Quadriceps tendon autograft and platelet rich plasma injection to treat chronic Achilles tears-a minimum two-year follow-up

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

BACKGROUND

Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

METHODS

A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

RESULTS

Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

CONCLUSION

Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Advances in the Clinical Application of Platelet-Rich Plasma in the Foot and Ankle: A Review

Autologous and recombinant biologic substances have been generated as a result of the research into the cellular features of the healing process. Orthobiologics are increasingly being used in sports medicine and musculoskeletal surgery. Nevertheless, clinical data are limited; consequently, further studies are required, particularly in foot and ankle pathologies. This review aims to provide evidence of the most recent literature results and ignite the interest of orthopedic specialists eager for an update about the most current discussion on platelet-rich plasma (PRP) clinical applications in the foot and ankle fields. Previous studies have shown that platelet-rich plasma can be beneficial in treating various conditions, such as chronic foot ulcers, osteoarthritis, Achilles tendinopathy, etc. Despite the positive effects of PRP on various musculoskeletal conditions, more prospective studies are needed to confirm its effectiveness at treating ankle and foot pathologies. In addition to clinical trials, other factors, such as the quality of the research and the procedures involved, must be considered before they can be used in patients. More long-term evaluations are needed to support or oppose its application in treating foot and ankle disorders. We present the most extensive review of PRP's clinical applications in the foot and ankle field.

Endoscopic-assisted locking block modified Krackow technique combined with a V-Y flap for chronic Achilles tendon rupture

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of the endoscopic-assisted locking block modified Krackow technique with a V-Y flap. The hypothesis was that the minimally invasive technique can reduce wound complications and facilitate early recovery.

METHODS

In total, 29 men with chronic Achilles tendon rupture who underwent either minimally invasive technique (n = 13) or open repair (n = 16) at our department between 2013 and 2019 were retrospectively analyzed. The rate of complications, time to return to moderate-intensity exercise, American Orthopedic Foot and Ankle Society ankle hindfoot score, Achilles tendon Total Rupture Score, heel-rise repetitions in 1 min, heel-rise height, and bilateral calf circumference at 6 months, 1 year, and 2 years postoperatively were recorded.

RESULTS

All incisions healed primarily in the minimally invasive technique group; however, three patients in the open repair group experienced wound complications. The time to return to moderate-intensity exercise, American Orthopedic Foot and Ankle Society score, Achilles tendon Total Rupture Score, heel-rise repetition ratio, and heel-rise height ratio at 6 months postoperatively in the minimally invasive technique group were significantly better than those in the open repair group. However, it was not significantly different between both groups at 2 years postoperatively.

CONCLUSION

Endoscopy allowed scar tissue and adhesions to be removed, allowing the tendon ends to be mobilized out of the small proximal and distal incisions. Minimally invasive technique may result in a lower wound complication incidence and provide better early functional recovery and return to moderate-intensity exercise time than the conventional open procedure in treating chronic Achilles tendon ruptures.

CLINICAL TRIAL REGISTRATION

Wuxi Ninth People's Hospital Medical Ethical Committee, LW2021026.

LEVEL OF EVIDENCE

III.

Platelet-Rich Plasma in acute Achilles tendon ruptures: A systematic review and meta-analysis

BACKGROUND

Platelet Rich Plasma (PRP) is known to exert multi-directional biological effects favouring tendon healing. However, conclusions drawn by numerous studies on its clinical efficacy for acute Achilles tendon rupture are limited. We performed a systematic review and meta-analysis to investigate this and to compare to those without PRP treatment.

METHODS

The Cochrane Controlled Register of Trials, Pubmed, Medline and Embase were used and assessed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ('plasma' OR 'platelet-rich' OR 'platelet-rich plasma' or 'PRP') AND ('Achilles tendon rupture/tear' OR 'calcaneal tendon rupture/tear' OR 'tendo calcaneus rupture/tear'). Data pertaining to biomechanical outcomes (heel endurance test, isokinetic strength, calf-circumference and range of motion), patient-reported outcome measures (PROMs) and incidence of re-ruptures were extracted. Meta-analysis was performed for same outcomes measured in at least three studies. Pooled outcome data were analysed by random- and fixed-effects models.

RESULTS

After abstract and full-text screening, 6 studies were included. In total there were 510 patients of which 256 had local PRP injection and 254 without. The average age was 41.6 years, mean time from injury to treatment 5.9 days and mean follow-up at 61 weeks. Biomechanically, there was similar heel endurance, isokinetic strength, calf circumference and range of motion between both groups. In general, there were no differences in patient reported outcomes from all scoring systems used in the studies. Both groups returned to their pre-injured level at a similar time and there were no differences on the incidence of re-rupture (OR 1.13, 95% CI, 0.46-2.80, p = 0.79).

CONCLUSION

PRP injections for acute Achilles tendon ruptures do not improve medium to long-term biomechanical and clinical outcomes. However, future studies incorporating the ideal application and biological composition of PRP are required to investigate its true clinical efficacy.

Interest of platelet rich plasma in Achilles tendon rupture management: a systematic review

OBJECTIVES

Acute Achilles tendon rupture (ATR) is a disabling sport-related injury. Its management involves conservative treatment with early weight-bearing or surgical treatment. Platelet-rich plasma (PRP) has raised interest as an adjuvant for treatment, given its properties on tendon repair and its anti-inflammatory effect. We aimed to assess clinical impact of PRP use in surgical or non-surgical treatment of acute ATR: range of motion, muscle strength, function, return to sport and adverse events.

