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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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Zhu S, Garofalo J, Abuhantash M, McRae S, MacDonald P, Longstaffe R, Ogborn D. Functional Performance and Tendon Morphology After Operative or Nonoperative Treatment of Achilles Tendon Ruptures. Int J Sports Phys Ther 2024; 19:670-680. [PMID: 38835984 PMCID: PMC11144663 DOI: 10.26603/001c.117549] [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: 01/16/2024] [Accepted: 04/03/2024] [Indexed: 06/06/2024] Open
Abstract
Background While controversy remains as to the relative benefit of operative (OM) versus non-operative management (NOM) of Achilles tendon (AT) ruptures (ATR), few studies have examined the effect on high impact maneuvers such as jumping and hopping. Hypothesis/Purpose The purpose of this study was to determine if functional performance including strength, jumping, and hopping outcomes differed between OM and NOM of acute ATR. The secondary objective was to assess the degree of association between AT morphology and performance outcomes. Study Design Retrospective cohort with a single prospective evaluation. Methods All patients were treated at an institutional secondary care center. Eligible participants (n=12 OM; 12 NOM) who were treated with OM or NOM of ATR within three weeks of injury were evaluated a minimum 20 months following ATR. AT length, thickness and gastrocnemius muscle thickness were assessed with B-mode ultrasound. Isokinetic plantar flexor strength, hop tests and countermovement and drop jumps were completed. Two-way ANOVAS were completed on all tests with unilateral values, independent t-tests were used for bilateral outcomes, and linear regressions were completed to assess the relationship between normalized AT length and performance. Results Affected limb AT was elongated and thickened (p\<0.01), gastrocnemius was atrophied (p\< 0.01) and angle-specific plantar flexor torque was reduced at 120°/s when measured at 20° plantar flexion (p = 0.028). Single leg drop vertical jump was higher in OM (p = 0.015) with no difference for hop and jump tests. AT length was related to plantar flexor torque but had no relationship with hopping performance. Conclusions Hop test performance was maintained despite plantarflexion weakness, gastrocnemius atrophy, and AT elongation. This may be the result of compensatory movement patterns. AT length holds limited explanatory power in plantar flexor strength, although this relationship should be evaluated further. Level of Evidence Level III.
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Affiliation(s)
- Sophie Zhu
- Department of Surgery, Orthopedic SectionUniversity of Manitoba
| | | | | | | | - Peter MacDonald
- Department of Surgery, Orthopedic SectionUniversity of Manitoba
- Pan Am Clinic
| | - Rob Longstaffe
- Department of Surgery, Orthopedic SectionUniversity of Manitoba
- Pan Am Clinic
| | - Dan Ogborn
- Department of Surgery, Orthopedic SectionUniversity of Manitoba
- Pan Am Clinic Foundation
- Faculty of Kinesiology and Recreation ManagementUniversity of Manitoba
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Hoeffner R, Agergaard AS, Svensson RB, Cullum C, Mikkelsen RK, Konradsen L, Krogsgaard M, Boesen M, Kjaer M, Magnusson SP. Tendon Elongation and Function After Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures: A Randomized Controlled Trial. Am J Sports Med 2024; 52:1022-1031. [PMID: 38353060 DOI: 10.1177/03635465241227178] [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: 03/17/2024]
Abstract
BACKGROUND Achilles tendon ruptures often result in long-term functional deficits despite accelerated (standard) rehabilitation. PURPOSE/HYPOTHESIS The purpose of this study was to investigate if delayed loading would influence functional, clinical, and structural outcomes of the muscles and tendon 1 year after a surgical repair. It was hypothesized that delaying the loading would reduce the heel-rise height deficit 1 year after Achilles tendon rupture. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In total, 48 patients with a surgically repaired Achilles tendon rupture were randomized to 2 groups: the standard group received the currently accepted rehabilitation, and the delayed group received the same rehabilitation except that initial loading was delayed by 6 weeks. The primary outcome was the heel-rise height difference between the injured and uninjured sides at 1 year. The secondary outcomes were (1) tendon length measured with magnetic resonance imaging, (2) muscle fascicle length and pennation angle of the gastrocnemius medialis muscle, (3) Doppler activity measured with ultrasonography, (4) Achilles tendon Total Rupture Score (ATRS), and (5) isometric muscle strength. RESULTS The mean heel-rise height deficits for the standard and delayed groups were -2.2 cm and -2.1 cm, respectively (P = .719). The soleus part of the tendon was already elongated 1 week after surgery in both groups without a between-group difference (side-to-side difference: