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Zeybek H, Cici H, Çıklaçandır S. A comparative biomechanical study of the krackow suture technique with three common percutaneous suture techniques in the treatment of Achilles tendon ruptures. Foot Ankle Surg 2024; 30:366-370. [PMID: 38368157 DOI: 10.1016/j.fas.2024.02.006] [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: 12/04/2023] [Revised: 01/25/2024] [Accepted: 02/09/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND The aim of this study was to compare the biomechanical resistance under tensile forces of the Krackow suture technique with the frequently used Dresden, Carmont & Maffulli, and Ma & Griffiths percutaneous repair techniques in bovine models of Achilles tendon rupture. METHODS Transverse Achilles tendon rupture models were created from 4 cm proximal of the calcaneal insertion point in a total of 20 bovine Achilles tendon specimens. These were randomly allocated to 4 groups and repaired with configurations appropriate to the Dresden, Carmont & Maffulli, Ma & Griffiths and Krackow techniques. Failure mechanisms were recorded with force values (as Newton units) creating a 5 mm gap and load to failure under tensile loading at a rate of 10 mm/sec in a static testing device. RESULTS In the Dresden technique group, the force required for a 5 mm gap was mean 41.21 ± 13.19 N and for load to failure, mean 193.83 ± 30.16 N, which were evaluated as statistically significantly higher than in the other techniques (p < 0.05). The lowest values were determined in the Ma & Griffiths technique group (5 mm gap: 11.06 ± 8.12 N, load to failure: 97.73 ± 29.60 N) but these were not significantly lower than the values in the Krackow and Carmont & Maffulli technique groups (p > 0.05). CONCLUSION The results of this study showed that the Dresden technique was biomechanically superior against tensile forces compared to the Krackow technique, and the other frequently used percutaneous techniques of Carmont & Maffulli and Ma & Griffiths.
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Affiliation(s)
- Hakan Zeybek
- Department of Orthopaedics and Traumatology, İzmir Katip Celebi University, Atatürk Training and Research Hospital, İzmir, Turkiye.
| | - Hakan Cici
- Department of Orthopaedics and Traumatology, İzmir Demokrasi University, Buca Seyfi Demirsoy Training and Research Hospital, İzmir, Turkiye.
| | - Samet Çıklaçandır
- Department of Biomedical Engineering, İzmir Katip Celebi University, İzmir, Turkiye.
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Wang R, Huang L, Jiang S, You G, Zhou X, Wang G, Zhang L. Immediate mobilization after repair of Achilles tendon rupture may increase the incidence of re-rupture: a systematic review and meta-analysis of randomized controlled trials. Int J Surg 2024; 110:3888-3899. [PMID: 38477123 PMCID: PMC11175757 DOI: 10.1097/js9.0000000000001305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/23/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Achilles tendon rupture (ATR) is a significant injury that can require surgery and can have the risk of re-rupture even after successful treatment. Consequently, to minimize this risk, it is important to have a thorough understanding of the rehabilitation protocol and the impact of different rehabilitation approaches on preventing re-rupture. MATERIALS AND METHODS Two independent team members searched several databases (PubMed, EMBASE, Web of Science, Cochrane Library, and CINAHL) to identify randomized controlled trials (RCTs) on operative treatment of ATR. We included articles that covered open or minimally invasive surgery for ATR, with a detailed rehabilitation protocol and reports of re-rupture. The study protocol has been registered at PROSPERO and has been reported in the line with PRISMA Guidelines, Supplemental Digital Content 1, http://links.lww.com/JS9/C85 , Supplemental Digital Content 2, http://links.lww.com/JS9/C86 and assessed using AMSTAR Tool, Supplemental Digital Content 3, http://links.lww.com/JS9/C87 . RESULTS A total of 43 RCTs were eligible for the meta-analysis, encompassing a combined cohort of 2553 patients. Overall, the postoperative incidence of ATR patients developing re-rupture was 3.15% (95% CI: 2.26-4.17; I2 =44.48%). Early immobilization group patients who had ATR had a 4.07% (95% CI: 1.76-7.27; I2 =51.20%) postoperative incidence of re-rupture; Early immobilization + active range of motion (AROM) group had an incidence of 5.95% (95% CI: 2.91-9.99; I2 =0.00%); Early immobilization + weight-bearing group had an incidence of 3.49% (95% CI: 1.96-5.43; I2 =20.06%); Early weight-bearing + AROM group had an incidence of 3.61% (95% CI: 1.00-7.73; I2 =64.60%); Accelerated rehabilitation (immobilization) group had an incidence of 2.18% (95% CI: 1.11-3.59; I2 =21.56%); Accelerated rehabilitation (non-immobilization) group had a rate of 1.36% (95% CI: 0.12-3.90; I2 =0.00%). Additionally, patients in the immediate AROM group had a postoperative re-rupture incidence of 3.92% (95% CI: 1.76-6.89; I2 =33.24%); Non-immediate AROM group had an incidence of 2.45% (95% CI: 1.25-4.03; I2 =22.09%). CONCLUSIONS This meta-analysis suggests the use of accelerated rehabilitation intervention in early postoperative rehabilitation of the Achilles tendon. However, for early ankle joint mobilization, it is recommended to apply after one to two weeks of immobilization.
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Affiliation(s)
- Ruihan Wang
- School of Physical Education, Southwest Medical University
- Department of Rehabilitation, Yibin Integrated Traditional Chinese and Western Medicine Hospital, Yibin, China
| | - Lei Huang
- School of Physical Education, Southwest Medical University
| | - Songtao Jiang
- School of Clinical Medicine, Southwest Medical University
| | - Guixuan You
- School of Physical Education, Southwest Medical University
| | - Xin Zhou
- Department of Orthopedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Center for Orthopedic Diseases Research, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Luzhou Key Laboratory of Orthopedic Disorders, Luzhou
| | - Guoyou Wang
- Department of Orthopedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Center for Orthopedic Diseases Research, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Luzhou Key Laboratory of Orthopedic Disorders, Luzhou
| | - Lei Zhang
- Department of Orthopedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Center for Orthopedic Diseases Research, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University
- Luzhou Key Laboratory of Orthopedic Disorders, Luzhou
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Yeo YH, Jo SK, Kim MH, Lee SJ, Han SY, Park MH, Kim DY, Kim DY, Yoo IH, Kang C, Song JH, Park WH. Fabrication of atelocollagen-coated bioabsorbable suture and the evaluation of its regenerative efficacy in Achilles tendon healing using a rat experimental model. Int J Biol Macromol 2024; 271:132564. [PMID: 38782324 DOI: 10.1016/j.ijbiomac.2024.132564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024]
Abstract
Recently, the incidence of Achilles tendon ruptures (ATRs) has become more common, and repair surgery using a bioabsorbable suture is generally preferred, particularly in the case of healthy patients. Sutures composed of poly(lactic-co-glycolic acid) (PLGA) are commonly used in ATR surgeries. Nevertheless, owing to the inherent limitations of PLGA, novel bioabsorbable sutures that can accelerate Achilles tendon healing are sought. Recently, several studies have demonstrated the beneficial effects of atelocollagen on tendon healing. In this study, poly(3,4-dihydroxy-L-phenylalanine) (pDOPA), a hydrophilic biomimetic material, was used to modify the hydrophobic surface of a PLGA suture (Vicryl, VC) for the stable coating of atelocollagen on its surface. The main objective was to fabricate an atelocollagen-coated VC suture and evaluate its performance in the healing of Achilles tendon using a rat model of open repair for ATR. Structural analyses of the surface-modified suture indicated that the collagen was successfully coated on the VC/pDOPA suture. Postoperative in vivo biomechanical analysis, histological evaluation, ultrastructural/morphological analyses, and western blotting confirmed that the tendons in the VC/pDOPA/Col group exhibit superior healing than those in the VC and VC/pDOPA groups after 1 and 6 weeks following the surgery. The this study suggests that atelocollagen-coated PLGA/pDOPA sutures are preferable for future medical applications, especially in the repair of ATR.
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Affiliation(s)
- Yong Ho Yeo
- Department of Organic Materials Engineering, Chungnam National University, Daejeon, Republic of Korea
| | - Seong Kyeong Jo
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, Republic of Korea
| | - Min Hee Kim
- Department of Textile Engineering, Kyungpook National University, Republic of Korea
| | - Su Jeong Lee
- R&D planning team, Organoid Sciences Co., Ltd., 331, Pangyo-ro, Bundang-gu, Seongnam-si, Republic of Korea
| | - Seung Yun Han
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Mun Hyang Park
- Department of Pathology, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Dae Young Kim
- Department of Pathology, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Dae Yeung Kim
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, Republic of Korea
| | - In Ha Yoo
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chan Kang
- Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jae Hwang Song
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, Republic of Korea.
| | - Won Ho Park
- Department of Organic Materials Engineering, Chungnam National University, Daejeon, Republic of Korea.
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Zhao Y, Wang H, Zhao B, Diao S, Gao Y, Zhou J, Liu Y. The learning curve for minimally invasive Achilles repair using the "lumbar puncture needle and oval forceps" technique. BMC Musculoskelet Disord 2024; 25:373. [PMID: 38730376 PMCID: PMC11088138 DOI: 10.1186/s12891-024-07489-9] [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: 01/03/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION An acute Achilles tendon rupture represents a common tendon injury, and its operative methods have been developed over the years. This study aimed to quantify the learning curve for the minimally invasive acute Achilles tendon rupture repair. METHODS From May 2020 to June 2022, sixty-seven patient cases who received minimally invasive tendon repair were reviewed. Baseline data and operative details were collected. The cumulative summation (CUSUM) control chart was used for the learning curve analyses. Achilles tendon rupture score (ATRS), American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score, and visual analog scale (VAS) at 3/6/9/12 months were calculated to assess the clinical outcomes. RESULTS Thirty-six cases underwent at least a year of follow up and were enrolled in this study. The gender ratio and average age were 80.5% and 32.5 years. The linear equation fitted well (R2 = 0.95), and CUSUM for operative time peaked in the 12th case, which was divided into the learning phase (n = 12) and master phase (n = 24). No significant difference was detected between the two groups in clinical variables, except for the operative time (71.1 ± 13.2 min vs 45.8 ± 7.2 min, p = 0.004). Moreover, we detected one case with a suture reaction and treated it properly. CONCLUSION Minimally invasive Achilles repair provides an opportunity for early rehabilitation. Notably, the learning curve showed that the "lumbar puncture needle and oval forceps" technique was accessible to surgeons.
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Affiliation(s)
- Yanrui Zhao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China
| | - Hanzhou Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China
| | - Binzhi Zhao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China
| | - Shuo Diao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China
| | - Yuling Gao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China
| | - Junlin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China.
| | - Yang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China.
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Christensen M, Silbernagel KG, Zellers JA, Kjær IL, Rathleff MS. Feasibility of an early progressive resistance exercise program for acute Achilles tendon rupture. Pilot Feasibility Stud 2024; 10:66. [PMID: 38650039 PMCID: PMC11034137 DOI: 10.1186/s40814-024-01494-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 04/14/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Long-term strength deficits are common after Achilles tendon ruptures. Early use of progressive resistance exercises may help reduce strength deficits, but the feasibility of this approach is unknown. The aim was to investigate the feasibility of early progressive resistance exercises regarding patient acceptability and compliance with the intervention. METHODS We recruited patients with an acute Achilles tendon rupture treated non-surgically. During 9 weeks of immobilisation with a walking boot, participants attended weekly supervised physiotherapy sessions of progressive resistance exercises and performed home exercises, consisting of isometric ankle plantarflexion, seated heel-rise, and elastic band exercises. Acceptability was evaluated using a 7-point Likert scale (1 = very unacceptable and 7 = very acceptable) with feasibility threshold at 80% of the participants rating ≥ 4. Adherence to the exercises was defined as 80% of the participants performing at least 50% of the home exercises. During the intervention, tendon healing and adverse events were monitored. RESULTS Sixteen participants (mean age 46 (range 28-61), male/female = 13/3) completed the intervention. Pre-injury Achilles tendon total rupture score was 98 (SD 8). All participants rated the acceptability of the exercises ≥ 5 (moderate acceptable to very acceptable) at 9- and 13-week follow-up and 9/16 rated 7 points (very acceptable). Participants performed 74% (range 4-117) of the total prescribed home exercises and 15/16 performed > 50%. One participant was not compliant with the home exercises due to feeling uncomfortable performing these independently. There were no re-ruptures, but one case of deep venous thrombosis. CONCLUSIONS The early progressive resistance exercise program for treatment of non-surgically treated Achilles tendon rupture was feasible. Future studies should investigate the efficacy of the progressive intervention. TRIAL REGISTRATION The study was registered at Clinical Trials (NCT04121377) on 29 September 2019. CLINICALTRIALS NCT04121377 .