METHOD

A systematic literature research was performed using PubMed, ScienceDirect, and Google Scholar databases to collect studies reporting clinical outcomes after acute ATR treated with PRP.

RESULTS

Eight studies were eligible and included 543 acute ATR. Four were randomized comparative studies. A total of 128 patients were treated surgically and 415 were treated conservatively, 271 received PRP injection. Five studies described the type of PRP used, which was variable. Only one study including 12 patients found significant outcomes in favor of the PRP group, with a 4-week earlier recovery of a normal range of motion and a 7-week earlier return to running. No difference in clinical or morphological evaluations, strength measurement, and functional outcomes was found in other studies both at short and long-term. PRP did not seem to modify the frequency of adverse events.

CONCLUSIONS

Data are not clearly in favor of a significant effect of the PRP use for treatment of ATR. There might be a slight effect on evolution during the first months. Its interest should be assessed in future studies with strong methodology.

Platelet-Rich Plasma Applications for Achilles Tendon Repair: A Bridge between Biology and Surgery

Achilles tendon ruptures are very common tendon ruptures and their incidence is increasing in modern society, resulting in work incapacity and months off sport, which generate a need for accelerated and successful therapeutic repair strategy. Platelet-rich plasma (PRP) is emerging as adjuvant human blood-derived constructs to assist Achilles tendon rupture treatment. However, myriad PRP preparation methods in conjunction with poor standardization in the modalities of their applications impinge on the consistent effectiveness of clinical and structural outcomes regarding their therapeutic efficacy. The purpose of this review is to provide some light on the application of PRP for Achilles tendon ruptures. PRP has many characteristics that make it an attractive treatment. Elements such as the inclusion of leukocytes and erythrocytes within PRP, the absence of activation and activation ex vivo or in vivo, the modality of application, and the adjustment of PRP pH can influence the biology of the applied product and result in misleading therapeutic conclusions. The weakest points in demonstrating their consistent effectiveness are primarily the result of myriad PRP preparation methods and the poor standardization of modalities for their application. Selecting the right biological scaffold and applying it correctly to restitutio ad integrum of ruptured Achilles tendons remains a daunting and complex task.

The efficacy of platelet-rich plasma in arthroscopic rotator cuff repair: A protocol of randomized controlled trial

BACKGROUND

Platelet-rich plasma (PRP), an autologous platelet concentrate (contain a large number of growth factors), has been widely investigated in healing and rebuilding the bone and tendon tissue. The objective of this prospective randomized research is to study and then compare the long-term effectiveness of the repair of arthroscopic rotator cuff without and with the platelet-rich plasma. It is assumed that there is no difference in the clinical results between patients receiving the repair of arthroscopic rotator cuff and the patients who do not receive PRP enhancement.

METHODS

This current study is a prospective, single-center, controlled, and randomized experiment. This study was reviewed and permitted via the institutional review committee of our hospital. All the patients will receive the written informed consent in order to involve in our clinical experiment. Patients were selected from the patients who received the repair of arthroscopic rotator cuff. Patients who meet the following conditions will be included in this study: ages ranges from 18 to 55; patients with complete tear of rotator cuff confirmed during operation; the patients agreed to wear the abduction stent for 4 weeks after operation; the preoperative count of platelet count is >150,000. All patients were evaluated at follow-up and baseline for the scores of Constant-Murley (CM) and American Shoulder and Elbow Surgeons (ASES), the numerical rating scale (NRS), and retear rate. The analysis is implemented with the SPSS 16.0 (SPSS Inc., Chicago, IL), the significance level remain at P < .05.

CONCLUSIONS

The results of this study will provide useful new information on whether PRP is effective in the arthroscopic rotator cuff repair patients.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6108).

Extracellular HMGB-1 activates inflammatory signaling in tendon cells and tissues

Background:

Increasing evidence indicates that secretion of high mobility group box 1 protein (HMGB-1) is functionally associated with tendinopathy development. However, the underlying effect and mechanism of extracellular HMGB-1 on tendon cells are unclear.

Methods:

We tested the effect of exogenous HMGB-1 on cell growth, migration, and inflammatory signaling responses with isolated rat Achilles tendon cells. Also, we studied the role of extracellular HMGB-1, when administrated alone or in combination with mechanical overloading induced by intensive treadmill running (ITR), in stimulating inflammatory effects in tendon tissues.

Results:

By using in vitro and in vivo models, we show for the first time that exogenous HMGB-1 dose-dependently induces inflammatory reactions in tendon cells and tendon tissue. Extracellular HMGB-1 promoted redistribution of HMGB-1 from the nucleus to the cytoplasm, and activated canonical nuclear factor kappa B (NF-κB) signaling and mitogen-activated protein kinase (MAPK) signaling. Short-term administration of HMGB-1 induced hyper-cellularity of rat Achilles tendon tissues, accompanied with enhanced immune cell infiltration. Additional ITR to HMGB-1 treatment worsens these responses, and application of HMGB-1 specific inhibitor glycyrrhizin (GL) completely abolishes such inflammatory effects in tendon tissues.

Conclusion:

Collectively, these results confirm that HMGB-1 plays key roles in the induction of tendinopathy. Our findings improve the understanding of the molecular and cellular mechanisms during tendinopathy development, and provide essential information for potential targeted treatments of tendinopathy.