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Olsen AA, Li A, Johnson DD, Manson HC. Pickleball Primer: An Overview of Common Injuries, Treatment, and Optimization Strategies in Pickleball Athlete. J Am Acad Orthop Surg 2024; 32:763-770. [PMID: 38773841 DOI: 10.5435/jaaos-d-23-00705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 04/13/2024] [Indexed: 05/24/2024] Open
Abstract
Pickleball is one of the fastest growing sports in the United States with millions of players nationwide. It is a relatively appealing sport because of its ease of access, low impact, and highly social atmosphere, allowing players of all ages to participate. As the number of players continues its dramatic increase, player injuries are certain to increase in turn. There is little to no orthopaedic research on pickleball-related injuries and a paucity of data regarding treatment and prevention strategies. This summary was designed to familiarize orthopaedic surgeons with the basics of the sport and highlight potential pickleball-related injuries they may encounter in practice.
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Affiliation(s)
- Aaron A Olsen
- From the Bone and Joint Sports Medicine Institute, Naval Medical Center Portsmouth, Portsmouth, VA
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2
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Hallinen M, Sallinen H, Keskinen H, Matilainen M, Ekman E. Regional variations in incidence and treatment trends of Achilles tendon ruptures in Finland: a nationwide study. Acta Orthop 2024; 95:401-406. [PMID: 39016345 PMCID: PMC11253709 DOI: 10.2340/17453674.2024.41089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND AND PURPOSE The aim of our study was to assess the regional variations in Achilles tendon rupture incidence and treatment methods in Finland during the period 1997-2019. METHODS The Finnish National Hospital Discharge Register (NHDR) and the Finnish Register of Primary Health Care Visits (PHCR) were searched to identify all adult patients diagnosed with Achilles tendon rupture during our study period. The population-based annual incidence and incidences of surgically and non-surgically treated Achilles tendon ruptures were calculated for each hospital district. RESULTS Achilles tendon rupture incidence increased from 17.3 per 105 person-years in 1997 to 32.3 per 105 in 2019. The mean incidence of Achilles tendon ruptures ranged from 26.4 per 105 (North Savo) to 37.2 per 105 (Central Ostrobothnia). The incidence of Achilles tendon ruptures increased in all areas. The proportion of non-surgical treatment of Achilles tendon ruptures ranged in 1997 from 7% (Vaasa) to 67% (Åland) and in 2019 from 73% (Southwest Finland) to 100% (East Savo, Kainuu, Länsi-Pohja, Åland). During the study period, a shift towards non-surgical treatment was evident in all hospital districts. CONCLUSION Regional variations in Achilles tendon rupture incidence exist in Finland; however, the incidence increased in all areas during the follow-up period. More Achilles tendon rupture patients are currently being treated non-surgically throughout the country.
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Affiliation(s)
- Marjukka Hallinen
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku.
| | - Henri Sallinen
- Department of Orthopedics and Traumatology, Satasairaala Central Hospital
| | - Heli Keskinen
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku; University of Turku, Turku, Finland
| | | | - Elina Ekman
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku; University of Turku, Turku, Finland
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Brodeur PG, Salameh M, Boulos A, Blankenhorn BD, Hsu RY. Surgical Management of Achilles Tendon Ruptures in the United States 2006-2020, an ABOS Part II Oral Examination Case List Database Study. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241266190. [PMID: 39091402 PMCID: PMC11292698 DOI: 10.1177/24730114241266190] [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] [Indexed: 08/04/2024] Open
Abstract
Background In correlation with a growing body of evidence regarding nonoperative management for Achilles tendon rupture (ATR), studies from Europe and Canada have displayed a decreasing incidence in surgical management, which has not been noted in the United States. The primary objective of this study is to evaluate the US trend in ATR repair volume. Methods The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination Case List Database was used. All cases using Current Procedural Terminology codes for primary ATR repair were requested from the years 2006-2020. Total submitted Achilles repair volume, the number of candidates submitting an Achilles repair case, and the overall submitted case volume per examination year was analyzed. Poisson and linear regressions were used to determine statistically significant trends. Results The total number of Achilles repair cases submitted for the ABOS Part II Oral Examination significantly increased from 2006 to 2011 and then decreased until 2020. Taking Achilles repair cases as a proportion of total orthopaedic cases submitted, the same trend was seen. The number of candidates submitting an Achilles repair case increased from 2006 to 2009 and then decreased until 2020. Foot and Ankle fellowship-trained candidates submitted an increasing number of ATR repair cases per candidate during the time period studied. Conclusion This is the first study to demonstrate a decline in the volume of ATR repair in the United States. The decline in ATR repair volume seen in the ABOS Part II Case Lists does not match previously published US surgeon practice patterns but is not necessarily generalizable to beyond this period. Although the overall ATR repair volume in the ABOS Part II Case Lists is decreasing, we found Foot and Ankle fellowship-trained surgeons are operating on an increasing number of ATRs during their board collection period. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Peter G. Brodeur
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Motasem Salameh
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alexandre Boulos
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Brad D. Blankenhorn
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Raymond Y. Hsu
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Acevedo D, Garcia JR, Grewal RS, Vankara A, Murdock CJ, Hardigan PC, Aiyer AA. Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis. J Orthop 2024; 52:112-118. [PMID: 38445100 PMCID: PMC10909967 DOI: 10.1016/j.jor.2024.02.034] [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: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/07/2024] Open
Abstract
Background This systematic review and meta-analysis investigated the treatment for Achilles tendon rupture (ATR) associated with the lowest risk of rerupture in older patients. Methods Five databases were searched through September 2022 for studies published in the past 10 years analyzing operative and nonoperative ATR treatment. Studies were categorized as "nonelderly" if they reported only on patients aged 18-60 years. Studies that included at least 1 patient older than age 70 were categorized as "elderly inclusive." Of 212 studies identified, 28 were eligible for inclusion. Of 2965 patients, 1165 were treated operatively: 429 (37%) from elderly-inclusive studies and 736 (63%) from nonelderly studies. Of the 1800 nonoperative patients 553 (31%) were from nonelderly studies and 1247 (69%) were from elderly-inclusive studies. Results For nonoperative treatment, the rate of rerupture was higher in nonelderly studies (83/1000 cases, 95% CI = 58, 113) than in elderly-inclusive studies (38/1000 cases, 95% CI = 22, 58; P<.001). For operative treatment no difference was found in the rate of rerupture between nonelderly studies (7/1000 cases, 95% CI = 0, 21) and elderly-inclusive studies (12/1000 cases, 95% CI = 0, 35; P<.78). Overall, operative treatment was associated with a rerupture rate of 1.5% (95% CI: 1.0%, 2.8%) (P<.001), which was lower than the 5% rate reported by other studies for nonoperative management (P<.001). Conclusion Older patients may benefit more than younger patients from nonoperative treatment of ATR. More studies are needed to determine the age at which rerupture rates decrease among nonoperatively treated patients. Level of Evidence 3.