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Affiliation(s)
- Marianne Christensen
- Physiotherapy and Occupational Therapy, Aalborg University Hospital, Hobrovej 18-22, Aalborg, 9000, Denmark.
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Jennifer A Zellers
- Program in Physical Therapy and Department of Orthopaedic Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Inge Lunding Kjær
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Michael Skovdal Rathleff
- Physiotherapy and Occupational Therapy, Aalborg University Hospital, Hobrovej 18-22, Aalborg, 9000, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Abstract
The Achilles tendon has a high incidence of ruptures often occurring in weekend warriors and the aging population. Based on anatomic studies of the Achilles tendon, ruptures are commonly found in the watershed area proximal to the insertion site. Traditionally, treatment options included conservative therapy with immobilization and a prolonged non-weight-bearing phase versus surgical treatment. Surgical treatment can vary between open, minimally invasive, or percutaneous approaches. In more recent years, early functional rehabilitation with or without surgery has shown to have successful results.
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Affiliation(s)
- Varsha Salunkhe Ivanova
- Kaiser Permanente Foot and Ankle Surgery, 700 Lawrence Expressway, Santa Clara, CA 95051, USA.
| | - Khanh Phuong Sieu Tong
- Kaiser Permanente Foot and Ankle Surgery, 700 Lawrence Expressway, Santa Clara, CA 95051, USA
| | - Cristian Neagu
- Kaiser Permanente Santa Clara Foot and Ankle Surgery, 700 Lawrence Expressway, Santa Clara, CA 95051, USA
| | - Christy M King
- Kaiser Permanente, Department of Foot & Ankle Surgery, 3600 Broadway, Clinic 17, Oakland, CA 94611, USA; Kaiser San Francisco Bay Area Foot & Ankle Residency Program, Oakland, CA, USA
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Nilsson N, Alim MDA, Dietrich-Zagonel F, Concaro S, Brorsson A, Nilsson Helander K, Eliasson P. The Delayed Presentation of Achilles Tendon Ruptures Is Associated With Marked Alterations in the Gene Expression of COL1A1, MMPs, TIMPs, and IL-6. Am J Sports Med 2024; 52:164-173. [PMID: 38164679 DOI: 10.1177/03635465231212669] [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: 01/03/2024]
Abstract
BACKGROUND Both acute and chronic Achilles tendon ruptures are affected by alterations in the extracellular matrix during the healing process of the tendon. Yet, these alterations in gene expression patterns are not well characterized. PURPOSE To characterize temporal and spatial differences in gene expression patterns after an Achilles tendon rupture and to evaluate if cells from chronic Achilles tendon ruptures have the same ability to form new tendon tissue (tendon constructs) as healthy tendon cells. STUDY DESIGN Controlled laboratory study. METHODS A total of 35 patients with surgically treated Achilles tendon ruptures were included in the study and divided into 3 groups: acute (<4 weeks), short-term chronic (1-6 months), and long-term chronic (>6 months). Biopsy specimens were collected during surgical repair and were used to analyze the gene expression within the different groups and to compare mRNA levels in the proximal and distal tendon ends. A complementary in vitro experiment was performed to evaluate if cells from chronic Achilles tendon ruptures can form tendon constructs. RESULTS The mRNA levels for COL1A1 and COL3A1 were significantly higher in the short-term chronic group compared with the acute group (P < .05). Both MMP-1 and MMP-13 had the highest mRNA levels in the acute group (P < .01) compared with the long-term chronic group, while MMP-2 had the highest mRNA level in the short-term chronic group. Significant differences between the proximal and distal tendon ends were only detected for the monocyte and macrophage marker CD163 (P < .05), which was more expressed proximally. Cells extracted from chronic Achilles tendon ruptures displayed a similar ability and effectiveness to form tendon constructs as healthy tendon cells. CONCLUSION A high collagenase gene activity after an Achilles tendon rupture indicated possible rapid matrix degradation in the acute phase. Chronic ruptures appeared to initiate the healing process even before treatment, indicated by the higher expression of collagen in the short-term chronic group. Cells from chronic Achilles tendon ruptures also displayed an ability to form new tendon tissue in vitro. CLINICAL RELEVANCE The study shows a rapid increase in collagenase gene expression, which could lead to matrix degradation that continues for months after an Achilles tendon rupture.
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Affiliation(s)
- Niklas Nilsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - M D Abdul Alim
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Franciele Dietrich-Zagonel
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Sebastian Concaro
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Annelie Brorsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- IFK Kliniken Rehab, Gothenburg, Sweden
| | - Katarina Nilsson Helander
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Pernilla Eliasson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Jo SK, Yoo IH, Park HY, Kang C, Han SY, Moon JH, Park WH, Yeo YH, Jun S, Yi YS, Lee SJ, Tae JY, Song JH. An Atelocollagen Injection Enhances the Healing of Nonoperatively Treated Achilles Tendon Tears: An Experimental Study in Rats. Orthop J Sports Med 2023; 11:23259671231200933. [PMID: 37868218 PMCID: PMC10586006 DOI: 10.1177/23259671231200933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 10/24/2023] Open
Abstract
Background There is growing interest in nonoperative treatment for the management of Achilles tendon ruptures (ATRs). However, nonoperative treatment is limited by the risk of tendon reruptures and low satisfaction rates. Recently, atelocollagen injections have been reported to have beneficial effects on tendon healing. Purpose To evaluate the beneficial effects of injected atelocollagen on Achilles tendon healing and investigate the mechanism of atelocollagen on tendon healing. Study Design Controlled laboratory study. Methods Percutaneous tenotomy of the right Achilles tendon in 66 rats was performed. The animals were equally divided into the noninjection group (NG) and the collagen injection group (CG). At 1, 3, and 6 weeks, the Achilles functional index, cross-sectional area, load to failure, stiffness, stress, and the modified Bonar score were assessed. Transmission electron microscopy, western blotting, and immunohistochemistry were also performed. Results The Achilles functional index (-6.8 vs -43.0, respectively; P = .040), load to failure (42.1 vs 27.0 N, respectively; P = .049), and stiffness (18.8 vs 10.3 N/mm, respectively; P = .049) were higher in the CG than those in the NG at 3 weeks. There were no significant differences in histological scores between the 2 groups. Transmission electron microscopy analysis showed that the mean diameter of collagen fibrils in the CG was greater than that in the NG at 3 weeks (117.2 vs 72.6 nm, respectively; P < .001) and 6 weeks (202.1 vs 144.0 nm, respectively; P < .001). Western blot analysis showed that the expression of collagen type I in the CG was higher than that in the NG at 1 week (P = .005) and 6 weeks (P = .001). Conclusion An atelocollagen injection had beneficial effects on the healing of nonoperatively treated Achilles tendon injuries. The Achilles tendon of CG rats exhibited better functional, biomechanical, and morphological outcomes compared with NG rats. The molecular data indicated that the mechanism of atelocollagen injections may be associated with an increased amount of collagen type I. Clinical Relevance An atelocollagen injection might be a good adjuvant option for the nonoperative treatment of ATRs.
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Affiliation(s)
- Seong Kyeong Jo
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, Republic of Korea
| | - In Ha Yoo
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyeon Yeong Park
- Department of Occupational Therapy, College of Medical Science, Konyang University, Daejeon, Republic of Korea
| | - Chan Kang
- Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Seung Yun Han
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Ji Hyun Moon
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Won Ho Park
- Department of Organic Materials Engineering, Chungnam National University, Daejeon, Republic of Korea
| | - Yong Ho Yeo
- Department of Organic Materials Engineering, Chungnam National University, Daejeon, Republic of Korea
| | - Sangmi Jun
- Center for Research Equipment, Korea Basic Science Institute, Daejeon, Republic of Korea
| | - Yoon-Sun Yi
- Center for Research Equipment, Korea Basic Science Institute, Daejeon, Republic of Korea
| | - Su Jeong Lee
- Department of Microbiology, School of Medicine, CHA University, Seongnam, Republic of Korea
| | - Jung Yeon Tae
- Department of Medicine, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Jae Hwang Song
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, Republic of Korea
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Bishop ME, Comer CD, Kane JM, Maltenfort MG, Raikin SM. Republication of "Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231188102. [PMID: 37506168 PMCID: PMC10369100 DOI: 10.1177/24730114231188102] [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: 07/30/2023] Open
Abstract
Background Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications. Methods A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted. Results There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected (P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature (P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature (P < .0001; CI 0.067-1.94). Conclusion In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature. Level of Evidence Level IV.
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Affiliation(s)
- Meghan E Bishop
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Carly D Comer
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Justin M Kane
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
- Baylor University Medical Center, Dallas, TX USA
| | - Mitchell G Maltenfort
- Rothman Institute of Orthopaedics at Thomas Jefferson University, Philadelphia, PA, USA
| | - Steven M Raikin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Institute of Orthopaedics at Thomas Jefferson University, Philadelphia, PA, USA
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Pearsall C, Arciero E, Czerwonka N, Gupta P, Vosseller JT, Trofa DP. A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures. Foot Ankle Surg 2023; 29:317-323. [PMID: 37098457 DOI: 10.1016/j.fas.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/04/2023] [Accepted: 04/08/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context. METHODS A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review. RESULTS Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study. CONCLUSION Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context. LEVEL OF EVIDENCE Level IV; Systematic Review.
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Affiliation(s)
- Christian Pearsall
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Emily Arciero
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Natalia Czerwonka
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Puneet Gupta
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | | | - David P Trofa
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA.
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11
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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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12
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Hansen MS, Bencke J, Kristensen MT, Kallemose T, Hölmich P, Barfod KW. Achilles tendon gait dynamics after rupture: A three-armed randomized controlled trial comparing an individualized treatment algorithm vs. operative or non-operative treatment. Foot Ankle Surg 2023; 29:143-150. [PMID: 36528540 DOI: 10.1016/j.fas.2022.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Individual treatment selection has been proposed as the key to optimized treatment. The purpose was to investigate if treatment selection using the individualized treatment algorithm Copenhagen Achilles Rupture Treatment Algorithm (CARTA) differs between patients treated as usual regarding gait dynamics and tendon elongation. METHODS The patients were randomized to one of three parallel groups: 1) intervention group: participants treated according to CARTA, 2) control group: participants treated non-operatively, 3) control group: participants treated operatively. The primary outcome was ankle peak power during push off during walking at 12 months. RESULTS 156 patients were assessed for eligibility. 21 were allocated to the intervention group, and 20 and 19 to the control groups. The results indicated no statistically significant differences between the intervention group and the control groups. CONCLUSIONS Individualized treatment selection based on CARTA did not demonstrate less affected gait dynamics or less tendon elongation than patients treated as usual.
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Affiliation(s)
- Maria Swennergren Hansen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark; Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Jesper Bencke
- Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Morten Tange Kristensen
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark.
| | - Thomas Kallemose
- Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Per Hölmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
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13
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Crook BS, Varshneya K, Meyer LE, Anastasio A, Cullen MM, Lau BC. Operative Versus Nonoperative Treatment of Acute Achilles Tendon Rupture: A Propensity Score-Matched Analysis of a Large National Dataset. Orthop J Sports Med 2023; 11:23259671231152904. [PMID: 36874053 PMCID: PMC9974620 DOI: 10.1177/23259671231152904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/09/2022] [Indexed: 03/02/2023] Open
Abstract
Background No consensus exists regarding the superiority of operative versus nonoperative management for Achilles tendon ruptures, as multiple randomized controlled trials conducted since the advent of early mobilization protocols have found outcomes for these 2 interventions to be more similar than were previously held. Purpose To use a large national database to (1) compare reoperation and complication rates between operative and nonoperative treatment of acute Achilles tendon ruptures and (2) evaluate trends in treatment and cost over time. Study Design Cohort study; Level of evidence, 3. Methods The MarketScan Commercial Claims and Encounters database was used to identify an unmatched cohort of 31,515 patients who sustained primary Achilles tendon ruptures between 2007 and 2015. Patients were stratified into operative and nonoperative treatment groups, and a propensity score-a matching algorithm-was used to establish a matched cohort of 17,996 patients (n = 8993 per treatment group). Reoperation rates, complications, and aggregate treatment costs were compared between groups with an alpha level of .05. A number needed to harm (NNH) was calculated from the absolute risk difference in complications between cohorts. Results The operative cohort experienced a significantly larger total number of complications within 30 days of injury (1026 vs 917; P = .0088). The absolute increase in cumulative risk was 1.2% with operative treatment, which resulted in an NNH of 83. Neither 1-year (1.1% [operative] vs 1.3% [nonoperative]; P = .1201) nor 2-year reoperation rates (1.9% [operative] vs 2% [nonoperative]; P = .2810) were significantly different. Operative care was more expensive than nonoperative care at 9 months and 2 years after injury; however, there was no difference in cost between treatments at 5 years. Before matching, the rate of surgical repair for Achilles tendon rupture remained stable, from 69.7% to 71.7% between 2007 and 2015, indicating little change in practice in the United States. Conclusion Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. Operative management was associated with an increased risk of complications and higher initial costs, which dissipated over time. Between 2007 and 2015 the proportion of Achilles tendon ruptures managed operatively remained similar despite increasing evidence that nonoperative management of Achilles tendon rupture may provide equivalent outcomes.