standard, 16.3 mm; delayed, 17.5 mm; P = .997) and did not change over 52 weeks. The gastrocnemius tendon length was unchanged at 1 week but elongated over time without a between-group difference (side-to-side difference at 52 weeks: standard, 10.5 mm; delayed, 13.0 mm; P = .899). The delayed group had less Doppler activity at 12 weeks (P = .006) and a better ATRS (standard, 60 points; delayed, 72 points; P = .032) at 52 weeks. CONCLUSION Delayed loading was not superior to standard loading in reducing the heel-rise height difference at 1 year. The data indirectly suggested reduced inflammation in the initial months and a better patient-reported outcome at 1 year in the delayed group. The soleus part of the tendon was already markedly elongated (35%) 1 week after surgery, while the length of the gastrocnemius tendon was unchanged at 1 week but was 6% elongated at 1 year. Together, these data indirectly suggest that the delayed group fared better, although this finding needs to be confirmed in future investigations. REGISTRATION NCT04263493 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Anne-Sofie Agergaard
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Rene B Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Cullum
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Rasmus Kramer Mikkelsen
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Lars Konradsen
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology, Department of Orthopedic Surgery, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Mikael Boesen
- Department of Radiology, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, University Hospital Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
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Talaski GM, Baumann AN, Salmen N, Curtis DP, Walley KC, Anastasio AT, de Cesar Netto C. Socioeconomic Status and Race Are Rarely Reported in Randomized Controlled Trials for Achilles Tendon Pathology in the Top 10 Orthopaedic Journals: A Systematic Review. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114231225454. [PMID: 38288287 PMCID: PMC10823864 DOI: 10.1177/24730114231225454] [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: 01/31/2024] Open
Abstract
Background Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals. Methods This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high-impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details. Results Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA. Conclusion This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results.
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Affiliation(s)
- Grayson M. Talaski
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Anthony N. Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Natasha Salmen
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Deven P. Curtis
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kempland C. Walley
- Department of Orthopedic Surgery, University of Michigan/Michigan Medicine, Ann Arbor, MI, USA
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Saarensilta A, Aufwerber S, Grävare Silbernagel K, Ackermann P. Early Tendon Morphology as a Biomarker of Long-term Patient Outcomes After Surgical Repair of Achilles Tendon Rupture: A Prospective Cohort Study. Orthop J Sports Med 2023; 11:23259671231205326. [PMID: 37941888 PMCID: PMC10629330 DOI: 10.1177/23259671231205326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 11/10/2023] Open
Abstract
Background Patient outcome after acute Achilles tendon rupture (ATR) varies and is difficult to predict. Whether early variations in healing, visualized with ultrasonography, can predict long-term patient outcome is unclear. Purpose To (1) examine the associations of Achilles tendon cross-sectional area (CSA) and elongation (TE) during healing of ATR repair with patient outcomes at 12 months postoperatively and (2) investigate the predictive or diagnostic capacity of the morphological biomarkers. Study Design Cohort study; Level of evidence, 2. Methods This study was based on previously collected data from 86 patients who underwent acute standardized ATR repair between 2013 and 2018 and who were included in a prior randomized trial investigating early functional mobilization (EFM). In the EFM group, loading was allowed immediately after surgery, while in the comparison group, loading was allowed first at 2 weeks postoperatively. Achilles tendon CSA and length were measured with ultrasound at 6 weeks, 6 months, and 12 months postoperatively. CSA ratio and absolute difference in the length of the healthy and injured tendons were calculated. Patient-reported outcome was registered with the validated Achilles tendon Total Rupture Score and functional outcome with the heel-rise endurance test at 12 months postoperatively. The limb symmetry index (LSI) was calculated for maximum heel-rise height (HRHmax) and total concentric work. Multiple linear regression adjusted for age was used, and the area under the receiver operating characteristic curve (AUC) was calculated to evaluate predictive capacity. Results A larger CSA ratio at 6 weeks was associated with higher LSI HRHmax at 12 months (R2, 0.35; P < .001) and exhibited good predictive capacity (AUC, 0.82). More TE at 12 months was associated with lower LSI total concentric work at 12 months (R2, 0.21; P = .001) and exhibited acceptable predictive capacity (AUC, 0.71). Conclusion Greater Achilles tendon CSA seen on ultrasound 6 weeks after surgical repair had good clinical prediction for long-term functional outcome. TE at 12 months was predictive of inferior functional outcome. Registration NCT02318472 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Annukka Saarensilta