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Affiliation(s)
- Daniel Acevedo
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, 3200 S University Drive, Davie, FL, 33328, USA
- The Johns Hopkins University School of Medicine, Department of Orthopaedic Surgery, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Jose R. Garcia
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, 3200 S University Drive, Davie, FL, 33328, USA
| | - Rajvarun S. Grewal
- California Health Sciences University, 120 Clovis Avenue, Clovis, CA, 93612, USA
| | - Ashish Vankara
- The Johns Hopkins University School of Medicine, Department of Orthopaedic Surgery, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Christopher J. Murdock
- The Johns Hopkins University School of Medicine, Department of Orthopaedic Surgery, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Patrick C. Hardigan
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, 3200 S University Drive, Davie, FL, 33328, USA
| | - Amiethab A. Aiyer
- The Johns Hopkins University School of Medicine, Department of Orthopaedic Surgery, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
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Čretnik A, Košir R. Incidence of Achilles tendon rupture: 25-year regional analysis with a focus on bilateral ruptures. J Int Med Res 2023; 51:3000605231205179. [PMID: 37976267 PMCID: PMC10657533 DOI: 10.1177/03000605231205179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 09/15/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE We aimed to fill the research gap regarding the incidence of Achilles tendon rupture (ATR), which is reportedly increasing, as there is a lack of data on the incidence of ATR and no data on bilateral ruptures in our region. METHODS We determined the incidence of complete ATR among 273,485 people during 1991 to 2015. RESULTS In the study period, 524 patients (486 [92.75%] men and 38 [7.25%] women, average age 39.03±10.86 [range 20-83] years, = sex ratio 12.8:1) were treated for ATR in our study area. The average incidence was 7.77 per 100,000 person-years, with an increasing trend until 2008 and peak incidence of 11.33 per 100,000 person-years. Most injuries (67.04%) occurred while performing sports activities. In total, 7 (1.34%) patients (six men [1.23%] and one woman [2.63%]) experienced ruptures on both sides, an average of 5.1 years apart; the average age at the second rupture was 57.71±16.69 (range 39-83) years, with a calculated incidence for bilateral ATR of 0.1 per 100,000 person-years. CONCLUSIONS The incidence of complete ATR in our study region increased gradually between 1991 and 2008, after which it declined. Bilateral ATR during that period was a very rare injury.
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Affiliation(s)
- Andrej Čretnik
- Department of Traumatology, University Clinical Center Maribor, Maribor, Slovenia
| | - Roman Košir
- Department of Traumatology, University Clinical Center Maribor, Maribor, Slovenia
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Wilder JH, Ofa SA, Lee OC, Gadinsky NE, Rodriguez RF, Sherman WF. Rates of Operative Management for Achilles Tendon Rupture Over the Last Decade and the Influence of Gender and Age. Foot Ankle Spec 2023; 16:377-383. [PMID: 35695472 DOI: 10.1177/19386400221102745] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND With emerging evidence supporting functional rehabilitation for Achilles tendon ruptures (ATRs), this study sought to evaluate the treatment trends for patients sustaining an acute ATR and whether gender and age may influence the rates of operative repair. METHODS A retrospective database review identified ATRs from 2010 through 2019. Patients were then stratified into three cohorts based on age (18-30, 30-45, and 46 and older), separated by gender, and then assessed whether patients were treated operatively or not. Cochran-Armitage Trend test was performed to analyze the trends of operative management. Chi-square analyses were performed to assess whether the proportion of patients who received operative management in each age cohort differed from 2010 to 2019. Logistic regression analyses were performed to assess whether gender influenced treatment. RESULTS Over the previous decade, the total rates of operative treatment for ATR significantly decreased (18.3%-12.3%, P < .0001). Each individual age cohort experienced a proportional decrease in operative management when comparing 2010 with 2019 (all P < .0001). Within all age cohorts, males were significantly more likely to receive operative treatment for an ATR over the previous decade (odds ratios: 2.63-3.22). Conclusion. Overall rates of operative management for ATR decreased across all cohorts likely due to previous studies providing evidence of similar results between operative and nonoperative managements. Over the previous decade, males were demonstrated to be far more likely than females to undergo operative management. Why females are less likely to receive an operation for ATR is likely multi-factorial and requires further exploration. LEVEL OF EVIDENCE Level III: Retrospective comparative study.
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Affiliation(s)
- J Heath Wilder
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sione A Ofa
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Olivia C Lee
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
- Department of Orthopaedic Surgery, Louisiana State University School of Medicine and Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana
| | - Naomi E Gadinsky
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ramon F Rodriguez
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Barton D, Manoharan A, Khwaja A, Sorenson J, Taylor M. Return to Play Following Achilles Tendon Rupture in NFL Players Based on Position. Foot Ankle Spec 2023; 16:427-436. [PMID: 34609159 DOI: 10.1177/19386400211040351] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to determine the return-to-play (RTP) rate and postinjury performance after Achilles tendon (AT) ruptures in National Football League (NFL) skill position players. METHODS The study included NFL skill positions with an AT rupture between the 2009-2010 and 2015-2016 seasons. Performance data were collected and compared against a matched control group. RTP was defined as playing in at least 1 game after repair. RESULTS RTP rate was 57% for the study cohort. The tight ends (TEs) had the highest RTP rate at 71% while the wide receivers (WRs) had the lowest RTP rate at 38%. Compared with the control group, WRs with successful RTP had significantly less receptions per game (P = .01). For defensive players with RTP there were significant decreases in postrepair performance in tackles, passes defended, and fumbles forced/recovered compared with the control group. CONCLUSION A total of 57% of players achieved RTP with WRs and running backs (RBs) having the lowest RTP rates and TEs and linebackers (LBs) having the highest RTP rates. RBs, defensive backs (DBs), and LBs with successful RTP had decreased performance in all categories. This updated information may be helpful for athletes, physicians, scouts, and coaches in evaluating players with a history of AT rupture. LEVELS OF EVIDENCE Analytic, level 3, retrospective cohort study, Epidemiologic study.
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Affiliation(s)
- Dane Barton
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona
| | - Aditya Manoharan
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona
| | - Ansab Khwaja
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona
| | - Jacob Sorenson
- University of Arizona School of Medicine, Tucson, Arizona
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Shen H, Lane RA. Extracellular Vesicles From Primed Adipose-Derived Stem Cells Enhance Achilles Tendon Repair by Reducing Inflammation and Promoting Intrinsic Healing. Stem Cells 2023; 41:617-627. [PMID: 37085269 PMCID: PMC10267691 DOI: 10.1093/stmcls/sxad032] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
Achilles tendon rupture is a common sports-related injury. Even with advanced clinical treatments, many patients suffer from long-term pain and functional deficits. These unsatisfactory outcomes result primarily from an imbalanced injury response with excessive inflammation and inadequate tendon regeneration. Prior studies showed that extracellular vesicles from inflammation-primed adipose-derived stem cells (iEVs) can attenuate early tendon inflammatory response to injury. It remains to be determined if iEVs can both reduce inflammation and promote regeneration in the later phases of tendon healing and the underlying mechanism. Therefore, this study investigated the mechanistic roles of iEVs in regulating tendon injury response using a mouse Achilles tendon injury and repair model in vivo and iEV-macrophage and iEV-tendon cell coculture models in vitro. Results showed that iEVs promoted tendon anti-inflammatory gene expression and reduced mononuclear cell accumulation to the injury site in the remodeling phase of healing. iEVs also increased collagen deposition in the injury center and promoted tendon structural recovery. Accordingly, mice treated with iEVs showed less peritendinous scar formation, much lower incidence of postoperative tendon gap or rupture, and faster functional recovery compared to untreated mice. Further in vitro studies revealed that iEVs both inhibited macrophage M1 polarization and increased tendon cell proliferation and collagen production. The iEV effects were partially mediated by miR-147-3p, which blocked the toll-like receptor 4/NF-κB signaling pathway that activated the M1 phenotype of macrophages. The combined results demonstrate that iEVs are a promising therapeutic agent that can enhance tendon repair by attenuating inflammation and promoting intrinsic healing.