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Affiliation(s)
- Bryan S Crook
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Kunal Varshneya
- Stanford University School of Medicine, Stanford, California, USA
| | - Lucy E Meyer
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Albert Anastasio
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Mark M Cullen
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Brian C Lau
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
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14
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Kumar P, Kagan BD, Michelson JD. Surgical versus nonsurgical treatment of acute Achilles ruptures in the high demand patient: Using decision analysis to help clinical decisions. Foot Ankle Surg 2023; 29:213-217. [PMID: 36646593 DOI: 10.1016/j.fas.2023.01.006] [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: 08/06/2022] [Revised: 11/11/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Recent literature suggests that functional treatment of acute non-insertional Achilles tendon ruptures yields outcomes (re-rupture and function) similar to those of surgery, but does not address the unique issues in treating high performance athletes or other high demand patients. METHODS Decision analysis was used to develop an estimate of outcome utility for both types of treatment using published Costs and Quality-Adjusted Life Years (QALYs) values. The expected value for either treatment was then calculated for high, intermediate, and normal demand patients, using the specific functional needs of the patients. RESULTS Nonoperative treatment is the preferred management for normal demand patients, while high and intermediate demand patients are more likely to experience better expected functional outcomes from surgery. CONCLUSION The combination of a decision analysis and expected value analysis provides evidence-based support for the existing intuitive recommendations that favor surgical treatment in elite athletes and other high demand patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Prasanna Kumar
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Benjamin D Kagan
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - James D Michelson
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA.
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15
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Xu H, Zhu Y, Xu J, Tong W, Hu S, Chen Y, Deng S, Yao H, Li J, Lee C, Chan HF. Injectable bioactive glass/sodium alginate hydrogel with immunomodulatory and angiogenic properties for enhanced tendon healing. Bioeng Transl Med 2023; 8:e10345. [PMID: 36684098 PMCID: PMC9842034 DOI: 10.1002/btm2.10345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/17/2022] [Accepted: 04/29/2022] [Indexed: 01/25/2023] Open
Abstract
Tendon healing is a complex process involving inflammation, proliferation, and remodeling, eventually achieving a state of hypocellularity and hypovascularity. Currently, few treatments can satisfactorily restore the structure and function of native tendon. Bioactive glass (BG) has been shown to possess immunomodulatory and angiogenic properties. In this study, we investigated whether an injectable hydrogel fabricated of BG and sodium alginate (SA) could be applied to enhance tenogenesis following suture repair of injured tendon. We demonstrated that BG/SA hydrogel significantly accelerated tenogenesis without inducing heterotopic ossification based on histological analysis. The therapeutic effect could attribute to increased angiogenesis and M1 to M2 phenotypic switch of macrophages within 7 days post-surgery. Morphological characterization demonstrated that BG/SA hydrogel partially reverted the pathological changes of Achilles tendon, including increased length and cross-sectional area (CSA). Finally, biomechanical test showed that BG/SA hydrogel significantly improved ultimate load, failure stress, and tensile modulus of the repaired tendon. In conclusion, administration of an injectable BG/SA hydrogel can be a novel and promising therapeutic approach to augment Achilles tendon healing in conjunction with surgical intervention.
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Affiliation(s)
- Hongtao Xu
- Musculoskeletal Research Laboratory, Department of Orthopedics and TraumatologyThe Chinese University of Hong KongHong Kong SARChina
- Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory, Li Ka Shing Institute of Health SciencesThe Chinese University of Hong KongHong Kong SARChina
- Department of OrthopedicsThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Yanlun Zhu
- Institute for Tissue Engineering and Regenerative Medicine, Faculty of MedicineThe Chinese University of Hong KongHong Kong SARChina
- Key Laboratory for Regenerative Medicine of the Ministry of Education of China, School of Biomedical Sciences, Faculty of MedicineThe Chinese University of Hong KongHong Kong SARChina
| | - Jiankun Xu
- Musculoskeletal Research Laboratory, Department of Orthopedics and TraumatologyThe Chinese University of Hong KongHong Kong SARChina
- Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory, Li Ka Shing Institute of Health SciencesThe Chinese University of Hong KongHong Kong SARChina
| | - Wenxue Tong
- Musculoskeletal Research Laboratory, Department of Orthopedics and TraumatologyThe Chinese University of Hong KongHong Kong SARChina
- Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory, Li Ka Shing Institute of Health SciencesThe Chinese University of Hong KongHong Kong SARChina
| | - Shiwen Hu
- Musculoskeletal Research Laboratory, Department of Orthopedics and TraumatologyThe Chinese University of Hong KongHong Kong SARChina
- Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory, Li Ka Shing Institute of Health SciencesThe Chinese University of Hong KongHong Kong SARChina
- School of Materials Science and EngineeringLanzhou University of TechnologyLanzhouChina
| | - Yi‐Fan Chen
- The Ph.D. Program for Translational Medicine, College of Medical Science and TechnologyTaipei Medical UniversityTaipeiTaiwan
- Graduate Institute of Translational Medicine, College of Medical Science and TechnologyTaipei Medical UniversityTaipeiTaiwan
- International Ph.D. Program for Translational Science, College of Medical Science and TechnologyTaipei Medical UniversityTaipeiTaiwan
- Master Program in Clinical Genomics and Proteomics, School of PharmacyTaipei Medical UniversityTaipeiTaiwan
| | - Shuai Deng
- Institute for Tissue Engineering and Regenerative Medicine, Faculty of MedicineThe Chinese University of Hong KongHong Kong SARChina
- Key Laboratory for Regenerative Medicine of the Ministry of Education of China, School of Biomedical Sciences, Faculty of MedicineThe Chinese University of Hong KongHong Kong SARChina
| | - Hao Yao
- Musculoskeletal Research Laboratory, Department of Orthopedics and TraumatologyThe Chinese University of Hong KongHong Kong SARChina
- Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory, Li Ka Shing Institute of Health SciencesThe Chinese University of Hong KongHong Kong SARChina
| | - Jie Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower HospitalThe Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Chien‐Wei Lee
- Center for Translational Genomics ResearchChina Medical University Hospital, China Medical UniversityTaichungTaiwan
| | - Hon Fai Chan
- Institute for Tissue Engineering and Regenerative Medicine, Faculty of MedicineThe Chinese University of Hong KongHong Kong SARChina
- Key Laboratory for Regenerative Medicine of the Ministry of Education of China, School of Biomedical Sciences, Faculty of MedicineThe Chinese University of Hong KongHong Kong SARChina
- Hong Kong Branch of CAS Center for Excellence in Animal Evolution and GeneticsThe Chinese University of Hong KongHong Kong SARChina
- Center for Neuromusculoskeletal Restorative MedicineHong Kong Science ParkHong Kong SARChina
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16
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Quantitative Analysis of Contrast-Enhanced Ultrasound That Can Be Used to Evaluate Angiogenesis during Patellar Tendon Healing in Rats. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:6867743. [PMID: 36313964 PMCID: PMC9584743 DOI: 10.1155/2022/6867743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/15/2022] [Indexed: 01/26/2023]
Abstract
Objective To investigate the efficacy of contrast-enhanced ultrasound (CEUS) in quantitatively evaluating angiogenesis during patellar tendon healing in rats. Methods A total of 40 Sprague-Dawley rats were used in this study. The patellar tendons of 30 rats (60 limbs) that underwent incision and suture were treated as the operation group and monitored after 7, 14, and 28 days. The normal patellar tendons of 10 rats (20 limbs) were treated as the control group and monitored on day 0. The ultrasound examination was used to evaluate the structure and blood perfusion of the patellar tendon. Immunohistochemistry was used to assess angiogenesis, and the biomechanical test was used to verify functional recovery of the patellar tendon. Results The tendons in the operation group were significantly thickened compared with those in the control group (p < 0.01). The peak intensity (PI) in CEUS of the tendons showed a clear difference at each time point after the surgery (p < 0.01). PI increased in the operation group with a maximum on day 7, and then gradually decreased until day 28 when PI was close to the basic intensity (BI) in the control group (p > 0.05). It was consistent with the change of the CD31-positive staining areas representing angiogenesis of the injured patellar tendons. The PI was positively correlated with the CD31-positive staining area fraction (R = 0.849, p < 0.001). The failure load and tensile strength of the repaired patellar tendons in the operation group increased over time. The PI showed negative correlations with the failure load (R = -0.787, p < 0.001) and tensile strength (R = -0.714, p < 0.001). Conclusion The PI in CEUS could quantitatively reflect the time-dependent change in the blood supply of the healing site, and the PI correlated with histologic and biomechanical properties of the healing tendon. Quantitative analysis of contrast-enhanced ultrasound could be a useful method to evaluate angiogenesis in healing tendons.
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17
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Kastoft R, Barfod K, Bencke J, Speedtsberg MB, Hansen SB, Penny JØ. 1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment. Knee Surg Sports Traumatol Arthrosc 2022; 30:3579-3587. [PMID: 35234975 DOI: 10.1007/s00167-022-06874-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics. METHODS The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control. RESULTS The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg. CONCLUSION The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain. LEVEL OF EVIDENCE II. CLINICAL TRIALS IDENTIFIER NCT02760784.
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Affiliation(s)
- Rasmus Kastoft
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Kristoffer Barfod
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jesper Bencke
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Merete B Speedtsberg
- Laboratory of Human Movement Analysis, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager, Hvidovre, Denmark
| | - Sanja Bay Hansen
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jeannette Ø Penny
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
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18
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Diniz P, Ferreira AS, Figueiredo L, Batista JP, Abdelatif N, Pereira H, Kerkhoffs GMMJ, Finkelstein SN, Ferreira FC. Early analysis shows that endoscopic flexor hallucis longus transfer has a promising cost-effectiveness profile in the treatment of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2022; 31:2001-2014. [PMID: 36149468 DOI: 10.1007/s00167-022-07146-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Current options for treating an Achilles tendon rupture (ATR) include conservative and surgical approaches. Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost-effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost-effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective. METHODS A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost-effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one-way sensitivity analysis was conducted by sequentially varying each model parameter within a given range. RESULTS For the reference case, incremental cost-effectiveness ratios exceeded the willingness-to-pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100,000, open surgery was cost-effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments. CONCLUSION Surgical treatments have a moderate likelihood of being cost-effective at a willingness-to-pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health-related quality of life may be better suited for improved cost-effectiveness. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Pedro Diniz
- Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela, 501, 2775-028, Parede, Lisbon, Portugal. .,Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. .,Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. .,Fisiogaspar, Lisbon, Portugal.
| | - André Soares Ferreira
- Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela, 501, 2775-028, Parede, Lisbon, Portugal
| | - Lígia Figueiredo
- Clinical Department Club Atletico Boca Juniors, CAJB Centro Artroscopico, Buenos Aires, Argentina
| | - Jorge Pablo Batista
- Head of Orthopedic Department, Dr Nasef OrthoClinic, Private Practice, Cairo, Egypt
| | - Nasef Abdelatif
- Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila Do Conde, Portugal
| | - Hélder Pereira
- Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence, Murcia/Madrid, Spain.,PT Government Associate Laboratory, University of Minho ICVS/3B's, Braga/Guimarães, Portugal.,Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam University Medical Centers, Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands
| | - Gino M M J Kerkhoffs
- Institute for Data, Systems and Society, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Stan N Finkelstein
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Bioceramed - Cerâmicos para Aplicações Médicas S.A., Loures, Portugal
| | - Frederico Castelo Ferreira
- Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal.,Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
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19
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Abdelatif NMN, Batista JP. Outcomes of Percutaneous Achilles Repair Compared With Endoscopic Flexor Hallucis Longus Tendon Transfer to Treat Achilles Tendon Ruptures. Foot Ankle Int 2022; 43:1174-1184. [PMID: 35686445 DOI: 10.1177/10711007221096674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Both percutaneous and endoscopically assisted methods are reported to produce good results in the surgical management of acute Achilles tendon ruptures. The aim of this retrospective study was to compare between a percutaneous method and a recently described isolated endoscopically assisted flexor hallucis longus (FHL) transfer method as surgical means of management in patients with acute Achilles tendon ruptures. METHODS One hundred seventeen patients were included in the current study and divided into 2 groups: 59 patients who underwent percutaneous Achilles repair (PAR Group) and 58 patients who underwent isolated endoscopic FHL transfer (FHL Group) were compared. Patients were clinically evaluated using American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score (ATRS), and Achilles tendon resting angle (ATRA) measures. In addition, ankle plantarflexion power, FHL dynamometry, Tegner activity levels, and return to previous levels of activity were also documented for all patients. RESULTS Nine months after surgery, patients in the FHL transfer group were more likely to be able to return to normal activities (91% vs 73%, P < .01). Thirty months after surgical treatment, we found no difference in ATRS, AOFAS, ATRA, ankle plantarflexion strength, or Tegner activity scores between study groups. Overall complications were reported in 6 patients in the FHL group (10.3%) and in 8 patients in the PAR group (13.6%). No major neurovascular or skin complications were encountered. CONCLUSION The current study demonstrated satisfactory and comparable results and complications when comparing isolated endoscopic FHL tendon transfer or percutaneous Achilles tendon repairs in the surgical management of acute Achilles tendon ruptures. LEVEL OF EVIDENCE Level III, retrospective controlled trial.