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Women’s Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | | | - Paul Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Trauma, Acute Surgery and Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
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Stake IK, Matheny LM, Comfort SM, Dornan GJ, Haytmanek CT, Clanton TO. Outcomes Following Repair of Achilles Midsubstance Tears: Percutaneous Knotless Repair vs Open Repair. Foot Ankle Int 2023; 44:499-507. [PMID: 37272593 DOI: 10.1177/10711007231160998] [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: 06/06/2023]
Abstract
BACKGROUND Optimum treatment for acute Achilles tendon rupture results in high mechanical strength, low risk of complications, and return to preinjury activity level. Percutaneous knotless repair is a minimally invasive technique with promising results in biomechanical studies, but few comparison clinical studies exist. Our study purpose was to compare functional outcomes and revision rates following acute Achilles tendon rupture treated between percutaneous knotless repair and open repair techniques. METHODS Patients 18 years or older with an acute Achilles tendon rupture, treated by a single surgeon with either open repair or percutaneous knotless repair, and more than 2 years after surgery were assessed for eligibility. Prospective clinical data were obtained from the data registry and standard electronic medical record. Additionally, the patients were contacted to obtain current follow-up questionnaires. Primary outcome measure was Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL). Secondary outcome measures were FAAM sports, 12-Item Short Form Health Survey (SF-12), Tegner activity scale, patient satisfaction with outcome, complications, and revisions. Postoperative follow-up closest to 5 years was used in this study. RESULTS In total, 61 patients were included in the study. Twenty-four of 29 patients (83%) in the open repair group and 28 of 32 patients (88%) in the percutaneous knotless repair group completed the questionnaires with average follow-up of 5.8 years and 4.2 years, respectively. We found no significant differences in patient-reported outcomes or patient satisfaction between groups (FAAM ADL: 99 vs 99 points, P = .99). Operative time was slightly longer in the percutaneous knotless repair group (46 vs 52 minutes, P = .02). Two patients in the open group required revision surgery compared to no patients in the percutaneous group. CONCLUSION In our study, we did not find significant differences in patient-reported outcomes or patient satisfaction by treating Achilles tendon midsubstance ruptures with percutaneous knotless vs open repair. LEVEL OF EVIDENCE Level IlI, retrospective cohort study.
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Affiliation(s)
- Ingrid K Stake
- Steadman Philippon Research Institute, Vail, CO, USA
- Department of Orthopedic Surgery, Ostfold Hospital Trust, Norway
| | - Lauren M Matheny
- Steadman Philippon Research Institute, Vail, CO, USA
- School of Data Science and Analytics, Kennesaw State University, Atlanta, Georgia
| | | | | | - C Thomas Haytmanek
- Steadman Philippon Research Institute, Vail, CO, USA
- The Steadman Clinic, Vail, CO, USA
| | - Thomas O Clanton
- Steadman Philippon Research Institute, Vail, CO, USA
- The Steadman Clinic, Vail, CO, 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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Yang S, Shi W, Yan W, Ao Y, Guo Q, Yang Y. Comparison between primary repair and augmented repair with gastrocnemius turn-down flap for acute Achilles tendon rupture: a retrospective study with minimum 2-year follow-up. BMC Musculoskelet Disord 2023; 24:163. [PMID: 36871017 PMCID: PMC9985193 DOI: 10.1186/s12891-023-06260-w] [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: 09/27/2022] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND To explore and compare the clinical outcomes in patients undergoing primary repair versus augmented repair with a gastrocnemius turn-down flap for acute Achilles tendon rupture. METHODS From 2012 to 2018, the clinical data of 113 patients with acute Achilles tendon rupture who were treated with primary repair or augmented repair with a gastrocnemius turn-down flap by the same surgeon were retrospectively reviewed. The patients' preoperative and postoperative scores on