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Affiliation(s)
- Hua Shen
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan A Lane
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
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9
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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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10
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Shen H, Lane RA. Extracellular Vesicles from Inflammation-Primed Adipose-Derived Stem Cells Enhance Achilles Tendon Repair by Reducing Inflammation and Promoting Intrinsic Healing. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.31.526532. [PMID: 36778262 PMCID: PMC9915600 DOI: 10.1101/2023.01.31.526532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achilles tendon rupture is a common sports-related tendon injury. Even with advanced clinical treatments, many patients suffer from long-term pain and reduced function. These unsatisfactory outcomes result primarily from an imbalanced injury response with excessive inflammation and inadequate regeneration. Prior studies showed that extracellular vesicles from inflammation-primed adipose-derived stem cells (iEVs) can attenuate inflammation in the early phase of tendon healing. However, the effect of iEVs on tendon inflammation and regeneration in the later phases of tendon healing and the underlying mechanism remain to be determined. Accordingly, this study investigated the mechanistic roles of iEVs in regulating tendon response to injury using a mouse Achilles tendon injury and repair model in vivo and iEV-macrophage and iEV-tendon cell co-culture models in vitro. Results showed that iEVs promoted tendon anti-inflammatory gene expression and reduced mononuclear cell infiltration in the remodeling phase of tendon healing. iEVs also increased injury site collagen deposition and promoted tendon structural recovery. As such, mice treated with iEVs showed less peritendinous scar formation, much lower incidence of postoperative tendon gap or rupture, and faster functional recovery compared to untreated mice. Further in vitro study revealed that iEVs both inhibited macrophage inflammatory response and increased tendon cell proliferation and collagen production. The iEV effects were partially mediated by miR-147-3p, which blocks the toll-like receptor 4/NF-κB signaling pathway that activates macrophage M1 polarization. The combined results demonstrated that iEVs are a promising therapeutic agent, which can enhance tendon repair by attenuating inflammation and promoting intrinsic healing. Significance statement Using a clinically relevant mouse Achilles tendon injury and repair model, this study revealed that iEVs, a biological product generated from inflammation-primed adipose-derived stem cells, can directly target both macrophages and tendon cells and enhance tendon structural and functional recovery by limiting inflammation and promoting intrinsic healing. Results further identified miR-147-3p as one of the active components of iEVs that modulate macrophage inflammatory response by inhibiting toll-like receptor 4/NF-κB signaling pathway. These promising findings paved the road toward clinical application of iEVs in the treatment of tendon injury and other related disorders.
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11
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Murphy CP, Safgren TJ, Piatt ET, Chong ACM, Piatt BE. Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair. J Foot Ankle Surg 2022; 62:45-49. [PMID: 35459614 DOI: 10.1053/j.jfas.2022.03.010] [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: 01/04/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/03/2023]
Abstract
Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.
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Affiliation(s)
- Colin P Murphy
- Department of Graduate Medical Education, Sanford Health, Fargo, ND; University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND; Sanford Orthopedics & Sports Medicine - Sanford Health, Fargo, ND
| | - Tyler J Safgren
- University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND; Sanford Orthopedics & Sports Medicine - Sanford Health, Fargo, ND
| | - Eric T Piatt
- Sanford Orthopedics & Sports Medicine - Sanford Health, Fargo, ND
| | - Alexander C M Chong
- Department of Graduate Medical Education, Sanford Health, Fargo, ND; University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND.
| | - Bruce E Piatt
- Department of Graduate Medical Education, Sanford Health, Fargo, ND; University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND; Sanford Orthopedics & Sports Medicine - Sanford Health, Fargo, ND
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12
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Leino O, Keskinen H, Laaksonen I, Mäkelä K, Löyttyniemi E, Ekman E. Incidence and Treatment Trends of Achilles Tendon Ruptures in Finland: A Nationwide Study. Orthop J Sports Med 2022; 10:23259671221131536. [PMID: 36389616 DOI: 10.1177/23259671221131536] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/04/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Global reports indicate rising Achilles tendon rupture (ATR) incidence. In recent decades, the optimal treatment for this injury has been widely studied. Alongside the cumulating comparative evidence regarding the optimal method of treatment, nonoperative treatment has increased in popularity compared with operative treatment. Purpose: To determine the current incidence of ATRs and their treatment in Finland and how these have changed from 1997 to 2019. Study Design: Descriptive epidemiology study. Methods: Two national registers (the National Hospital Discharge Register and the Finnish Register of Primary Health Care Visits) were used to identify all ATR cases and operations to treat them; the incidence was calculated based on the annual adult population size. Results: During the study period, ATR incidence increased from 17.3 to 32.3 per 100,000 person-years. The increase in incidence seemed to plateau starting in the second half of the study period. The rise in ATR incidence occurred in both sexes and all age groups but most markedly among the elderly. The incidence of operative treatment decreased from 13.6 to 4.9 per 100,000 person-years. This decline was observed from 2008 onward and in all age groups. Conclusion: The incidence of ATRs increased and the use of operative treatment decreased. The decreasing trend of operative treatment is in line with other international reports and resonates with the current literature about the optimal treatment of ATRs.