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Affiliation(s)
| | - Jorge Pablo Batista
- Ankle and Knee Section, Orthopaedics Department, Centro Artroscópico Jorge Batista, Ciudad Autónoma de Buenos Aires, Argentina.,Department of Sport Medicine, Club Atlético Boca Juniors, Buenos Aires, Argentina
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Amendola F, Barbasse L, Carbonaro R, Alessandri-Bonetti M, Cottone G, Riccio M, De Francesco F, Vaienti L, Serror K. The Acute Achilles Tendon Rupture: An Evidence-Based Approach from the Diagnosis to the Treatment. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1195. [PMID: 36143872 PMCID: PMC9500605 DOI: 10.3390/medicina58091195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022]
Abstract
Background and Objective: Acute Achilles tendon rupture (AATR) is a common injury with a significant impact on daily living. Although various systematic reviews and meta-analyses have been written on the topic, no actual consensus exists on the best treatment. We aimed to collect the highest quality of evidence on the subject and to produce a document to which to refer, from the diagnosis to the final treatment. Material and Methods: Inclusion criteria were systematic reviews discussing Achilles tendon rupture, concerning either diagnostic criteria, classification, or treatment; English language; clearly stated inclusion and exclusion criteria for patients' selection. Results: Thirteen systematic reviews were included in the study. A strong consensus exists about the higher risk of re-rupture associated with non-operative treatment and a higher risk of complications associated with surgical repair. Conclusions: The combination of minimally invasive repair and accelerated functional rehabilitation seems to offer the best results in the treatment of Achilles tendon rupture.
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Affiliation(s)
- Francesco Amendola
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Léa Barbasse
- Plastic and Reconstructive Department, AP-HP, Hôpital Saint-Louis, 75010 Paris, France
| | - Riccardo Carbonaro
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Mario Alessandri-Bonetti
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Giuseppe Cottone
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Michele Riccio
- Hand Surgery Unit, Department of Plastic and Reconstructive Surgery, Azienda “Ospedali Riuniti”, Via Conca 21, 60126 Ancona, Italy
| | - Francesco De Francesco
- Hand Surgery Unit, Department of Plastic and Reconstructive Surgery, Azienda “Ospedali Riuniti”, Via Conca 21, 60126 Ancona, Italy
| | - Luca Vaienti
- Plastic and Reconstructive Surgery Department, I.R.C.C.S. Istituto Ortopedico Galeazzi, 20122 Milan, Italy
| | - Kevin Serror
- Plastic and Reconstructive Department, AP-HP, Hôpital Saint-Louis, 75010 Paris, France
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21
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Effects and Mechanism of Particulate Matter on Tendon Healing Based on Integrated Analysis of DNA Methylation and RNA Sequencing Data in a Rat Model. Int J Mol Sci 2022; 23:ijms23158170. [PMID: 35897746 PMCID: PMC9332732 DOI: 10.3390/ijms23158170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 02/01/2023] Open
Abstract
Exposure to particulate matter (PM) has been linked with the severity of various diseases. To date, there is no study on the relationship between PM exposure and tendon healing. Open Achilles tenotomy of 20 rats was performed. The animals were divided into two groups according to exposure to PM: a PM group and a non-PM group. After 6 weeks of PM exposure, the harvest and investigations of lungs, blood samples, and Achilles tendons were performed. Compared to the non-PM group, the white blood cell count and tumor necrosis factor-alpha expression in the PM group were significantly higher. The Achilles tendons in PM group showed significantly increased inflammatory outcomes. A TEM analysis showed reduced collagen fibrils in the PM group. A biomechanical analysis demonstrated that the load to failure value was lower in the PM group. An upregulation of the gene encoding cyclic AMP response element-binding protein (CREB) was detected in the PM group by an integrated analysis of DNA methylation and RNA sequencing data, as confirmed via a Western blot analysis showing significantly elevated levels of phosphorylated CREB. In summary, PM exposure caused a deleterious effect on tendon healing. The molecular data indicate that the action mechanism of PM may be associated with upregulated CREB signaling.
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22
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Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2022; 52:312-344. [PMID: 35647883 DOI: 10.2519/jospt.2022.11075] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions. DESIGN Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021. STUDY SELECTION CRITERIA RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year. DATA SYNTHESIS Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials. RESULTS One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias. CONCLUSION The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.
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Song JH, Kang C, Han SY, Park WH, Kim MH, Moon JH, Tae JY, Park HY, Yoo IH, Park JH, Yeo YH, Kim DY. Comparative analysis of Achilles tendon healing outcomes after open tenotomy versus percutaneous tenotomy: An experimental study in rats. J Orthop Res 2022; 40:1446-1456. [PMID: 34370341 DOI: 10.1002/jor.25159] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/25/2021] [Accepted: 07/30/2021] [Indexed: 02/04/2023]
Abstract
There is growing interest in conservative treatment of Achilles tendon rupture. However, the majority of experimental studies of Achilles tendon have been performed by open tenotomy. More appropriate model of conservative treatment of Achilles tendon rupture is required. We performed an experimental study to evaluate whether outcomes differ between open tenotomy and percutaneous tenotomy of the Achilles tendon in rats. The Achilles tendons of 48 rats were transected. The animals were divided into two groups according to surgical technique: open tenotomy or microscopy-assisted percutaneous tenotomy. After 1, 2, and 4 weeks, functional, biomechanical, and histological analyses were performed. Western blot was performed for quantitative molecular analysis at 1 week. The Achilles functional index was superior in the percutaneous tenotomy group, compared with the open tenotomy group, at 1 week. The cross-sectional area was significantly larger in the percutaneous tenotomy group than in the open tenotomy group at 4 weeks. Relative to the native tendons, load to failure and stiffness yielded comparable results at 2 weeks in the percutaneous tenotomy group and at 4 weeks in the open tenotomy group. The histological score was significantly better in the percutaneous tenotomy group than in the open tenotomy group at 1 week. At 1 week, interleukin-1β expression in the open tenotomy group was higher than in the percutaneous tenotomy group. In summary, Achilles tendon healing was substantially affected by the tenotomy method. We presume that our percutaneous tenotomy method might constitute a useful experimental animal model for conservative treatment of Achilles tendon rupture.
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Affiliation(s)
- Jae H Song
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, Republic of Korea
| | - Chan Kang
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Seung Y Han
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Won H Park
- Department of Advanced Organic Materials and Textile Engineering System, Chungnam National University, Daejeon, Republic of Korea
| | - Min H Kim
- Department of Biomedical Engineering, Purdue School of Engineering & Technology, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Ji H Moon
- Department of Anatomy, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Jung Y Tae
- Department of Medicine, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Hyeon Y Park
- Department of Occupational Therapy, Konyang University, Daejeon, Republic of Korea
| | - In H Yoo
- Department of Occupational Therapy, Konyang University, Daejeon, Republic of Korea
| | - Jong H Park
- Department of Biomedical Material, College of Medical Engineering, Konyang University, Daejeon, Republic of Korea
| | - Yong H Yeo
- Department of Advanced Organic Materials and Textile Engineering System, Chungnam National University, Daejeon, Republic of Korea
| | - Dae Y Kim
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, Republic of Korea
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Doyle TR, Davey MS, Hurley ET. Statistical Findings Reported in Randomized Control Trials for the Management of Acute Achilles Tendon Ruptures are at High Risk of Fragility: A Systematic Review. J ISAKOS 2022; 7:72-81. [DOI: 10.1016/j.jisako.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/18/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
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Sanada T, Iwaso H, Fukai A, Honda E, Yoshitomi H. Comparison Study of Mini-Incision Versus Original Open Technique of the Half-Mini-Bunnell Achilles Tendon Repair. J Foot Ankle Surg 2022; 61:355-362. [PMID: 34656416 DOI: 10.1053/j.jfas.2021.02.017] [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: 02/03/2020] [Revised: 01/30/2021] [Accepted: 02/07/2021] [Indexed: 02/03/2023]
Abstract
Mini-incision surgical procedures in our institution have been developed by decreasing the total skin incision length from the original mini half-Bunnell tendon repair technique. We hypothesized that the mini-incision, or minimum invasive Achilles tendon repair technique, would promote the tendon healing process leading to better outcomes and a reduced complication rate compared to the conventional open repair. The study sought to determine the more optimal method by comparing 44 mini-incision sutures to the 99 sutures in the original open Achilles tendon repairs. The mean skin incision length of the mini-incision surgery was 2.9 (range 2.5-3.0) cm and the original repair was 4.2 (range 3.5-7.0) cm. The mean surgery time was 60.0 minutes in the mini-incision repair and 68.1 minutes in the original one (p = .0003). The mean achievement time of bilateral heel-rise, starting jogging, single-legged heel-rise movement and the time to return-to-play was not significantly different between the 2 groups. Achilles Tendon Rupture Score was not significantly different from 3 to 9 months after surgery. Re-injury rate was 1/44 (2.3%) in mini-incision and 4/99 (4.0%) in conventional open repair (p = .36). No patients in either group developed any postoperative infections nor deep vein thrombosis complications. Although the mini-incision half-mini-Bunnell suture was showed equivalent clinical results to the original open repair, the technique is recommended in terms of curtailment of the surgery time without increase of complication ratio.
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Affiliation(s)
- Takaki Sanada
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan.
| | - Hiroshi Iwaso
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan
| | - Atsushi Fukai
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan
| | - Eisaburo Honda
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan
| | - Hiroki Yoshitomi
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshi cho, Nakahara ku, Kawasaki city, Kanagawa prefecture, Japan
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Melcher C, Renner C, Piepenbrink M, Fischer N, Büttner A, Wegener V, Birkenmaier C, Jansson V, Wegener B. Biomechanical comparisons of three minimally invasive Achilles tendon percutaneous repair suture techniques. Clin Biomech (Bristol, Avon) 2022; 92:105578. [PMID: 35093798 DOI: 10.1016/j.clinbiomech.2022.105578] [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: 05/21/2021] [Revised: 12/14/2021] [Accepted: 01/11/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND While no gold standard exists for the management of Achilles tendon ruptures, surgical repair is common in healthy and active patients. Minimally invasive repair methods have become increasingly popular, while biomechanical equivalency hasn't been proven yet. METHODS A mid-substance Achilles tendon rupture was created 6 cm proximal to the calcaneal insertion in 27 fresh-frozen cadaveric ankles. Specimens were randomly allocated to 1 of 3 repair techniques: Huttunen et al. (2014) (1) PARS Achilles Jig System, Nyyssönen et al. (2008) (2) Achilles Midsubstance SpeedBridge™, Schipper and Cohen (2017) (3) Dresdner Instrument and subsequently subjected to cyclic loading with 250 cycles each at 1 Hz with 4 different loading ranges (20-100 N, 20-200 N, 20-300 N, and 20-400 N). FINDINGS After 250 cycles no significant differences in elongation were observed between PARS and Dresdner Instrument(p = 1.0). Furthermore, SpeedBridge™ repairs elongated less than either Dresdner Instrument (p = 0.0006) or PARS (p = 0.102). Main elongation (85%) occurred within the first 10 cycles with a comparable elongation in between 10 and 100 and 100-250 cycles. While all repairs withstood the first 250 cycles of cyclic loading from 20 to 100 N, only the PARS (468 ± 175) and Midsubstance SpeedBridge™ (538 ± 208) survived more cycles. Within all 3 groups suture cut out was seen to be the most common failure mechanism. INTERPRETATION Within all groups early repair elongation was seen. While this was least obvious within the SpeedBridge™ technique, ultimate strengths of repairs (cycles to failure) were comparable across PARS and SpeedBridge™ with a decline in the Dresdner Instrument group.