the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society Ankle⁃Hindfoot (AOFAS) score, the Victorian Institute of Sport Assessment⁃Achilles (VISA-A), the Achilles tendon total rupture score (ATRS), and the Tegner Activity Scale were examined and compared. The postoperative calf circumference was measured. A Biodex isokinetic dynamometer was used to evaluate the plantarflexion strength on both sides. The time to return to life and exercise as well as the strength deficits in both groups were recorded. Finally, the correlation analyses between patient characteristics and treatment details with clinical outcomes were conducted. RESULTS In total, 68 patients were included and completed the follow-up. The 42 and 26 patients who were treated with primary repair and augmented repair were assigned to group A and B, respectively. No serious postoperative complications were reported. No significant between-group differences in any outcomes were observed. It was found that female sex was correlated with poorer VISA-A score (P = 0.009), complete seal of paratenon was correlated with higher AOFAS score (P = 0.031), and short leg cast was correlated with higher ATRS score (P = 0.006). CONCLUSIONS Augmented repair with a gastrocnemius turn-down flap provided no advantage over primary repair for the treatment of acute Achilles tendon rupture. After surgical treatment, females tended to had poorer outcomes, while complete seal of paratenon and short leg cast contributed to better results. LEVEL OF EVIDENCE Cohort study; Level of evidence, 3.
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Affiliation(s)
- Shuai Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Weili Shi
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Wenqiang Yan
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Yingfang Ao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Qinwei Guo
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China.
| | - Yuping Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China.
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Harada Y, Yokoya S, Sumimoto Y, Adachi N. Clinical outcomes and tendon lengthening after arthroscopic rotator cuff repair. J Shoulder Elbow Surg 2022; 32:1214-1221. [PMID: 36567014 DOI: 10.1016/j.jse.2022.11.013] [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: 08/12/2022] [Revised: 10/25/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is a phenomenon in which the tendon appears to increase the length after rotator cuff repair. However, it is unclear in which cases tendon lengthening occurs and how the degree of lengthening affects the surgical outcome. This study aimed to evaluate preoperative and postoperative musculotendinous junction (MTJ) and tendon length on magnetic resonance imaging and assess the postoperative tendon lengthening and its impact on postoperative outcomes. METHODS We reviewed 109 patients with good repair integrity after arthroscopic rotator cuff repair. Patients whose supraspinatus tendons were simply pulled out laterally without any additional procedures were included. They underwent serial magnetic resonance imaging before surgery and at 3, 6, and 24 months after surgery. The location of the MTJ in relation to the line of the glenoid fossa and the supraspinatus tendon length were measured. Clinical evaluation was conducted 2 years after surgery, including the range of shoulder motion, shoulder strength index (affected/unaffected strength), Constant score, University of California, Los Angeles score, and pain numeric rating scale. The characteristics of the preoperative tendon, change in tendon length over time, amount of the lateral shift of MTJ location and tendon length, and impact of tendon lengthening on postoperative clinical outcomes were analyzed. RESULTS The preoperative tendon retraction significantly correlated with the MTJ location (r = -0.75; P < .0001) and preoperative tendon length (r = -0.46; P < .0001). The tendon length at 3, 6, and 24 months after surgery was significantly longer than those before surgery (26.7 ± 5.8 mm, 27.9 ± 6.6 mm, 28.5 ± 5.6 mm, and 21.5 ± 5.1 mm, respectively). From before surgery to 24 months after surgery, the MTJ location moved 8.4 ± 8.6 mm laterally and the tendon length increased 7.0 ± 6.1 mm. A significant and weak negative correlation was found between tendon lengthening and the abduction strength index (r = -0.22; P = .03); however, no significant correlation with pain, range of shoulder motion, external rotation strength index, Constant score, and University of California, Los Angeles score was found. Multiple linear regression analysis also showed that tendon lengthening was only associated with the abduction strength index (standardized coefficient = -0.20, P = .03). CONCLUSIONS Tendon lengthening and lateral shift of MTJ location were observed after arthroscopic rotator cuff repair, and they correlated with preoperative tendon retraction. Although the amount of tendon lengthening had negative weak correlation with abduction strength index, it did not affect other postoperative outcomes.