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Affiliation(s)
- Oskari Leino
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Heli Keskinen
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Inari Laaksonen
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Eliisa Löyttyniemi
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Elina Ekman
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
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Giordano J, Partan M, Iturriaga C, Granata J, Katsigiorgis G, Cohn R, Bitterman A. The Relationship Between Patient Demographics, Tear Locations, and Operative Techniques on the Surgical Treatment of Acute Achilles Tendon Ruptures. Cureus 2022; 14:e28300. [PMID: 36168374 PMCID: PMC9506559 DOI: 10.7759/cureus.28300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Achilles tendon ruptures (ATRs) have classically been thought to affect the middle-aged “weekend warrior” participating in basketball, volleyball, soccer, or any ground sport; however, with a more active elderly population, these tears are becoming more common in older patients. We sought to examine the role of demographics, tear location, and operative technique for acute Achilles tendon ruptures treated surgically. Methods A retrospective query was performed to identify patients who presented with Achilles tendon ruptures. Inclusion data were primary end-to-end repairs, augmented repairs with flexor hallucis longus (FHL) transfers, augmented repairs with graft, augmented repairs with both FHL transfer and graft use, isolated FHL transfers, and revision Achilles tendon procedures. Demographics and tear locations were collected and analyzed. Results Midsubstance tears were the most common tear location occurring in 237 of 286 (82.9%) patients. Distal insertional tears of the Achilles tendon were treated in 35 (12.2%) patients, while 14 (4.9%) patients had a more proximal tear located at the myotendinous junction. Older patients (average age: 53.3±12.5) had significantly more distal insertional tears (p<0.001), while younger patients (average age: 35.1±7.4) presented with significantly more tears at the myotendinous junction (p<0.001). The average BMI was significantly higher (average BMI: 32.2±6.6; p<0.001) in patients with distal insertional tears compared to midsubstance and proximal tears (28.5±4.6 and 28.5±5.3, respectively). There was a higher percentage of diabetic patients who underwent operative treatment for distal insertional tears (20%) compared to midsubstance tears (7.2%). Conclusion The findings of our study suggest that a subset of patients, particularly those with advanced age and higher BMI, is more likely to present with a distal Achilles tendon rupture. Additionally, patients in our series who had distal tears more commonly required an augmented repair technique. Our results highlight the need for future research to further define the relationship between increasing age and higher BMI patients sustaining distal tears more often than midsubstance tears.
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14
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Zhang X, Deng L, Yang Y, Xiao S, Li L, Fu W. Effects of 12-week transition training with minimalist shoes on Achilles tendon loading in habitual rearfoot strike runners. J Biomech 2021; 128:110807. [PMID: 34670150 DOI: 10.1016/j.jbiomech.2021.110807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/18/2022]
Abstract
Minimalist shod runners have reported greater material and mechanical properties of the Achilles tendon (AT) due to increased loading than runners who wear more cushioned running shoes. This study aimed to investigate the effects of 12-week transition training from conventional shoes to minimalist shoes on AT loading in habitual rearfoot strike runners. Seventeen healthy male habitual rearfoot strikers completed 12-week transition training. They were instructed either to run in minimalist shoes with a forefoot strike pattern (MIN + FFS, n = 9) or run in minimalist shoes but were free to develop their strike pattern (MIN, n = 8). Ultrasound images were captured to determine the cross-sectional area of the AT. Sagittal plane ankle kinematics and ground reaction forces were recorded simultaneously to quantify ankle joint mechanics and AT loading. The strike angle significantly decreased in MIN + FFS after the transition training, indicating a flatter foot at initial contact, whereas no changes were observed in MIN. After training, a significant increase in peak plantarflexion moment was observed for MIN + FFS (15.4%) and MIN (7.6%). Significantly increased peak AT force, peak loading rate and peak stress were observed after training in both groups. Specifically, MIN + FFS had a greater increase in peak AT force (20.3% versus 10.1%), peak loading rate (37.2% versus 25.4%) and peak AT stress (13.7% versus 8.1%) than MIN. Furthermore, for both groups, there were no significant differences in the moment arm and cross-sectional area of the AT observed before and after 12 weeks of training. The results of this study suggested that it was insufficient to promote the morphological adaptation of the AT, but the mechanical loading of the AT was adapted during running after 12-week transition training with minimalist shoes in MIN + FFS and MIN. Preliminary evidence showed that a gradual transition to minimalist shoes with a forefoot strike pattern may be beneficial to the mechanical loading of the AT.
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Affiliation(s)
- Xini Zhang
- School of Kinesiology, Shanghai University of Sport, Shanghai 200438, China
| | - Liqin Deng
- School of Kinesiology, Shanghai University of Sport, Shanghai 200438, China
| | - Yang Yang
- School of Kinesiology, Shanghai University of Sport, Shanghai 200438, China
| | - Songlin Xiao
- School of Kinesiology, Shanghai University of Sport, Shanghai 200438, China
| | - Lu Li
- School of Kinesiology, Shanghai University of Sport, Shanghai 200438, China; Institute of Sport and Sport Science, University of Freiburg, Schwarzwaldstraße 175, 79117 Freiburg, Germany
| | - Weijie Fu
- School of Kinesiology, Shanghai University of Sport, Shanghai 200438, China; Key Laboratory of Exercise and Health Sciences of Ministry of Education, Shanghai University of Sport, Shanghai 200438, China; Shanghai Frontiers Science Research Base of Exercise and Metabolic Health, Shanghai University of Sport, Shanghai 200438, China.
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15
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Yamaguchi S, Kimura S, Akagi R, Yoshimura K, Kawasaki Y, Shiko Y, Sasho T, Ohtori S. Increase in Achilles Tendon Rupture Surgery in Japan: Results From a Nationwide Health Care Database. Orthop J Sports Med 2021; 9:23259671211034128. [PMID: 34708136 PMCID: PMC8543583 DOI: 10.1177/23259671211034128] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/30/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Nationwide epidemiologic studies in Scandinavian countries have shown that the incidence of Achilles tendon ruptures (ATRs) has increased, and the rate of surgical treatment has declined markedly in the past decade. However, there is a lack of national-level data on the trend of ATRs and surgical procedures in other regions. Purpose: To clarify the trend in the incidence of ATRs and the proportion of surgery using the nationwide health care database in Japan. Study Design: Descriptive epidemiology study. Methods: Age- and sex-stratified data on the annual number of ATRs and surgical procedures between 2010 and 2017 were obtained from the Japanese national health care database, which includes almost all inpatient and outpatient medical claims nationwide. The Japanese population data were also obtained from the population census. The change in the annual incidence of ATRs per 100,000 people was assessed using a Poisson regression analysis. The trend in the annual proportion of surgeries relative to the occurrence of tendon ruptures was determined using a linear regression analysis. Results: A total of 112,601 ATRs, with men accounting for 67%, were identified over 8 years. Patients aged ≥60 years accounted for 27,106 (24%), while those aged 20 to 39 years and 40 to 59 years accounted for 36,164 (32%) and 49,331 (44%), respectively. The annual incidence of ATR ranged from 12.8/100,000 to 13.9/100,000 (women, 8.2-8.9/100,000; men, 17.2-19.5/100,000), which did not change over the study period (P = .82). Moreover, the annual incidences did not change across sexes and age categories. The annual proportion of surgery increased significantly, from 67% in 2010 to 72% in 2017 (P = .003). The annual proportions increased across sexes and age categories except for women aged 40 to 59 years. Conclusion: The incidence of ATR did not change between 2010 and 2017, according to the Japanese nationwide health care database. Furthermore, the proportion of surgical treatment increased during the study period. Overall, 70% of patients underwent surgical treatment. This study suggested that the trend in ATR and surgery differed across regions.