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Affiliation(s)
- C Melcher
- University Hospital Ulm, Department of Orthopedic Surgery (RKU), Oberer Eseelsberg 45, 89081 Ulm, Germany; University Hospital LMU Munich, Department of Orthopaedics, Physical Medicine and Rehabilitation, Marchioninistr 15, 81377 Munich, Germany.
| | - C Renner
- Arthrex GmbH, Erwin-Hielscher-Straße 9, 81249 München, Germany.
| | - M Piepenbrink
- Arthrex GmbH, Erwin-Hielscher-Straße 9, 81249 München, Germany.
| | - N Fischer
- Arthrex GmbH, Erwin-Hielscher-Straße 9, 81249 München, Germany.
| | - A Büttner
- University Hospital Rostock, Department of Forensic Medicine, St. Georg-Str.108, 18055 Rostock, Germany.
| | - V Wegener
- University Hospital LMU Munich, Department of Orthopaedics, Physical Medicine and Rehabilitation, Marchioninistr 15, 81377 Munich, Germany.
| | - C Birkenmaier
- University Hospital LMU Munich, Department of Orthopaedics, Physical Medicine and Rehabilitation, Marchioninistr 15, 81377 Munich, Germany.
| | - V Jansson
- University Hospital LMU Munich, Department of Orthopaedics, Physical Medicine and Rehabilitation, Marchioninistr 15, 81377 Munich, Germany.
| | - B Wegener
- University Hospital LMU Munich, Department of Orthopaedics, Physical Medicine and Rehabilitation, Marchioninistr 15, 81377 Munich, Germany.
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Abdelatif NMN, Batista JP. Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures in Professional Soccer Players. Foot Ankle Int 2022; 43:164-175. [PMID: 34558318 DOI: 10.1177/10711007211036439] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR. METHODS Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated. RESULTS All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength. CONCLUSION The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort. LEVEL OF EVIDENCE Level II, prospective cohort case series study.
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Affiliation(s)
| | - Jorge Pablo Batista
- Head Ankle and Knee Section, Orthopaedics Department, Centro Artroscópico Jorge Batista SA, Ciudad Autónoma de Buenos Aires (CABA), CP, Argentina.,Department of Sport Medicine, Club Atlético Boca Juniors, Buenos Aires, Argentina
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Kvist J, Silbernagel KG. Fear of Movement and Reinjury in Sports Medicine: Relevance for Rehabilitation and Return to Sport. Phys Ther 2022; 102:6480895. [PMID: 34971375 DOI: 10.1093/ptj/pzab272] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 10/21/2021] [Accepted: 11/15/2021] [Indexed: 11/14/2022]
Abstract
Athletes are defined by their ability to move and are often accustomed to pain as it relates to their sports and exercise regime. The forced movement restriction and pain associated with an acute or overuse injury has a profound effect not only on their physical abilities but also on their psychological well-being and social context. With the goal of returning to sport, the rehabilitation focus historically has been on recovery of physical attributes, but more recent research is addressing the psychological factors. This Perspective proposes that-according to the current evidence in sports medicine-the fear that affects choice of treatment, rehabilitation, and return to sports is intertwined with physical capacity and recovery of function. Past injury is also 1 of the main risk factors for a sports injury; therefore, fear of reinjury is not irrational. For an athlete, the fear related to a sports injury encompasses the fear of reinjury along with fear of not being able to return to the sport at their highest performance level-and the fear of having lifelong debilitating pain and symptoms. This Perspective reviews the evidence for the influence of fear of movement and reinjury on choice of treatment, rehabilitation, and return to sport and provides suggestions on how to address this fear during the continuum of treatment and return to sports.
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Affiliation(s)
- Joanna Kvist
- Unit of Physiotherapy, Department of Health, Medicine, and Caring Science, Linköping University, Linköping, Sweden.,Stockholm Sports Trauma Research Center, Dept of Molecular Medicine & Surgery, Karolinska Institute, Stockholm, Sweden
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The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2022; 30:1109-1117. [PMID: 34657973 PMCID: PMC8901518 DOI: 10.1007/s00167-021-06767-6] [Citation(s) in RCA: 4] [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: 05/22/2021] [Accepted: 10/04/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE Operative repair of Achilles tendon rupture may lead to complications, which influence outcome adversely. The aim of this study was to determine the incidence, impact and response to treatment of post-operative adhesions. METHODS From February 2009 to 2021, 248 patients operated on with percutaneous or minimally invasive surgical repair have been prospectively evaluated using the Achilles tendon Total Rupture Score (ATRS) and Heel-Rise Height Index (HRHI), following acute Achilles tendon rupture. RESULTS Fourteen (5.6%) patients were identified as having adhesions. Four patients reported superficial adhesions and ten patients reported a deeper tightness of the tendon. At a mean (SD) of 10.5 (2.3) months following repair, the overall ATRS was at a median (IQR) 65 (44.5-78) points and (HRHI) was mean (SD) 81.5 (13.5)%. Of those deemed to have deep adhesions the antero-posterior diameter of the tendon was at mean (SD) 15.6 (4.6) mm. Open release of superficial adhesions resulted in improved ATRS in all patients. Endoscopic debridement anterior to the Achilles tendon led to alleviation of symptoms of tightness and discomfort from deep adhesions and improved outcome in terms of the ATRS score. At a mean (SD) of 15.9 (3.3)-month follow-up from initial rupture and repair, the patients reported at median (IQR) ATRS scores of 85 (64.8-92.8) points, Tegner level 5 (3-9) and mean (SD) HRHI 86.2 (9.5)%. Patients significantly improved both ATRS and HRHI following release at median (IQR) of 16.5 (- 1.8-29.3) points (p = 0.041) and mean (SD) 5.6 (8.3)% (p = 0.043). CONCLUSIONS The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. The occurrence of superficial adhesions was associated with a lower outcome scores as well as symptoms of anterior tendon tightness and stiffness were associated with a lower score in most patients. Surgical release of adhesions led to a significant improvement in outcome.
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Park CH, Yan H, Park J, Chang MC. Mini-open Repair for Acute Achilles Tendon Rupture: Ring Forceps vs the Achillon Device. Am J Sports Med 2021; 49:3613-3619. [PMID: 34612717 DOI: 10.1177/03635465211044464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Repair of acute Achilles tendon rupture using the Achillon device is a representative mini-open repair technique; however, the limitations of this technique include the need for special instruments and decreased repair strength. A modified mini-open repair using ring forceps might overcome these limitations. PURPOSE To compare the Achillon device with ring forceps in mini-open repairs of acute Achilles tendon rupture. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Fifty patients (41 men and 9 women) with acute Achilles tendon rupture on 1 foot were consecutively treated using mini-open repair techniques. The first 20 patients were treated using the Achillon device (Achillon group), and the subsequent 30 were treated using a ring forceps (forceps group). Clinical, functional, and isokinetic results and postoperative complications were compared between the groups at the last follow-up. Clinical evaluations were performed using the AOFAS (American Orthopaedic Foot and Ankle Society) score, Achilles Tendon Total Rupture Score, length of incision, and operation time. Functional evaluations included active range of motion of the ankle joint, maximum calf circumference, hopping test, and single-limb heel rise (SLHR). Isokinetic evaluations were performed using the isokinetic test for ankle plantar flexion. RESULTS The AOFAS score (P = .669), Achilles Tendon Total Rupture Score (P = .753), and length of incision (P = .305) were not significantly different between the groups (mean ± SD, 90.1 ± 8.7, 88.3 ± 9.9, and 2.7 ± 0.3 cm in the Achillon group vs 92.2 ± 9.4, 89.9 ± 10.9, and 2.5 ± 0.4 cm in the forceps group, respectively). Operation times in the Achillon group were significantly shorter than those in the forceps group (41.4 ± 9.6 vs 62.8 ± 14.1 minutes, P < .001). The maximum height of the SLHR (P = .042) and the number of SLHRs (P = .043) in the forceps group (79.7% ± 7.4% and 72.9% ± 10.2%) were significantly greater than those in the Achillon group (75.3% ± 7.1% and 66.7% ± 11.0%). No significant differences were detected between the groups in mean peak torques for plantar flexion at angular speeds of 30 deg/s (P = .185) and 120 deg/s (P = .271). There was no significant difference in the occurrence of postoperative complications between the groups (P = .093). CONCLUSION The ring forceps technique is comparable to the Achillon technique with respect to clinical, functional, and isokinetic results and postoperative complications. Given that no special instrument is required, the ring forceps technique could be a better option for acute Achilles tendon rupture repair.
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Affiliation(s)
- Chul Hyun Park
- Department of Orthopaedic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Hongfei Yan
- Department of Orthopaedic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jeongjin Park
- Department of Orthopaedic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Korea
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Seow D, Yasui Y, Calder JDF, Kennedy JG, Pearce CJ. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. Am J Sports Med 2021; 49:3728-3748. [PMID: 33783229 DOI: 10.1177/0363546521998284] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling. PURPOSE To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 1. METHODS Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I2 < 25%) and by random-effects models if heterogeneity was moderate to high (I2≥ 25%). RESULTS Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications. CONCLUSION This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.