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Affiliation(s)
- Yohei Harada
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan.
| | - Shin Yokoya
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Yasuhiko Sumimoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
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10
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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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11
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Hoeffner R, Svensson RB, Bjerregaard N, Kjær M, Magnusson SP. Persistent Deficits after an Achilles Tendon Rupture: A Narrative Review. TRANSLATIONAL SPORTS MEDICINE 2022; 2022:7445398. [PMID: 38655161 PMCID: PMC11022787 DOI: 10.1155/2022/7445398] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/03/2022] [Accepted: 06/15/2022] [Indexed: 04/26/2024]
Abstract
Persistent muscle weakness, tendon elongation, and incomplete return to preinjury level are frequent sequelae after acute Achilles tendon rupture, and evidence-based knowledge of how to best rehabilitate the injury is largely absent in the literature. The objective of this review is to illuminate and discuss to what extent an Achilles tendon rupture affects muscle, tendon, and function when assessed with the Achilles tendon total rupture score (ATRS), muscle strength, muscle cross-sectional area, tendon length, and the heel-rise test. The patient-reported outcome measures (PROM) data in the literature suggest that the recovery takes longer than 6 months (ATRS, 70 out of 100), that one-year postinjury, the ATRS only reaches 82, and that this does not appear to noticeably improve thereafter. Loss of muscle mass, strength, and function can in some cases be permanent. Over the first 6 months postinjury, the tendon undergoes elongation, which appears to be negatively correlated to heel-rise function. More recently, there has been some interest in how muscle length and excursion is related to the reduced function. The available literature indicates that further research is highly warranted and that efforts to restore normal tendon length may improve the likelihood of returning to preinjury level after an Achilles tendon rupture.
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Affiliation(s)
- Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Rene B. Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai Bjerregaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Michael Kjær
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stig Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Center for Healthy Aging, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
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12
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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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13
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Khair RM, Stenroth L, Cronin NJ, Reito A, Paloneva J, Finni T. Muscle-tendon morphomechanical properties of non-surgically treated Achilles tendon 1-year post-rupture. Clin Biomech (Bristol, Avon) 2022; 92:105568. [PMID: 35066440 DOI: 10.1016/j.clinbiomech.2021.105568] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 10/12/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Achilles tendon rupture appears to alter stiffness and length of the tendon. These alterations may affect the function of tendon in force transmission and in energy storage and recovery. We studied the mechanical properties of the Achilles' tendon post-rupture and their association with function. METHODS Twenty-four (20 males, 4 females) participants (mean age: 43 y, 176 cm, 81 kg) were recruited. Ultrasonography and dynamometry were used to assess the muscle-tendon unit morphological and mechanical properties of non-surgically treated patients 1-year post rupture. FINDINGS Injured tendons were longer with difference of 1.8 cm (95%CI: 0.5-1.9 cm; P < 0.001), and thicker by 0.2 mm (0.2-0.3 mm; P < 0.01). Medial gastrocnemius cross-sectional area was 1.0 cm2 smaller (0.8-1.1 cm2; P < 0.001), fascicles were 0.6 cm shorter (0.5-0.7 cm; P < 0.001) and pennation angle was 2.5° higher (1.3-3.6°; P < 0.001) when compared to the uninjured limb. We found no differences between injured and uninjured tendon stiffness 1-year post-rupture (mean difference: 29.8 N/mm, -7.7-67.3 N/mm; P = 0.170). The injured tendon showed 1.8 mm (1.2-2.4 mm; P < 0.01) lower elongation during maximal voluntary isometric contractions. Patient-reported functional outcome was related to the tendon resting length (β = 0.68, r(10) = 4.079, P = 0.002). Inter-limb differences in the medial gastrocnemius fascicle length were related to inter-limb differences in maximum contractions (β = 1.17, r(14) = 2.808, P = 0.014). INTERPRETATION Longer Achilles tendon resting length was associated with poorer self-evaluated functional outcome. Although the stiffness of non-surgically treated and uninjured tendons was similar 1-year post rupture, plantar flexion strength deficit was still present, possibly due to shorter medial gastrocnemius fascicle length.
