orthop Surg 2017; 25:635-647. [PMID: 28837456 PMCID: PMC5603242 DOI: 10.5435/jaaos-d-16-00620] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Achilles tendon ruptures affect 15 of 100,000 women and 55 of 100,000 men each year. Controversy continues to exist regarding optimal treatment and rehabilitation protocols. The objective of this study was to investigate the temporal effects of surgical repair and immobilization or activity on Achilles tendon healing and limb function after complete transection in rodents. METHODS Injured tendons were repaired (n = 64) or left nonrepaired (n = 64). The animals in both cohorts were further randomized into groups immobilized in plantar flexion for 1, 3, or 6 weeks that later resumed cage and treadmill activity for 5, 3, or 0 weeks, respectively (n = 36 for each regimen), which were euthanized at 6 weeks after injury, or into groups immobilized for 1 week and then euthanized (n = 20). RESULTS At 6 weeks after injury, the groups that had 1 week of immobilization and 5 weeks of activity had increased range of motion and decreased ankle joint toe stiffness compared with the groups that had 3 weeks of immobilization and 3 weeks of activity. The groups with 6 weeks of immobilization and no activity period had decreased tendon cross-sectional area but increased tendon echogenicity and collagen alignment. Surgical treatment dramatically decreased fatigue cycles to failure in repaired tendons from groups with 1 week of immobilization and 5 weeks of activity. Normalized comparisons between 1-week and 6-week postinjury data demonstrated that changes in tendon healing properties (area, alignment, and echogenicity) were maximized by 1 week of immobilization and 5 weeks of activity, compared with 6 weeks of immobilization and no activity period. DISCUSSION This study builds on an earlier study of Achilles tendon fatigue mechanics and functional outcomes during early healing by examining the temporal effects of different immobilization and/or activity regimens after initial postinjury immobilization. CONCLUSION This study demonstrates how the temporal postinjury healing response of rodent Achilles tendons depends on both surgical treatment and the timing of immobilization/activity timing. The different pattern of healing and qualities of repaired and nonrepaired tendons suggest that two very different healing processes may occur, depending on the chosen immobilization/activity regimen.
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