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Affiliation(s)
- Dexter Seow
- National University Health System, Singapore
| | - Youichi Yasui
- Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, Japan
| | - James D F Calder
- Fortius Clinic, London, UK.,Department of Bioengineering, Imperial College London, London, UK
| | - John G Kennedy
- NYU Langone Orthopedic Hospital, New York, New York, USA
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Meulenkamp B, Woolnough T, Cheng W, Shorr R, Stacey D, Richards M, Gupta A, Fergusson D, Graham ID. What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Clin Orthop Relat Res 2021; 479:2119-2131. [PMID: 34180874 PMCID: PMC8445578 DOI: 10.1097/corr.0000000000001861] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study designs is problematic; multiarm clinical trials often are logistically constrained to small sample sizes, and traditional meta-analyses are limited to comparisons of only two treatments that have been compared in head-to-head trials. Network meta-analyses allow for simultaneous comparison of all existing treatments utilizing both direct (head-to-head comparison) and indirect (not previously compared head-to-head) evidence. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized controlled trials (RCTs) to answer the following questions: Considering open repair, minimally invasive surgery (MIS) repair, functional rehabilitation, or primary immobilization for acute Achilles tendon ruptures, (1) which intervention is associated with the lowest risk of rerupture? (2) Which intervention is associated with the lowest risk of complications resulting in surgery? METHODS This study was conducted with methods guided by the Cochrane Handbook for Systematic Reviews of Interventions and is reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for incorporating network meta-analysis. Five databases and grey literature sources (such as major orthopaedic meeting presentation lists) were searched from inception to September 30, 2019. Included studies were RCTs comparing treatment of acute Achilles tendon ruptures using two or more of the following interventions: primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. We excluded studies enrolling patients with chronic ruptures, reruptures, and preexisting Achilles tendinopathy as well as studies with more than 20% loss to follow-up or less than 6 months of follow-up. Nineteen RCTs (1316 patients) were included in the final analysis. The mean number of patients per study treatment arm was 35 ± 16, mean age was 41 ± 5 years, mean sex composition was 80% ± 10% males, and mean follow-up was 22 ± 12 months. The four treatment groups were compared for the main outcomes of rerupture and complications resulting in operation. The analysis was conducted using random-effects Bayesian network meta-analysis with vague priors. Evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation methodology. We found risk of selection, attrition, and reporting bias to be low across treatments, and we found the risk of performance and detection bias to be high. Overall risk of bias between treatments appeared similar. RESULTS We found that treatment with primary immobilization had a greater risk of rerupture than open surgery (odds ratio 4.06 [95% credible interval {CrI} 1.47 to 11.88]; p < 0.05). There were no other differences between treatments for risk of rerupture. Minimally invasive surgery was ranked first for fewest complications resulting in surgery and was associated with a lower risk of complications resulting in surgery than functional rehabilitation (OR 0.16 [95% CrI 0.02 to 0.90]; p < 0.05), open surgery (OR 0.22 [95% CrI 0.04 to 0.93]; p < 0.05), and primary immobilization (OR < 0.01 [95% CrI < 0.01 to 0.01]; p < 0.05). Risk of complications resulting in surgery was no different between primary immobilization and open surgery (OR 1.46 [95% CrI 0.35 to 5.36]). Data for patient-reported outcome scores and return to activity were inappropriate for pooling secondary to considerable clinical heterogeneity and imprecision associated with small sample sizes. CONCLUSION Faced with acute Achilles tendon rupture, patients should be counseled that, based on the best-available evidence, the risk of rerupture likely is no different across contemporary treatments. Considering the possibly lower risk of complications resulting in surgery associated with MIS repair, patients and surgeons must balance any benefit with the potential risks of MIS techniques. As treatments continue to evolve, consistent reporting of validated patient-reported outcome measures is critically important to facilitate analysis with existing RCT evidence. Infrequent but serious complications such as rerupture and deep infection should be further explored to determine whether meaningful differences exist in specific patient populations. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
| | - Taylor Woolnough
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Risa Shorr
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Dawn Stacey
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Megan Richards
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Arnav Gupta
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dean Fergusson
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian D. Graham
- Centre for Practice-Changing Research, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Zhang YJ, Long X, Du JY, Wang Q, Lin XJ. Is Early Controlled Motion and Weightbearing Recommended for Nonoperatively Treated Acute Achilles Tendon Rupture? A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:23259671211024605. [PMID: 34568502 PMCID: PMC8461133 DOI: 10.1177/23259671211024605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/28/2021] [Indexed: 12/28/2022] Open
Abstract
Background There is disagreement as to whether early controlled motion and weightbearing confer a beneficial effect for nonoperatively treated acute Achilles tendon rupture (ATR) compared with immobilization and late weightbearing. Purpose To conduct a meta-analysis of randomized controlled trials (RCTs) to determine whether early controlled motion and weightbearing results in different outcomes compared with immobilization and late weightbearing for nonoperatively treated patients with acute ATR. Study Design Systematic review; Level of evidence, 1. Methods We conducted a search in the PubMed, Web of Science, and EMBASE databases for relevant RCTs in humans from January 1981 to August 2020. The primary outcome was the Achilles Tendon Total Rupture Score (ATRS) at 1-year follow-up. The secondary outcomes were the rerupture rate, return to sports activity and work, and the heel-rise work (limb symmetry index [LSI]). Study quality was assessed using the Cochrane Collaboration risk of bias tool. Results Included were 7 RCTs involving 424 participants (n = 215 treated with early controlled motion and weightbearing [early group], n = 209 treated with immobilization and late weightbearing [late group]). The quality assessment indicated a low risk of bias in all included RCTs. There was no difference between the early and late groups regarding the ATRS (mean difference [MD], -0.220; 95% CI, -4.489 to 4.049; P = .920). Likewise, we found no difference between the 2 groups in terms of the rerupture rate (odds ratio [OR], 1.107; 95% CI, 0.552 to 2.219; P = .775), the number of patients who returned to sports (OR, 0.766; 95% CI, 0.438 to 1.341; P = .351) and returned to work (OR, 0.706; 95% CI, 0.397 to 1.253; P = .234), the time to return to work (MD, -2.802 days; 95% CI, -6.525 to 0.921 days; P = .140), or the heel-rise work LSI (MD, -0.135; 95% CI, -6.243 to 5.973; P = .965). Conclusion No significant differences were found between early controlled motion and weightbearing compared with immobilization and late weightbearing regarding the ATRS, the rerupture rate, return to sports activity and work, and the heel-rise work in nonoperatively treated patients with acute ATR.
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Affiliation(s)
- Yi-Jun Zhang
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Xiao Long
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Jing-Yu Du
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Quan Wang
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
| | - Xiang-Jin Lin
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, PR China
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Alegre B, Seijas R, Alvarez P, Pérez A. The Achilles Tendon Rupture in Basketball: Systematic Review of the Present Literature. Surg J (N Y) 2021; 7:e265-e270. [PMID: 34541320 PMCID: PMC8440049 DOI: 10.1055/s-0041-1733988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/10/2021] [Indexed: 11/23/2022] Open
Abstract
Background
The most common cause of the Achilles tendon ruptures in the U.S. population is sports, basketball is one among them. It is not one of the most frequent injuries of this sport, but it is one of the most serious and impactful in its practice.
Purpose
The objective of this work is to gather evidence and evaluate the relationship between Achilles' tendon ruptures and basketball.
Study Design
This study designed as a systematic review.
Material and Methods
A search of literature in the databases PubMed, Cochrane Library, and ClinicalTrials.gov was conducted during January and February 2020.
Results
After the search and selection, three relevant articles were obtained due to their epidemiological content, Raikin et al and Lemme et al. In 2013 and 2018, they, respectively, conducted studies in U.S. populations, establishing sport as the most frequent injury mechanism in Achilles' tendon ruptures. It was analyzed according to injury mechanism, gender, body mass index (BMI), and age. In both studies, the lesion resulted more frequently in men and the sport involved in most of the cases was basketball (32 and 42.6%, respectively). In 2019, Lemme et al published an epidemiological design analyzing the Achilles tendon ruptures in the National Basketball Association (NBA), identifying risk factors and results in professional players. After suffering the injury, 36.8% of the patients had to retire or were holders in less than 10 games to the rest of their sports career.
Conclusions
The relationship between basketball and Achilles' tendon rupture is clear in the general population. Despite this, new studies are required to complement the evidence obtained so far.
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Affiliation(s)
- Berta Alegre
- Instituto Cugat Hospital Quiron Barcelona, Barcelona, Spain.,Medicine Department, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Roberto Seijas
- Instituto Cugat Hospital Quiron Barcelona, Barcelona, Spain.,Medicine Department, Universitat Internacional de Catalunya, Barcelona, Spain.,Fundación Garcia Cugat, Barcelona, Spain
| | - Pedro Alvarez
- Instituto Cugat Hospital Quiron Barcelona, Barcelona, Spain.,Medicine Department, Universitat Internacional de Catalunya, Barcelona, Spain.,Fundación Garcia Cugat, Barcelona, Spain.,Mutualitat Catalana de Futbolistas (FCF), Real Federación Española de Futbol, Madrid, Spain
| | - Albert Pérez
- Medicine Department, Universitat Internacional de Catalunya, Barcelona, Spain
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Jamjoom BA. The Influence of Early Weightearing, Controlled Motion, and Timing of Orthosis Removal on the Nonoperative Management of Achilles Tendon Rupture: A Systematic Review. J Foot Ankle Surg 2021; 60:777-786. [PMID: 33785241 DOI: 10.1053/j.jfas.2020.04.024] [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: 04/05/2020] [Accepted: 04/08/2020] [Indexed: 02/03/2023]
Abstract
This is a systematic review of the non-operative treatment for Achilles tendon rupture aimed at assessing the effect of early weightbearing, controlled motion and orthosis removal on 5 outcome measures. The literature was searched for relevant RCTs and prospective cohort studies. The primary outcome measure was the re-rupture rate. The secondary outcome measures were the rates for DVT, duration before return to work (RTW), return to sports (RTS) and the mean Achilles Tendon Rupture Score (ATRS). Eighteen publications reporting a total of 1068 patients were reviewed. The pooled rates were: re-rupture: 7.3%, DVT: 5.5%, RTW: 10.3 weeks, RTS: 47.7% and ATRS: 78.7. Early compared to late weightbearing was associated with significantly lower rates of DVT, RTW and ATRS but no difference in the rates of re-rupture and RTS. Early controlled motion compared to no motion was associated with significantly lower rates of re-rupture, RTW and ATRS but no difference in the rates of DVT and RTS. Early compared to late orthosis removal was associated with significantly higher rates of re-rupture and ATRS as well as a lower rate of RTW but no difference in the rates of DVT and RTS. The findings relating to re-rupture, DVT, RTW and RTS support the adoption of early weightbearing and controlled motion in the non-operative treatment for Achilles tendon rupture. Early removal of orthosis is not advisable due to an increased risk of re-rupture. The ATRS results were considered inconclusive probably due to inconsistencies in the reporting or heterogeneity in the study population.
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Affiliation(s)
- Bakur A Jamjoom
- Specialist Registrar, Department of Trauma and Orthopaedics, East Midland (North) Deanery Affiliated Hospitals, Nottingham, UK.
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36
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Shi F, Wu S, Cai W, Zhao Y. Multiple comparisons of the efficacy and safety for six treatments in Acute Achilles Tendon Rupture patients: A systematic review and network meta-analysis. Foot Ankle Surg 2021; 27:468-479. [PMID: 32732151 DOI: 10.1016/j.fas.2020.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/21/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The choice of the best therapeutic regimen for Acute Achilles Tendon Rupture (AATR) remains controversial. Our study aims to evaluate the efficacy and safety of therapeutic regimens in AATR patients using a network meta-analysis of data from clinical randomized controlled trials. MATERIAL/METHODS The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA). RESULTS 38 randomized controlled trials involving 2480 participants were included. The studies were published between 1981 and 2019. A total of 6 therapeutic regimens -open repair (OR), minimally invasive repair (MIR) and nonoperative treatment (non) combined with traditional standard rehabilitation (TSR) and accelerated functional rehabilitation (AFR) - were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the re-rupture rate, the therapeutic regimens were ranked as follows: OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR. In terms of the wound-related complication, the therapeutic regimens were ranked as follows: MIR&AFR, nonoperative treatment &AFR, MIR&TSR, nonoperative treatment &TSR, OR&AFR and OR&TSR. In terms of the sural nerve injury, the therapeutic regimens were ranked as follows: non, OR and MIR. In terms of the deep venous thrombosis, the therapeutic regimens were ranked as follows: MIR&AFR, OR&AFR, nonoperative treatment &AFR, OR&TSR, MIR&TSR and nonoperative treatment &TSR. In terms of the returning back to sport, the therapeutic regimens were ranked as follows: MIR&TSR, OR&AFR, OR&TSR, nonoperative treatment &AFR, nonoperative treatment &TSR and MIR&AFR. CONCLUSIONS MIR can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications. AFR is superior to TSR without increasing the risk of rerupture. MIR&AFR is the best therapeutic regime for AATR. More RCTs focused on AATR are needed to further indicate this conclusion.
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Affiliation(s)
- Fangling Shi
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shiyuan Wu
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Cai
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Youming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China.
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Naldo J, Agnew P, Brucato M, Dayton P, Shane A. ACFAS Clinical Consensus Statement: Acute Achilles Tendon Pathology. J Foot Ankle Surg 2021; 60:93-101. [PMID: 33199168 DOI: 10.1053/j.jfas.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/29/2020] [Indexed: 02/03/2023]
Abstract
Injuries to the Achilles tendon are a challenge to the foot and ankle surgeon. In recent years, research has led to a relative change in the way that many surgeons view acute Achilles tendon rupture. In an effort to fully evaluate these trends, as well as to evaluate all aspects of care for acute Achilles tendon rupture, the American College of Foot and Ankle Surgeons convened a panel of experts to create a clinical consensus statement to address selected aspects of care of the acute Achilles tendon injury.