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Affiliation(s)
- Ra'ad M Khair
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland.
| | - Lauri Stenroth
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Neil J Cronin
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland; School of Sport & Exercise, University of Gloucestershire, UK
| | | | - Juha Paloneva
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland; Central Finland Health Care District, Finland
| | - Taija Finni
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, Jyväskylä, Finland
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14
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Stake IK, Miles JW, Douglass BW, Dornan GJ, Clanton TO. Biomechanical Evaluation of Achilles Tendon Midsubstance Repair: The Effects of Anchor Angle and Position. Foot Ankle Spec 2022; 15:67-75. [PMID: 34142573 DOI: 10.1177/19386400211009360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The percutaneous knotless repair technique for Achilles tendon ruptures utilizes a Percutaneous Achilles Repair System (PARS) device for suturing the proximal tendon and 2 suture anchors for fixing the sutures into the calcaneus. Determining the best position of the suture anchors may optimize the strength of this repair. METHODS Twelve pairs of human ankle cadaveric specimens were randomly assigned to receive suture anchors placed at 45°, 90°, or 135° from the sagittal plane. The anchors were tensioned according to a protocol representing progressive, postoperative rehabilitation. Load, number of loading cycles, displacement, and mode of failure were recorded. RESULTS With the anchors placed at 45°, 90°, and 135°, the ultimate failure loads were mean 265 ± 64 N, 264 ± 75 N, and 279 ± 40 N, and the total number of loading cycles were mean 459 ± 166, 466 ± 158, and 469 ± 110, respectively. The effect of anchor angle on failure load, number of loading cycles, and displacement was not statistically significant. Visually, the anchors at 45° and 90° demonstrated sutures cutting through the bone. CONCLUSION We found no statistically significant difference in pullout strength between the 3 different anchor angles. Sutures cutting through the bone may be a concern with acute anchor angles. This suggests that a 135° anchor angle may result in a lower risk of tendon elongation with the percutaneous knotless repair technique. LEVELS OF EVIDENCE Cadaveric laboratory study.
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Affiliation(s)
- Ingrid K Stake
- Steadman Philippon Research Institute, Vail, Colorado.,Department of Orthopedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Jon W Miles
- Steadman Philippon Research Institute, Vail, Colorado
| | | | | | - Thomas O Clanton
- Steadman Philippon Research Institute, Vail, Colorado.,The Steadman Clinic, Vail, Colorado
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15
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Maffulli N, Oliva F, Migliorini F. Check-rein technique for Achilles tendon elongation following conservative management for acute Achilles tendon ruptures: a two-year prospective clinical study. J Orthop Surg Res 2021; 16:690. [PMID: 34819119 PMCID: PMC8611836 DOI: 10.1186/s13018-021-02830-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/03/2021] [Indexed: 12/28/2022] Open
Abstract
Background Following conservative management for acute Achilles tendon (AT) ruptures, the tendon may heal in continuity, and some patients may present with an elongated Achilles tendon–gastrosoleus complex. This study investigated the efficacy and feasibility of a novel minimally invasive technique, which we named “check-rein procedure”, in patients with intact and elongated AT following conservative management for AT ruptures. Methods All patients who underwent the check-rein procedure for elongation of the gastrosoleus–AT complex by one experienced surgeon were prospectively enrolled. The AT resting angle (ATRA) and AT rupture score (ATRS) were assessed at baseline and repeated at 2-year follow-up, as were calf circumference and isometric plantarflexion strength of both ankles. Results Forty-three patients (43 procedures) were analysed. The mean time elapsed from injury to surgery was 28.7 ± 7.9 weeks. The mean age at surgery was 38.5 ± 5.7 years. At the last follow-up, ATRS, ATRA, isometric strength difference, and calf circumference of the affected side were increased (P < 0.0001). The rate of the return to sport was 98% (42 of 43). No wound complications or rupture were experienced by any patient. Conclusion The check-rein technique for AT elongation after conservative management of AT tears is effective and feasible to restore tendon length and calf function. The surgical outcome was influenced by the preoperative performance status, and longer time elapsed from injury to surgery worsens the outcomes.