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Affiliation(s)
- Satoshi Yamaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan.,Graduate School of Global and Transdisciplinary Studies, Chiba University, Chiba, Japan
| | - Seiji Kimura
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Ryuichiro Akagi
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Kensuke Yoshimura
- Center for Next Generation of Community Health, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan.,Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
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16
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Liu CY, Wu TC, Yang KC, Li YC, Wang CC. Ultrasonography-Guided Minimally Invasive Surgery for Achilles Sleeve Avulsions. Foot Ankle Int 2021; 42:544-553. [PMID: 33459043 DOI: 10.1177/1071100720975717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Achilles sleeve avulsion, a relatively rare disorder, is characterized by sleeve-shaped injury extending from the calcaneus, located near the tendon insertion site. Unlike midsubstance tears of the Achilles tendon, end-to-end repair is difficult because less soft tissue is preserved distally. Open repair with transosseous sutures or suture anchors is currently favored. The purpose of this study was to evaluate the technical feasibility and functional outcomes of ultrasonography-guided Achilles sleeve avulsion repair. METHODS From November 2009 to April 2018, 21 patients with Achilles sleeve avulsions (mean age, 57.8 years; range, 25-82 years) who underwent repair by the same surgeon were retrospectively reviewed. The repair was achieved through a stab wound under ultrasonographic guidance. Two parallel Bunnell-type sutures were crossed over the proximal stump and tied with sutures from suture anchors fixed in the calcaneal tuberosity. RESULTS The mean operative time was 44 minutes, and the mean wound size was 1.5 cm. The patients were allowed to walk freely on postoperative week 6 with using high-ankle shoes. At postoperative 2 years' follow-up, the American Orthopaedic Foot & Ankle Society score significantly improved from 70.9 to 97.1 (P < .05); similarly, their 12-item Short Form Health Survey scores improved significantly (P < .05). Only 2 patients had superficial wound infections, which resolved with wound care and oral antibiotics. CONCLUSION Our ultrasonography-guided surgical technique for Achilles sleeve avulsions provided excellent soft tissue visualization and availability as well as minimized the wound length to achieve good postsurgical outcomes. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Chi-Yuan Liu
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Tsung-Chiao Wu
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Kai-Chiang Yang
- School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chen Li
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Chen-Chie Wang
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.,Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien, Taiwan
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17
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Abstract
There is an ever-evolving debate about the best treatment option for Achilles tendon ruptures. There was a relative consensus that operative treatment yielded the best outcomes. Much of this is based on results in athletic populations. Conservative treatment was considered only for the elderly and those with very inactive lifestyles. There has been an evolution, however, with more surgeons utilizing an aggressive functional rehabilitation with conservative management. Surgical intervention still is the treatment of choice for elite-level athletes. The treatment of choice for patient populations other than elite athletes remains an individual choice between patient and physician.
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18
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Khazi ZM, Lu Y, Cregar W, Shamrock AG, Gulbrandsen TR, Mascarenhas R, Forsythe B. Inpatient Arthroscopic Rotator Cuff Repair Is Associated With Higher Postoperative Complications Compared With Same-Day Discharge: A Matched Cohort Analysis. Arthroscopy 2021; 37:42-49. [PMID: 32721541 DOI: 10.1016/j.arthro.2020.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare 90-day postoperative complications between patients undergoing outpatient versus inpatient arthroscopic rotator cuff repairs (RCR) and identify risk factors associated with postoperative complications. METHODS An administrative claims database was used to identify patients undergoing arthroscopic RCR from 2007 to 2015. Patients were categorized based on length of hospital stay (LOS) with inpatient RCR defined as patients with ≥1 day LOS, and outpatient RCR as patients discharged day of surgery (LOS = 0). Inpatient and outpatient RCR groups were matched based on age, sex, Charlson comorbidity index (CCI), and various medical comorbidities using 1:1 propensity score analysis. Patient factors, concomitant procedures, total adverse events (TAEs), medical adverse events (MAEs), and surgical adverse events (SAEs) were compared between the matched groups. Multiple logistic regression analysis was performed to identify risk factors associated with increased complications. RESULTS After matching, there were 2812 patients (50% outpatient) included in the study. Within 90 days following arthroscopic RCR, the incidence of TAEs (8.9% vs 3.6%, P < .0001), SAEs (2.7% vs 0.9%, P = .0002), and MAEs (6.4% vs 3.0%, P < .0001) were significantly greater for the inpatient RCR group. The multivariate model identified inpatient RCR (LOS ≥1 day), greater CCI, and anxiety or depression as independent predictors for TAEs after arthroscopic RCR. Open biceps tenodesis and inpatient RCR were independent predictors of SAEs, whereas greater CCI, anxiety or depression, and inpatient RCR were independent predictors for MAEs within 90 days after arthroscopic RCR. CONCLUSIONS Inpatient arthroscopic RCR is associated with increased risk of 90-day postoperative complications compared with outpatient. However, there is no difference for all-cause or pain-related emergency department visits within 90 days after surgery. In addition, the multivariate model identified inpatient RCR, greater CCI, and diagnosis of anxiety or depression as independent risk factors for 90-day TAEs after arthroscopic RCR. LEVEL OF EVIDENCE III, Retrospective cohort study.
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Affiliation(s)
- Zain M Khazi
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A..
| | - Yining Lu
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - William Cregar
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - Alan G Shamrock
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Trevor R Gulbrandsen
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Randy Mascarenhas
- McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
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19
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Patient perception of Achilles tendon rupture treatment. Injury 2020; 51:2710-2716. [PMID: 32773115 DOI: 10.1016/j.injury.2020.08.003] [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: 04/18/2020] [Revised: 07/27/2020] [Accepted: 08/02/2020] [Indexed: 02/02/2023]
Abstract
The optimal treatment of Achilles tendon ruptures (ATRs) is a subject of some debate amongst orthopedic surgeons. Many patients' understanding of Achilles injuries is limited and may be more informed by popular culture than anything objective. We sought to assess patient perceptions of ATRs using a proprietary questionnaire and correlate that with demographic information and the health literacy of the patient. Patients presenting with an Achilles tendon injury were asked to fill out a demographic form, the Literacy in Musculoskeletal Problems (LiMP) survey, to assess musculoskeletal health literacy, and a 22-question survey on ATRs designed to assess patient knowledge and perception of ATRs. Seventy percent of patients responded that surgery with or without other modalities is the most appropriate treatment for ATRs, while only 20% of patients responded that nonoperative treatment is most appropriate. Perceptions of treatment were not associated with demographic data or LiMP scores and appear to be biased to some degree towards surgery. In a setting in which the optimal treatment has not been fully worked out by surgeons, it is difficult to tell what influence patient perceptions may have on treatment, although it is possible these patient perceptions may cause surgeons to be more surgically aggressive.