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Affiliation(s)
- Jason Naldo
- Chairperson, ACFAS Acute Achilles Tendon Pathology Clinical Consensus Statement, Chicago, IL; Assistant Professor, Department of Orthopaedics, Virginia Tech Carilion School of Medicine, Roanoke, VA; Foot and Ankle Surgeon, Institute for Orthopaedics and Neurosciences, Carilion Clinic, Roanoke, VA.
| | - Patrick Agnew
- Director of Podiatric Medical and Surgical Education, Associate Professor, Eastern Virginia Medical School, Norfolk, VA
| | | | - Paul Dayton
- Private Practice, Foot & Ankle Center of Iowa, Ankeny, IA
| | - Amber Shane
- Chair, Department of Podiatric Surgery, Advent Health System, Orlando, FL; Faculty, Advent Health East Orlando Podiatric Surgical Residency, Orlando, FL
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Nilsson L, Thorlund JB, Kjær IL, Kazlauskas A, Christensen M. Long-term follow-up after acute achilles tendon rupture - Does treatment strategy influence functional outcomes? Foot (Edinb) 2021; 47:101769. [PMID: 33962113 DOI: 10.1016/j.foot.2020.101769] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 11/27/2020] [Accepted: 11/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients struggle to fully recover after an Achilles tendon rupture. Although several studies has investigated surgical and non-surgical treatment, the best treatment is still uncertain. The aim of this study was to investigate long-term patient-reported outcomes and objective measures 4 years after acute Achilles tendon rupture and compare whether outcomes differed between patients treated on basis of the previous regimen preferring surgical treatment and the new regimen preferring functional rehabilitation. METHODS Achilles tendon Total Rupture Score (ATRS), number of re-ruptures and the objective measures; Achilles tendon resting angle, calf circumference, heel-rise height, and muscle endurance were measured at a 4-year follow-up. Patients were recruited from Aalborg University Hospital. RESULTS Seventy-six patients were included (29% female). The mean ATRS was 71.4 (95% CI: 65.8 to 77.1) at 4 years follow-up. No difference in ATRS was observed between Previous regimen and New regimen at any timepoint (time x group interaction, (p=0.851). The injured side was still significantly impaired compared with the non-injured side in terms of all objective measures. Impairments in objective measures were not dependent on the preferred treatment strategy. CONCLUSIONS Patient reported impairments and objective functional deficits persist 4 years after an acute Achilles tendon rupture. No differences in patient reported outcome or objective measures at the 4 years follow-up was observed between the old treatment regimen preferring surgery compared with the new treatment regimen preferring functional rehabilitation.
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Affiliation(s)
- Laurine Nilsson
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark.
| | - Jonas Bloch Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Research Unit of General Practice, Department of Public Health Odense, University of Southern Denmark, Odense, Denmark.
| | - Inge Lunding Kjær
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark.
| | - Andrius Kazlauskas
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark.
| | - Marianne Christensen
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark; Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Mini-Invasive, Ultrasound Guided Repair of the Achilles Tendon Rupture-A Pilot Study. J Clin Med 2021; 10:jcm10112370. [PMID: 34071173 PMCID: PMC8197928 DOI: 10.3390/jcm10112370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 11/17/2022] Open
Abstract
Percutaneous acute Achilles tendon rupture suturing has become a leading treatment option in recent years. A common complication after this mini-invasive procedure is sural nerve injury, which can reduce the patients’ satisfaction and final outcomes. High-resolution ultrasound is a reliable method for localizing the sural nerve, and it can be performed intra-operatively; however, the long-term results are yet unknown. The aim of the study was to retrospectively evaluate the long-term results of percutaneous Achilles tendon repair supported with real-time ultrasound imaging. We conducted 57 percutaneous sutures of acute Achilles tendon rupture between 2005 and 2015; 30 were sutured under sonographic guidance, while 27 were performed without sonographic assistance. The inclusion criteria were acute (less than 7 days) full tendon rupture, treatment with the percutaneous technique, age between 18 and 65 years, and a body mass index (BMI) below 35. The operative procedure was carried out by two surgeons, according to the surgical technique reported by Maffulli et al. In total, 35 patients were available for this retrospective assessment; 20 (16 men and 4 women) were treated with sonographic guidance, while 15 (12 men and 3 women) underwent the procedure without it. The mean follow-up was 8 years (range, 3–13 years). The sural nerve was localized 10 mm to 20 mm (mean, 15.8; SD, 3.02) laterally from the scar of the Achilles tendon tear. There was no significant difference between groups with respect to the FAOQ score (P < 0.05). High-resolution ultrasounds performed intra-operatively can minimize the risk of sural nerve injury during percutaneous Achilles tendon repair.
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Andreasen KR, Hansen MS, Bencke J, Hölmich P, Barfod KW. The heel-rise work test overestimates the performed work with 21-25% after an Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2021; 29:1604-1611. [PMID: 33236164 DOI: 10.1007/s00167-020-06369-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to evaluate concurrent validity of the heel-rise work test performed with use of the heel as a surrogate for the center of body mass. METHODS The study was a validity study performed on a prospective cohort of consecutive patients. Forty-five patients were included in the study. The heel-rise work test estimates the total work performed by repeated heel-rises until fatigue. In this study, the heel-rise work was assessed by the linear encoder and a motion capture system simultaneously for validation. The linear encoder was attached to the patient's heel and reflective marker was attached to the pelvis and heel. Student's paired t-test, linear regression analysis and Bland Altman plots were used to estimate the measurement error of the linear encoder. RESULTS The heel-rise work test overestimated the total work with 21.0% on the injured leg and 24.7% on the non-injured leg. Student's paired t-test showed no difference in measurement error between the limbs (n.s.). The linear regression analysis showed no difference in limb symmetry index between the two methods of heel-rise work estimation (a (slope) = 1.00, R = 0.94, p < 0.0001). CONCLUSION The heel-rise work test performed using the heel as a surrogate for center of body mass overestimates the total work with 21.0-24.7% compared to a gold standard but was able to precisely detect the relative difference between the limbs. The heel marker can be considered a valid measurement device for assessing relative differences between the limbs. CLINICAL RELEVANCE Clinical testing of injuries to the lower body using the heel-rise work test is valid when using the relative difference between the limbs. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Kristine Rask Andreasen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark. .,Department of Orthopaedic Surgery, Sports Orthopaedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.
| | - Maria Swennergren Hansen
- Department of Physical and Occupational Therapy, Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark.,Department of Orthopaedic Surgery, Sports Orthopaedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Jesper Bencke
- Department of Orthopaedic Surgery, Laboratory of Human Movement Analysis, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Per Hölmich
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Orthopaedic Surgery, Sports Orthopaedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Orthopaedic Surgery, Sports Orthopaedic Research Center-Copenhagen (SORC-C), Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
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41
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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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42
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Curcillo CP, Duffy DJ, Chang YJ, Moore GE. Ex Vivo Biomechanical Assessment of a Novel Multi-Strand Repair of Canine Tendon Lacerations. Vet Comp Orthop Traumatol 2021; 34:248-256. [PMID: 33792007 DOI: 10.1055/s-0041-1725014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effect of increasing the number of suture strands traversing the transection site, level of suture purchase and depth of suture penetrance on the biomechanical properties of repaired gastrocnemius tendons. STUDY DESIGN Thirty-eight adult cadaveric gastrocnemius tendons were randomized, transected and repaired with either two-, four- or six-strand locking multi-level repair. Tensile loads required to create a 1 and 3 mm gap, yield, peak and failure loads and failure mode were analysed. Significance was set at p < 0.05. RESULTS Mean ± standard deviation yield, peak and failure force for six-strand repairs was 90.6 ± 22.1 N, 111.4 ± 15.2 N and 110.3 ± 15.1 N respectively. This was significantly greater compared with both four-strand (55.0 ± 8.9 N, 72.9 ± 7.8 N and 72.1 ± 8.2 N) and two-strand repairs (24.7 ± 8.3 N, 36.5 ± 6.0 N and 36.1 ± 6.3 N) respectively (p < 0.001). Occurrence of 3 mm gap formation was significantly less using six-strand repairs (p < 0.001). Mode of failure did not differ between groups with all repairs (36/36; 100%) failing by suture pull-through. CONCLUSION Pattern modification by increasing the number of suture strands crossing the repair site, increasing points of suture purchase from the transection site and depth of suture penetrance is positively correlated with repair site strength while significantly reducing the occurrence of gap formation in a canine cadaveric model. Additional studies in vivo are recommended to evaluate their effect on tendinous healing, blood supply and glide resistance prior to clinical implementation.
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Affiliation(s)
- Chiara P Curcillo
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, United States
| | - Daniel J Duffy
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, United States
| | - Yi-Jen Chang
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, United States
| | - George E Moore
- Veterinary Administration, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, United States
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43
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Xu XY, Gao S, Lv Y, Zhou F, Jiao C, Fan JX, Zhu TJ. Duration of immobilisation after Achilles tendon rupture repair by open surgery: a retrospective cohort study. J Orthop Surg Res 2021; 16:196. [PMID: 33731160 PMCID: PMC7968267 DOI: 10.1186/s13018-021-02342-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/09/2021] [Indexed: 12/28/2022] Open
Abstract
Background The best treatment for acute Achilles tendon ruptures remains controversial. No cohort studies have compared different immobilisation durations after open surgery. This retrospective cohort study aimed to determine the optimal duration of immobilisation after this surgery. Methods A total of 266 patients with acute Achilles tendon rupture were divided into 4 groups (A, B, C, and D) according to immobilisation duration of 0, 2, 4, and 6 weeks, respectively. All patients underwent the same suture technique with a similar rehabilitation protocol and were examined clinically at 2, 4, 6, 8, 10, 12, 14, 16, 24, and 48 weeks, with a final follow-up at a mean of 22.3 months postoperatively. The primary outcome was the time of return to light sports activity (LSA). Secondary outcomes included range of motion (ROM) and single-legged heel rise height (SHRH). Data on operation time, complications, visual analogue pain scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and Achilles tendon Total Rupture score (ATRS) were also collected. Demographic baseline data were analysed using one-way analysis of variance; outcome parameters were analysed using Kruskal-Wallis H test, and complications were analysed using Fisher’s exact test. Statistical significance was considered at P ≤ 0.05. Results VAS scores decreased significantly, reaching 0 in all groups after 12 weeks. The AOFAS and ATRS scores were significantly different between the groups from weeks 2 to 12 (P<0.001) and weeks 2 to 16 (P<0.001), respectively. All the mean scores showed better results in group B than in the other groups. In terms of recovery time of ROM, SHRH, and LSA, groups A and B were significantly faster than groups C and D (P<0.001). There were 13 (13/266, 4.9%) complications: 5 superficial infections, 3 deep venous thrombosis, and 5 trauma-related re-ruptures. On the last follow-up, all complications had recovered. There were no significant differences in complications between the groups. Conclusions Immobilisation for 2 weeks after this open surgery is the best choice for early rehabilitation and weight-bearing while minimising pain and other complications.
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Affiliation(s)
- Xiang Yu Xu
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Shan Gao
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Yang Lv
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China.
| | - Fang Zhou
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China.
| | - Chen Jiao
- Department of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Ji Xing Fan
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
| | - Teng Jiao Zhu
- Orthopaedic Department, Peking University Third Hospital, Haidian District, Beijing, 100191, China
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44
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Akoh CC, Fletcher A, Sharma A, Parekh SG. Clinical Outcomes and Complications Following Limited Open Achilles Repair Without an Instrumented Guide. Foot Ankle Int 2021; 42:294-304. [PMID: 33148032 DOI: 10.1177/1071100720962493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We report the clinical outcomes and complications following our limited open incision Achilles tendon repair technique without instrument guides. METHODS A total of 33 patients were included in this study. We recorded pre- and postoperative scores on the Foot and Ankle Disability Index (FADI), visual analog scale (VAS), and the Foot and Ankle Outcome Score (FAOS). Subgroup analyses were performed for acute (<2 weeks) and subacute (2-6 weeks) Achilles tendon repairs. A P value <.05 was considered significant for all statistical analyses. RESULTS The median time from injury to surgery was 10.0 days (range, 1-45 days). At a median follow-up of 3.7 years (range, 1.0-9.8 years), the average pre- and postoperative outcome scores improved significantly for the following: FADI index (49.1-98.4, P < .001), VAS (4.8-0.2, P < .001), FAOS Pain (54.8-99.2, P < .001), FAOS Symptoms (84.6-97.0, P < .001), FAOS activities of daily living (61.4-97.2, P < .001), FAOS Sports and Recreational Activity (39.5-98.5, P < .001), and FAOS quality of life (39.7-88.7, P < .001). There were no significant differences between pre- and postoperative outcome scores between the acute and subacute Achilles repair groups. There were no wound complication, reruptures, or reoperations in the entire cohort. CONCLUSION Patients showed improvements in postoperative patient-reported outcome scores with minimal complications. There was no significant difference in outcomes for acute vs subacute repairs. Our limited open incision Achilles tendon repair, which required no additional targeting instrumentation, had favorable midterm results. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | | | | | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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45
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Park CH, Na HD, Chang MC. Clinical Outcomes of Minimally Invasive Repair Using Ring Forceps for Acute Achilles Tendon Rupture. J Foot Ankle Surg 2021; 60:237-241. [PMID: 33358383 DOI: 10.1053/j.jfas.2020.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 03/07/2020] [Indexed: 02/08/2023]
Abstract
Mini-open techniques using special devices, introduced to preclude the complications of open and percutaneous techniques, have limited usefulness because of the need for the devices and the weak strength of the repair. We developed a mini-open technique using a ring forceps. This technique is easy to use and increases the strength of the repair with crossed sutures. Twenty-six consecutive patients were treated using a mini-open technique using a ring forceps for acute Achilles tendon rupture. American Orthopaedic Foot and Ankle Society (AOFAS) scores and Achilles tendon total rupture scores (ATRS) were evaluated at the last follow-up. The active range of motion of ankle joint and maximum calf circumference (MCC) were measured and compared with the uninjured side at the last follow-up, as well as hopping and single-limb heel-rise (SLHR) tests and isokinetic tests for ankle plantarflexion. AOFAS score and ATRS were 92.2 ± 9.4 and 89.9 ± 10.9, respectively, at the last follow-up. The MCC (p = .035) and maximum height of SLHR (p = .001) were significantly different between uninvolved and involved legs. No significant differences in mean peak torques for plantarflexion at angular speeds of 30°/s (60.9 ± 23.6 vs 50.8 ± 20.4 Nm/kg; p = .299) and 120°/s (31.6 ± 16 vs 29.6 ± 17.7 Nm/kg; p = .776) were observed between uninvolved and involved legs. The mini-open technique using a ring forceps for acute Achilles tendon rupture showed satisfactory clinical outcomes and favorable functional outcomes without complications.