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Affiliation(s)
- Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
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16
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Seow D, Yasui Y, Calder JDF, Kennedy JG, Pearce CJ. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. Am J Sports Med 2021; 49:3728-3748. [PMID: 33783229 DOI: 10.1177/0363546521998284] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling. PURPOSE To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 1. METHODS Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I2 < 25%) and by random-effects models if heterogeneity was moderate to high (I2≥ 25%). RESULTS Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications. CONCLUSION This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.
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Affiliation(s)
- Dexter Seow
- National University Health System, Singapore
| | - Youichi Yasui
- Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, Japan
| | - James D F Calder
- Fortius Clinic, London, UK.,Department of Bioengineering, Imperial College London, London, UK
| | - John G Kennedy
- NYU Langone Orthopedic Hospital, New York, New York, USA
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17
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Ma Y, Meng X, Su Y, Yan Z, Shao Q, Chen Y. Evaluation of a Modified Spoon-Shaped Medial Incision in the Surgical Repair of a Chronic Achilles Tendon Rupture. J Foot Ankle Surg 2021; 60:729-732. [PMID: 33773920 DOI: 10.1053/j.jfas.2020.11.007] [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: 12/30/2018] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 02/03/2023]
Abstract
This study aims to investigate the clinical significance of preventing incision skin necrosis and the improved function offered in patients with a chronic Achilles tendon rupture treated surgically with a modified spoon-shaped medial incision. From January 2013 to January 2017, 50 patients (N = 50) who were admitted to our department with a clinically and radiologically confirmed chronic Achilles tendon rupture met inclusion criteria and were divided retrospectively into two groups. In group A (n = 26), a modified spoon-shaped medial incision in the surgical repair of Achilles tendon rupture was performed. In group B (n = 24), a traditional posterior medial incision was used. All skin healing was observed. Functional evaluation was performed using American Orthopedic Ankle & Foot Society scale(AOFAS) hindfoot score and Achilles tendon total rupture score(ATRS). Return-to-work time and major complications were also measured. The patients were followed for 12 to 48 months. All incisions exhibited primary healing in group A, while four incisions healed delay for skin necrosis which includes superficial, deeper necrosis, and skin defection caused by the necrosis in group B. Both groups had similar results regarding return-to-work time. There were no infections in either group. There was no rerupture of the Achilles tendon in either group. Patients in group A had better AOFAS hindfoot score (p = .020) and ATRS (p = .010), and the difference was significant (p ≤ .05).Using the modified spoon-shaped medial incision in the surgical repair of a chronic Achilles tendon rupture seems to be a safe and effective method that may reduce risk of incision skin necrosis and offers better function in patients with a chronic Achilles tendon rupture.
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Affiliation(s)
- Yanming Ma
- Surgeon, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
| | - Xiangjun Meng
- Professor, Department of Ophthalmology, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
| | - Yun Su
- Professor, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China.
| | - Zuofa Yan
- Surgeon, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
| | - Quansheng Shao
- Surgeon, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
| | - Yiqing Chen
- Surgeon, Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning Province, China
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18
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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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19
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Parisien RL, Trofa DP, Gualtieri AP, Dodson CC, Li X, Levine WN, Vosseller JT. How Do Sports Medicine and Foot and Ankle Specialists Treat Acute Achilles Tendon Ruptures? Foot Ankle Spec 2021; 14:114-119. [PMID: 31971006 DOI: 10.1177/1938640019901055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. The purpose of this study is to evaluate the treatment considerations and surgical techniques utilized by fellowship-trained orthopaedic sports medicine and foot and ankle specialists in the management of Achilles tendon ruptures. Methods. A blinded electronic survey was distributed to 2062 fellowship-trained sports medicine and 1319 fellowship-trained foot and ankle orthopaedic surgeons. The total number of acute Achilles tendon ruptures managed per year, patient-specific factors associated with surgical decision making and surgical techniques were evaluated. Results. Of the 3381 surveys distributed, 524 responses were included for analysis. Only 9% of respondents manage more than 20 acute Achilles tendon ruptures per year with the majority (75%) managing less than 10 per year. Operative management is the treatment of choice for 76% of total respondents with only 8% managing acute ruptures nonoperatively. Activity level and patient age were the single most important factors for 60.8% and 29.3% of surgeons, respectively, with regard to operative versus nonoperative decision making. Socioeconomic status and workers compensation were the least important patient factors. Conclusion. Surgical repair in the young and active patient is the preferred treatment for the majority of fellowship-trained subspecialists who most commonly encounter this pathology.Levels of Evidence: Therapeutic, Level V: Consensus of Expert Analysis.