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20
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Su AW, Bogunovic L, Johnson J, Klein S, Matava MJ, McCormick J, Smith MV, Wright RW, Brophy RH. Operative Versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Pilot Economic Decision Analysis. Orthop J Sports Med 2020; 8:2325967120909918. [PMID: 32284940 PMCID: PMC7139191 DOI: 10.1177/2325967120909918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/17/2019] [Indexed: 11/15/2022] Open
Abstract
Background The operative treatment of Achilles tendon ruptures has been associated with lower rerupture rates and better function but also a risk of surgery-related complications compared with nonoperative treatment, which may provide improved outcomes with accelerated rehabilitation protocols. However, economic decision analyses integrating the updated costs of both treatment options are limited in the literature. Purpose To compare the cost-effectiveness of operative and nonoperative treatment of acute Achilles tendon tears. Study Design Economic and decision analysis; Level of evidence, 2. Methods An economic decision model was built to assess the cost-utility ratio (CUR) of open primary repair versus nonoperative treatment for acute Achilles tendon ruptures, based on direct costs from the practices of sports medicine and foot and ankle surgeons at a single tertiary academic center, with published outcome probabilities and patient utility data. Multiway sensitivity analyses were performed to reflect the range of data. Results Nonoperative treatment was more cost-effective in the average scenario (nonoperative CUR, US$520; operative CUR, US$1995), but crossover occurred during the sensitivity analysis (nonoperative CUR range, US$224-US$2079; operative CUR range, US$789-US$8380). Operative treatment cost an extra average marginal CUR of US$1475 compared with nonoperative treatment, assuming uneventful healing in both treatment arms. The sensitivity analysis demonstrated a decreased marginal CUR of operative treatment when the outcome utility was maximized, and rerupture rates were minimized compared with nonoperative treatment. Conclusion Nonoperative treatment was more cost-effective in average scenarios. Crossover indicated that open primary repair would be favorable for maximized outcome utility, such as that for young athletes or heavy laborers. The treatment decision for acute Achilles tendon ruptures should be individualized. These pilot results provide inferences for further longitudinal analyses incorporating future clinical evidence.
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Affiliation(s)
- Alvin W Su
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA.,Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Ljiljana Bogunovic
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Jeffrey Johnson
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Sandra Klein
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Jeremy McCormick
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Matthew V Smith
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Rick W Wright
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
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21
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Lemme NJ, Li NY, Kleiner JE, Tan S, DeFroda SF, Owens BD. Epidemiology and Video Analysis of Achilles Tendon Ruptures in the National Basketball Association. Am J Sports Med 2019; 47:2360-2366. [PMID: 31268773 DOI: 10.1177/0363546519858609] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a paucity of literature regarding risk factors and mechanisms of Achilles tendon (AT) ruptures in the National Basketball Association (NBA). PURPOSE To identify the risk factors and outcomes of AT ruptures in NBA athletes. Furthermore, using video analysis, to characterize the mechanisms of rupture by identifying the most common playing situations and lower extremity positions at the time of injury. STUDY DESIGN Descriptive epidemiology study. METHODS AT ruptures in the NBA that occurred between the seasons of 1969-1970 and 2017-2018 were identified. Player data collected included age, position, body mass index, total games started before and after injury, and Player Efficiency Rating. Injury-related variables collected included date of injury, laterality, minutes played before injury, operative versus nonoperative treatment, and time to return to play. Available video footage was analyzed for the mechanism and body position at the time of injury. Univariable and multivariable linear regression was used to compare changes in performance before and after AT rupture. Statistical significance was set at P < .05. RESULTS Forty-four ruptures were identified between 1970 and 2018. The mean age was 28.3 years, with players averaging 6.8 seasons before AT rupture. AT ruptures were most prevalent during early-season game play (27.3%), followed by preseason (18.2%) and late season (18.2%). More than a third (36.8%) of players either did not return to play or started in fewer than 10 games in the remainder of their career, with 21% of ruptures leading to retirement. The mean time to return to play was 10.5 months. The Player Efficiency Rating declined by an average of 2.9 points (range, -11.5 to +2.3) (P < .001). Analysis of available injury footage (n = 12) demonstrated all ruptures to be noncontact in nature, most commonly occurring just before takeoff as the player began to push off from a stopped position, with the foot in dorsiflexion, the knee in early flexion, and the hip in extension. CONCLUSION In the NBA, a majority of AT ruptures occur early in the season, in veteran players, with almost half not returning to play or starting fewer than 10 games in the remainder of their career. The most common mechanism of injury is taking off from a stopped position just before toe-off in a dorsiflexed foot.
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Affiliation(s)
- Nicholas J Lemme
- Department of Orthopaedic Surgery, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Neill Y Li
- Department of Orthopaedic Surgery, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Justin E Kleiner
- Department of Orthopaedic Surgery, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Sydney Tan
- Department of Orthopaedic Surgery, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Aujla RS, Patel S, Jones A, Bhatia M. Non-operative functional treatment for acute Achilles tendon ruptures: The Leicester Achilles Management Protocol (LAMP). Injury 2019; 50:995-999. [PMID: 30898390 DOI: 10.1016/j.injury.2019.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/06/2019] [Accepted: 03/09/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study is to present outcomes and objective measures of assessment for acute Achilles tendon (AT) ruptures treated with an eight-week functional dynamic treatment protocol in a VACOped® boot with immediate full weight bearing mobilisation, the Leicester Achilles Management Protocol (LAMP). METHODS A prospective study of all patients treated with the LAMP with minimum 12-month follow-up was performed. Patients completed the Achilles Tendon Rupture Score (ATRS) and in the latter part of the study, objective measures of the calf muscle girth and heel raise height were obtained. RESULTS 442 patients were treated with the LAMP. There were nine (2%) re-ruptures in the 442 non-operative treated group of patients throughout the study period. ATRS at twelve months or more were available in 234 patients and objective measures in 77 patients. The mean age was 50 years. The mean ATRS was 75.5 at an average of 23 months post injury. Men had a statistically significant higher ATRS score when compared to women (p < 0.05). There was statistically significant difference in the calf muscle girth and the heel raise height when compared to the uninjured side at 12-months post-injury (p < 0.05). These differences did not correlate with the ATRS (p > 0.05). CONCLUSIONS The LAMP is a simple yet effective regime for the non-operative treatment of acute AT ruptures, which can be universally adopted without the need for many resources. Compared to other studies, the overall time in the boot is less with low complication rates and similar patient reported outcomes.
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Affiliation(s)
- Randeep S Aujla
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
| | - Shakil Patel
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Annette Jones
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maneesh Bhatia
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
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23
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Zhou K, Song L, Zhang P, Wang C, Wang W. Surgical Versus Non-Surgical Methods for Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg 2019; 57:1191-1199. [PMID: 30368430 DOI: 10.1053/j.jfas.2018.05.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Indexed: 02/03/2023]
Abstract
We performed a meta-analysis to (1) compare surgical and non-surgical treatment methods for repair of acute rupture of the Achilles tendon, in terms of the re-rupture rate, incidence of complications other than re-rupture, functional outcomes, and proportion of patients returning to previous levels of sporting activities, and (2) explore the difference in the re-rupture rate if proven early functional rehabilitation protocols were followed. PubMed, EMBASE, Medline, and Cochrane Central Register of Controlled Trials databases were searched to identify randomized clinical trials. The quality of included studies was assessed by the Cochrane risk-of-bias tool. The random-effects model or subgroup analysis would be chosen to perform the meta-analysis if the data were heterogeneous; otherwise, the fixed-effect model would be selected. Ten randomized clinical trials with a total of 934 randomized patients were included. Patients in the non-surgical group underwent higher re-ruptures than patients in the surgical group (p = .0002), but the re-rupture rates were equivalent in the non-surgical group and the surgical group (p = .08) if an early range of motion exercises protocol was performed. Lower incidence of complications excluding re-rupture was found in non-surgical patients (p = .006). However, the surgical group had better results in functional outcomes when evaluated by 2 different jump tests (drop counter-movement jump [p = .002], Hopping [p = .004]) and 1 muscular endurance test (Heel-rise work [p = .01]). The 2 groups had no significant difference in the proportion of patients returning to previous levels of sporting activities (p = 0.87). The risk of re-rupture after surgical or non-surgical treatment was equivalent if a functional rehabilitation protocol with early range of motion was performed, but the risk of other complications happening after surgical treatment was higher than in non-surgical treatment.