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Affiliation(s)
- Chul Hyun Park
- Professor, Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea.
| | - Ho Dong Na
- Surgeon, Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Min Cheol Chang
- Professor, Department of Physical Medicine and Rehabilitation, Yeungnam University Medical Center, Daegu, Korea
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46
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She G, Teng Q, Li J, Zheng X, Chen L, Hou H. Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture: A Comprehensive Meta-Analysis of RCTs. Front Surg 2021; 8:607743. [PMID: 33681281 PMCID: PMC7931800 DOI: 10.3389/fsurg.2021.607743] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/11/2021] [Indexed: 12/28/2022] Open
Abstract
Background: The Achilles tendon is the strongest tendon in human and is frequently injured, mainly in the young to middle age active population. Increasing incidence of Achilles tendon rupture (ATR) is still reported in several studies. Surgical repair and conservative treatment are two major management strategies widely adopted in ATR patients, but the consensus of the optimal treatment strategy is still debated. We aimed at thoroughly reviewing the ATR topic with additional assessments and performed a most comprehensive meta-analysis of randomized controlled trials (RCTs). Method: We comprehensively searched PubMed, Embase, Cochrane, and ClinicalTrial.gov and retrieved all RCTs comparing surgical and conservative treatment on ATR for further analysis. Two independent reviewers performed data extraction and random effect model was adopted when I 2 > 50%, with data presentation of risk ratio, risk difference, or mean difference and 95% confidence interval. Results: A total of 13 RCTs were included in this meta-analysis. A significant difference was observed in re-rupture, complication rate, adhesion to the underlying tendon, sural nerve injury, and superficial infection. A substantial reduction in re-rupture rate could be observed for surgical treatment while the complication rate was higher compared with conservative treatment. Conclusion: Surgical treatment revealed significance in reducing the re-rupture rate but was associated with a higher complication rate, while conservative treatment showed similar outcomes with a lower complication rate. Collectively, we recommend conservative treatment if patients' status and expectations are suitable, but surgeon and physician discretion is also crucial in decision making.
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Affiliation(s)
- Guorong She
- Department of Sport Medicine, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Qiang Teng
- Department of Sport Medicine, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jieruo Li
- Department of Sport Medicine, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaofei Zheng
- Department of Sport Medicine, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lin Chen
- Drug Clinical Trial Institution, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Huige Hou
- Department of Sport Medicine, First Affiliated Hospital of Jinan University, Guangzhou, China
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47
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Comparing Absorbable and Nonabsorbable Suture Materials for Repair of Achilles Tendon Rupture: A Magnetic Resonance Imaging-Based Study. Diagnostics (Basel) 2020; 10:diagnostics10121085. [PMID: 33322173 PMCID: PMC7764032 DOI: 10.3390/diagnostics10121085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 11/17/2022] Open
Abstract
We aimed to compare magnetic resonance imaging (MRI) findings and corresponding clinical outcomes of repaired Achilles tendons using absorbable and nonabsorbable sutures. Patients who underwent Achilles tendon repair were divided into 2 groups, with 11 in the absorbable group (group A) and 11 in the nonabsorbable group (group B). For all patients, MRI findings taken 6 months postoperatively were evaluated for morphological changes in the tendon. Concurrently, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score and incidence of postoperative complications were evaluated. Regarding MRI findings, the extent to which the cross-sectional area of the repaired tendon was thicker than that of the preoperative tendon was significantly greater in group B than in group A (p = 0.0012). Notably, more stitches remained within the tendon in group B than in group A (p = 0.0063). No other MRI findings showed a significant difference between the two groups. No significant difference was observed in the AOFAS score, and there was one re-rupture each in both groups. Because nonabsorbable suture material in the treatment of Achilles tendon rupture yielded a thicker postoperative MRI cross-sectional area, enhanced rehabilitation is recommended in order to prevent scar formation.
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48
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Duffy DJ, Curcillo CJ, Chang YJ, Moore GE. Effect of suture caliber on the tensile strength of tenorrhaphies in cadaveric canine tendons. Am J Vet Res 2020; 81:714-719. [PMID: 33112169 DOI: 10.2460/ajvr.81.9.714] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effect of suture caliber on the tensile strength of tenorrhaphies performed with a locking-loop technique in cadaveric canine tendons. SAMPLE 60 superficial digital flexor tendons (SDFTs) from 30 cadaveric adult dogs. PROCEDURES Transverse tenotomy was performed, and SDFTs were repaired with a locking-loop technique and polypropylene suture of 5 randomly assigned calibers: size-0, 2-0, 3-0, 4-0, or 5-0 (n = 12 SDFTs/suture caliber). Tendon constructs were tested to failure. Yield, peak, and failure forces and causes of failure were compared between groups. RESULTS Mean ± SD failure force for the constructs was significantly greater with large-caliber suture (size-0: 73.5 ± 3.1 N; size 2-0: 54.4 ± 7.1 N; size 3-0: 28.7 ± 4.9 N; size 4-0: 18.7 ± 3.4 N; and size 5-0: 8.8 ± 2.8 N). The likelihood of construct failure by suture pullout through the tendon substance increased with large-caliber suture (size-0: 12/12), whereas the likelihood of construct failure by suture breakage increased with small-caliber suture (2-0: 10/12; 3-0, 4-0, and 5-0: 12/12 each). CONCLUSIONS AND CLINICAL RELEVANCE Large-caliber suture had greater tensile strength for tenorrhaphies performed with a locking-loop technique in cadaveric canine tendons. Prior to the use of large-caliber suture in patients requiring tenorrhaphy, however, in vivo studies are required to confirm the results obtained here.
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49
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Carpenter D, Dederer K, Weinhold P, Tennant JN. Clinical Outcomes and Cadaveric Biomechanical Analysis of Endoscopic Percutaneous Achilles Tendon Rupture Repair With Absorbable Suture. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420965967. [PMID: 35097413 PMCID: PMC8564947 DOI: 10.1177/2473011420965967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Percutaneous repair of acute Achilles tendon rupture (ATR) continues to gain in popularity. The primary aim of the study was to review the outcomes of a patient cohort undergoing a novel technique of endoscopic percutaneous Achilles tendon repair with absorbable suture. A secondary purpose of this study was to evaluate the basic biomechanical properties of the technique. Methods: A cohort of 30 patients who underwent percutaneous ATR repair was retrospectively analyzed with Achilles Tendon Rupture Scores (ATRS), complications, and additional outcome measures. For a biomechanical analysis portion of the study, 12 cadaveric specimens were paired and randomized to either novel percutaneous repair or open Kessler repair with absorbable suture. These specimens were subjected to 2 phases of cyclical testing (100 cycles 10-43 N followed by 200 cycles 10-86 N) and ultimate strength testing. Results: In the clinical portion of the study we report excellent patient reported outcomes (mean ATRS 94.1), high level of return to sport, and high patient satisfaction. One partial re-rupture was reported but with no major wound or neurologic complications. In the biomechanical portion of the study we found no significant difference in tendon gapping between percutaneous and open repairs in phase 1 of testing. In phase 2, increased gapping occurred between percutaneous (17.8 mm [range 10.7-24.1, SD 6.4]) and open repairs (10.8 mm [range 7.6-14.9, SD 2.7, P = .037]). The ultimate load at failure was not statistically different between the 2 repairs. Conclusions: A percutaneous ATR repair technique using endoscopic assistance and absorbable suture demonstrated low complications and good outcomes in a cohort of patients, with high satisfaction, and excellent functional outcomes including high rates of return to sport. Cadaveric biomechanical testing demonstrated excellent survival during testing and minimal increase in gapping compared with open repair technique, representing sufficient strength to withstand forces seen in early rehabilitation. A percutaneous Achilles tendon repair technique with absorbable suture may minimize risks associated with operative repair while still maintaining the benefit of operative repair. Level of Evidence: Level IV, retrospective case series.
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Affiliation(s)
| | | | - Paul Weinhold
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Joshua N. Tennant
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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50
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Maempel JF, Clement ND, Duckworth AD, Keenan OJF, White TO, Biant LC. A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures. Am J Sports Med 2020; 48:2755-2764. [PMID: 32816521 DOI: 10.1177/0363546520944905] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been a shift toward functional nonoperative rehabilitation in the treatment of Achilles tendon rupture (ATR) despite a shortage of studies directly comparing nonoperative functional rehabilitation with traditional nonoperative immobilization. PURPOSE To compare patient-reported outcome measures and functional outcomes for nonoperatively treated ATR with traditional cast immobilization or functional rehabilitation in a walking boot. STUDY DESIGN Randomized controlled clinical trial; Level of evidence, 2. METHODS In a single-center nonblinded study, 140 patients were randomized to compare treatment for acute ATR in (1) an immobilizing cast in reducing degrees of equinus over a 10-week period with 8 weeks of nonweightbearing mobilization or (2) a walking boot for 8 weeks with reducing equinus and immediate full weightbearing. Exclusion criteria were delayed presentation >2 weeks after injury, tendon reruptures, and latex allergy. Analysis was undertaken on an intention-to-treat basis. RESULTS A total of 69 patients (median age, 41 years [interquartile range, 33-50.5 years]) were randomized to walking boot treatment and 71 patients (41 [32-49]) to cast treatment. At 6 months, patients treated in a walking boot reported better Short Musculoskeletal Function Assessment (SMFA) dysfunction index (6.62 [2.21-12.50] vs 10.66 [4.96-13.42]; P = .050), SMFA bother index (7.29 [2.08-14.58] vs 10.42 [5.73-19.27]; P = .04), Achilles Tendon Total Rupture Score (71.5 [53.50-84.25] vs 54.0 [37-76]; P = .01), and Foot and Ankle Questionnaire core score (91 [81.89-97.55] vs 85 [78.25-92.09]; P = .04). At 1 year, there was no difference in SMFA dysfunction index (2.21 [0.74-5.88] vs 2.94 [1.47-6.62]; P = .25), SMFA bother index (2.08 [0-9.38] vs 5.21 [0.52-11.98]; P = .25), Achilles Tendon Total Rupture Score (92 [72.50-96] vs 87.5 [66.0-94.75]; P = .21), or Foot and Ankle Questionnaire core score (97.75 [89.46-99.00] vs 95.50 [90.88-97.50]; P = .18). Rerupture occurred in 5 and 11 patients (P = .075) and venous thromboembolism in 2 and 3 patients (P = .67) in the boot and cast groups, respectively. Fifteen patients in the boot group but none in the cast group had skin problems (P < .001). Patients treated in a boot returned to driving at a median 12 weeks (vs 13 weeks for cast; P = .045), but there was no difference in time to return to work (P = .48). CONCLUSION Functional rehabilitation with early weightbearing is a safe alternative to traditional immobilizing treatment for ATR, giving better early functional outcomes, albeit with a higher incidence of transient minor skin complications. REGISTRATION NCT02598843 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Julian F Maempel
- Royal Prince Alfred Hospital, Sydney, Australia.,University of Malta Medical School, Msida, Malta
| | | | - Andrew D Duckworth
- Royal Infirmary of Edinburgh, Edinburgh, UK.,University of Edinburgh, Edinburgh, UK
| | | | - Tim O White
- Royal Infirmary of Edinburgh, Edinburgh, UK.,University of Edinburgh, Edinburgh, UK
| | - Leela C Biant
- University of Manchester Medical School, Manchester, UK.,Manchester Orthopaedic Centre, Manchester University NHS Foundation Trust, Manchester, UK
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