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Affiliation(s)
- Ke Zhou
- Surgeon, Joint Surgery of The First People's Hospital of Jingmen, Hubei, China
| | - Lei Song
- Surgeon, Postgraduate Training Base, Affiliated Hospital of Logistics University of Chinese People's Armed Police Force, Jinzhou Medical University, Tianjin, China
| | - Peng Zhang
- Surgeon, Department of Orthopaedic Center, Affiliated Hospital of Logistics University of Chinese People's Armed Police Force, Tianjin, China
| | - Chengshuang Wang
- Nurse, School of Nursing, Tongji Medical, HuaZhong University of Science & Technology, Wuhan, China
| | - Wenliang Wang
- Professor, Department of Orthopaedic Center, Affiliated Hospital of Logistics University of Chinese People's Armed Police Force, Tianjin, China.
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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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Lemme NJ, Li NY, DeFroda SF, Kleiner J, Owens BD. Epidemiology of Achilles Tendon Ruptures in the United States: Athletic and Nonathletic Injuries From 2012 to 2016. Orthop J Sports Med 2018; 6:2325967118808238. [PMID: 30505872 PMCID: PMC6259075 DOI: 10.1177/2325967118808238] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Achilles tendon (AT) ruptures are one of the most common tendon ruptures, but there have been no studies investigating these injuries in the United States (US) using data representative of the entire US population. Purpose/Hypothesis The purpose of this study was to determine the incidence and risk factors for AT ruptures in the US. We hypothesized that male sex, older age, and sport participation would increase the risk for AT ruptures. Study Design Descriptive epidemiology study. Methods All patients presenting to an emergency department with ruptured AT in the US from 2012 through 2016 were selected from the National Electronic Injury Surveillance System (NEISS) database. Incidence was calculated for sex, race, and age. AT ruptures were characterized based on the mechanism of injury, with subanalyses performed on sport-related AT ruptures to examine sex-, race-, and age-related differences. Results From 2012 to 2016, a significant increase in the incidence of AT ruptures was observed, from 1.8 per 100,000 person-years in 2012 to 2.5 per 100,000 person-years in 2016 (P < .01), for an overall incidence of 2.1 per 100,000 person-years. The majority of AT ruptures occurred in male compared with female patients, with an incidence rate ratio of 3.5 (P < .01). The largest overall incidence of AT ruptures occurred in those aged 20-39 years for male patients (5.6/100,000 person-years) and in those aged 40-59 years for female patients (1.2/100,000 person-years). The largest rise in the incidence of AT ruptures during the study period was observed in patients aged 40-59 years (78% increase). The most common injury mechanism was participation in a sport or recreational activity (81.9% of all injuries), with basketball being the most common overall cause of AT ruptures. Conclusion While AT ruptures in the US most commonly occur in young male patients (20-39 years old), the largest rise in the incidence was observed in middle-aged patients (40-59 years old), with participation in recreational sports being the most likely mechanism. Recognizing high-risk patients can help physicians counsel them and recommend strategies for injury prevention.
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Affiliation(s)
- Nicholas J Lemme
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Neill Y Li
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Justin Kleiner
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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Humbyrd CJ, Bae S, Kucirka LM, Segev DL. Incidence, Risk Factors, and Treatment of Achilles Tendon Rupture in Patients With End-Stage Renal Disease. Foot Ankle Int 2018; 39:821-828. [PMID: 29582683 PMCID: PMC6023765 DOI: 10.1177/1071100718762089] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Dialysis-dependent patients and kidney transplant recipients may be at increased risk for Achilles tendon rupture (ATR). METHODS We studied Medicare patients with end-stage renal disease (ESRD) from 1999 through 2013. Patients were categorized as waitlisted for a transplant, not waitlisted, or received a transplant. We performed multivariate negative binomial regression using demographic characteristics, comorbidities, and year of study entry to estimate adjusted incidence rate ratios (aIRRs), identify ATR risk factors, and determine treatment patterns and outcomes. RESULTS We identified 1091 ATRs (incidence, 3.80/10 000 person-years; 95% confidence interval [CI], 3.58-4.03). Compared with transplant recipients, nonwaitlisted patients had a lower incidence (aIRR, 0.44; 95% CI, 0.37-0.53), and waitlisted patients had a similar incidence (aIRR, 0.94; 95% CI, 0.78-1.12) of ATR. ATR incidence was higher among patients taking fluoroquinolones (aIRR, 1.65; 95% CI, 1.32-1.84) and corticosteroids (aIRR, 1.72; 95% CI, 1.44-2.05) compared with those who did not. Patients with ATR were younger, had higher mean body mass index, and had fewer comorbidities than patients without ATR. Seventeen percent of patients received operative treatment within 14 days of ATR diagnosis. The 30-day cumulative incidence of operative site infections was 6.5%. CONCLUSION The incidence of ATR was higher among transplant recipients and waitlisted patients compared with nonwaitlisted patients. Younger age, higher body mass index, fewer comorbidities, fluoroquinolone use, and corticosteroid use were risk factors for ATR. Patients were more likely to receive nonoperative than operative treatment for ATR. Those who underwent operative treatment had a low incidence of operative site infection. LEVEL OF EVIDENCE Prognostic level III, comparative study.
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Affiliation(s)
- Casey Jo Humbyrd
- Department of Orthopaedic Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Sunjae Bae
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD,Department of Epidemiology, The Johns Hopkins School of Public Health, Baltimore, MD
| | - Lauren M. Kucirka
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD,Department of Epidemiology, The Johns Hopkins School of Public Health, Baltimore, MD
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Abstract
There has been a dramatic rise in the use of large-scale health administrative databases to investigate clinical outcomes within sports medicine over the past few years. Although these data sets identify large numbers of patients, allowing for the investigation of regional trends, health care utilization, and outcomes of surgical intervention, they were not designed with the intention of answering clinical questions. Recognizing the methodological limitations associated with these databases is prudent to avoid propagating spurious conclusions. This article offers an overview of the administrative databases commonly used within the orthopedic sports medicine literature and provides key principles for their critical appraisal.
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Affiliation(s)
- David Wasserstein
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, MG323 - 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
| | - Ujash Sheth
- Division of Orthopaedic Surgery, University of Toronto, MG323 - 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
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Dams OC, Reininga IHF, Gielen JL, van den Akker-Scheek I, Zwerver J. Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review. Injury 2017; 48:2383-2399. [PMID: 28943056 DOI: 10.1016/j.injury.2017.09.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/10/2017] [Accepted: 09/11/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the role of imaging in the diagnosis and monitoring of the Achilles tendon rupture (ATR). STUDY DESIGN Systematic review. DATA SOURCES PubMed and EMBASE in November 2016. ELIGIBILITY CRITERIA Clinical studies providing information on the methods and role of imaging in the diagnosis and monitoring of the ATR were included. RESULTS Fifty-six studies were included, most concerning the use of ultrasound (n=37) or MRI (n=18). Seven studies provided data on the diagnostic accuracy of imaging. Most ultrasound studies used a 7.5MHz probe (19/32 studies) and scanned the patient bilaterally in prone position, with recent studies tending to use higher frequency probes (r=0.42). Sensitivity [for detecting a rupture] ranged from 79.6 to 100%; the spread in specificity was large but two studies showed perfect (100%) data. Negative and positive likelihood ratios ranged from 0 to 0.23 and 1.0 to 10 respectively. MRI examination was generally performed with 1.5Tesla (T) MRI (6/12 studies) with a strong trend for higher T strength in more recent studies (r=0.71). One study reported a sensitivity of 90.9% and one a specificity of 100%. Although imaging can visualize structure and healing, these results were generally not related to the clinical picture. Overall, ultrasound was recommended over MRI for diagnosis and monitoring. Results of other imaging modalities remain inconclusive. CONCLUSION The adjunct role of imaging, especially of ultrasound and MRI, in the diagnosis and monitoring of ATRs was established. It is therefore recommended to rely primarily on the clinical examination and evaluation and to use imaging for ruling out other injuries and providing additional clinical information. More high-quality research is warranted into the diagnostic accuracy of imaging as well as less conventional imaging modalities' diagnostic and monitoring capabilities.
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Affiliation(s)
- Olivier C Dams
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Inge H F Reininga
- University of Groningen, University Medical Center Groningen, Department of Trauma Surgery, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jan L Gielen
- Antwerp University Hospital, S.P.O.R.T.S., Wilrijkstraat 10, Edegem-Antwerp, 2650, Belgium
| | - Inge van den Akker-Scheek
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johannes Zwerver
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Ho G, Tantigate D, Kirschenbaum J, Greisberg JK, Vosseller JT. Increasing age in Achilles rupture patients over time. Injury 2017; 48:1701-1709. [PMID: 28457569 DOI: 10.1016/j.injury.2017.04.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. METHODS Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. RESULTS The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. CONCLUSION Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. LEVEL OF EVIDENCE Level III; Retrospective cohort study.
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Affiliation(s)
- Gavin Ho
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Direk Tantigate
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Josh Kirschenbaum
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Justin K Greisberg
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - J Turner Vosseller
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States.
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Erickson BJ, Basques BA, Griffin JW, Taylor SA, O'Brien SJ, Verma NN, Romeo AA. The Effect of Concomitant Biceps Tenodesis on Reoperation Rates After Rotator Cuff Repair: A Review of a Large Private-Payer Database From 2007 to 2014. Arthroscopy 2017; 33:1301-1307.e1. [PMID: 28336230 DOI: 10.1016/j.arthro.2017.01.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 12/15/2016] [Accepted: 01/05/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine if reoperation rates are higher for patients who underwent isolated rotator cuff repair (RCR) than those who underwent RCR with concomitant biceps tenodesis using a large private-payer database. METHODS A national insurance database was queried for patients who underwent arthroscopic RCR between the years 2007 and 2014 (PearlDiver, Warsaw, IN). The Current Procedural Terminology (CPT) 29,827 (arthroscopy, shoulder, surgical; with RCR) identified RCR patients who were subdivided into 3 groups-group 1: RCR without biceps tenodesis; group 2: RCR with concomitant arthroscopic biceps tenodesis (CPT 29827 and 29,828); group 3: RCR with concomitant open biceps tenodesis (CPT 29827 and 23,430). Reoperation rates (revision RCR, subsequent biceps surgeries) and complications at 30 days, 90 days, 6 months, and 1 year were analyzed. Multivariate logistic regression was used to compare reoperations and complications between groups. Rotator cuff tear size, whether the biceps was ruptured and whether a biceps tenotomy was performed, was not available. RESULTS Group 1: 27,178 patients. Group 2: 4,810 patients. Group 3: 1,493 patients. More patients underwent concomitant arthroscopic than concomitant open tenodesis (P < .001). A total of 2,509 patients underwent a reoperation for RCR or biceps tenodesis within 1 year after RCR. When adjusted for age, sex, and comorbidities, no significant differences in reoperation rates at 30 days or 90 days among the 3 groups, but significantly more patients who had a tenodesis, required a reoperation compared with those who did not have a tenodesis at 6 months and 1 year (both P < .001). Urinary tract infections were more common in patients who did not have a tenodesis, whereas dislocation, nerve injury, and surgical site infection were more common in tenodesis patients. CONCLUSIONS Higher reoperation rates at 1 year were seen in patients who had concomitant biceps tenodesis. LEVEL OF EVIDENCE Level III, case-control database review study.
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Affiliation(s)
- Brandon J Erickson
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A..
| | - Bryce A Basques
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Justin W Griffin
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | | | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Anthony A Romeo
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
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Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal SB. The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27 607 patients. Bone Joint J 2017; 99-B:78-86. [PMID: 28053261 DOI: 10.1302/0301-620x.99b1.bjj-2016-0434.r1] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/19/2016] [Indexed: 11/05/2022]
Abstract
AIMS The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada. PATIENTS AND METHODS Patients ≥ 18 years of age who presented with an AATR to an emergency department in Ontario, Canada between 1 January 2003 and 31 December 2013 were identified using administrative databases. The overall and annual incidence density rate (IDR) of AATR were calculated for all demographic subgroups. The annual rate of surgical repair was also calculated and compared between demographic subgroups. RESULTS A total of 27 607 patients (median age, 44 years; interquartile range 26 to 62; 66.5% male) sustained an AATR. The annual IDR increased from 18.0 to 29.3 per 100 000 person-years between 2003 and 2013. The mean IDR was highest among men between the ages of 40 and 49 years (46.0/100 000 person-years). The annual rate of surgical repair dropped from 20.1 in 2003 to 9.2 per 100 AATRs in 2013. There was a noticeable decline after 2009. CONCLUSION The incidence of AATR is increasing in Ontario, while the annual rate of surgical repair is decreasing. A sharp decline in the rate of surgical repair was noted after 2009. This coincided with the publication of several high-quality RCTs which showed similar outcomes for the 'functional' non-operative management and surgical repair. Cite this article: Bone Joint J 2017;99-B:78-86.
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Affiliation(s)
- U Sheth
- University of Toronto, Division of Orthopaedic Surgery, 160-500 University Avenue, Toronto, Ontario, Canada
| | - D Wasserstein
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada
| | - R Jenkinson
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada
| | - R Moineddin
- University of Toronto, 500 University Avenue, Ontario, Canada
| | - H Kreder
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada
| | - S B Jaglal
- Institute of Health Policy, Management and Evaluation, University of Toronto, Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
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