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Affiliation(s)
- Robert L Parisien
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - David P Trofa
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Anthony P Gualtieri
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Christopher C Dodson
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - William N Levine
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
| | - J Turner Vosseller
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts (RLP, XL).,Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York (DPT, WNL, JTV).,Columbia University, College of Physicians and Surgeons, New York, New York (APG).,Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania (CCD)
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20
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Szaro P, Nilsson-Helander K, Carmont M. MRI of the Achilles tendon - a comprehensive pictorial review. Part two. Eur J Radiol Open 2021; 8:100343. [PMID: 33850972 PMCID: PMC8039832 DOI: 10.1016/j.ejro.2021.100343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/18/2021] [Accepted: 03/20/2021] [Indexed: 12/28/2022] Open
Abstract
The abnormalities on MRI should be correlated with the clinical findings. Higher signal of the Achilles tendon is a common postoperative finding. The fluid signal within the Achilles tendon graft indicates a rupture. Postoperative complications of Haglund’s syndrome should be assessed on MRI. Elongation of the Achilles tendon is seen after surgical or conservative treatment.
The most common disorder affecting the Achilles tendon is midportion tendinopathy. A focal fluid signal indicates microtears, which may progress to partial and complete rupture. Assessment of Achilles tendon healing should be based on tendon morphology and tension rather than structural signal. After nonoperative management or surgical repair of the Achilles tendon, areas of fluid signal is pathologic because it indicates re-rupture. A higher signal in the postoperative Achilles tendon is a common finding and is present for a prolonged period following surgical intervention and needs to be interpreted alongside the clinical appearance.
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Affiliation(s)
- Pawel Szaro
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Descriptive and Clinical Anatomy, Medical University of Warsaw, Warsaw, Poland
| | - Katarina Nilsson-Helander
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Michael Carmont
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.,The Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, UK
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21
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Abousayed MM, Coleman MM, Abbasi P, Bean BA, Thompson JM, Guyton GP. Load to Failure and Stiffness of Interference Screw vs Pulvertaft Weave for Distal Fixation in Peroneal Allograft Reconstruction. Foot Ankle Int 2021; 42:83-88. [PMID: 32969276 DOI: 10.1177/1071100720952092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Allograft reconstruction of the peroneal tendons is an option for treatment of major tears of 1 or both peroneal tendons. No consensus on a superior distal fixation method has been reported. The purpose of the study was to compare load to failure and stiffness of a Pulvertaft weave (PTW) through a residual tendon stump to direct-to-bone interference screw (IS) fixation. METHODS Fifteen pairs of long leg cadaver specimens were used. All grafts were secured proximally to the peroneus brevis myotendinous junction via a PTW technique. Distally, the tendons were either sutured to the peroneus brevis stump via PTW or secured to the base of the fifth metatarsal via IS. Stiffness (slope of force/displacement) was measured for the intact tendon and after reconstruction, and finally each specimen was loaded to failure. RESULTS Mean load to failure was significantly higher in the PTW group compared with the IS group (373.6 ± 265.5 N vs 150.1 ± 93.1 N; P = .01). The PTW and IS groups had significantly lower stiffness compared with the intact specimens (P < .001). There was no statistical significance in stiffness between the 2 techniques (P = .96). CONCLUSION The PTW technique yielded higher load to failure in comparison to IS. There was no difference in overall construct stiffness between both techniques. Both constructs demonstrated 19% decrease in stiffness compared to the intact state. CLINICAL RELEVANCE The PTW and IS constructs were biomechanically similar, and these results suggest that both should be moderately overtensioned to compensate for an inherent decreased initial stiffness.
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Affiliation(s)
- Mostafa M Abousayed
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Michelle M Coleman
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Pooyan Abbasi
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Bryan A Bean
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - John M Thompson
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gregory P Guyton
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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22
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Open Achilles Tendon Rerupture: A Case Report and Review of the Literature. Case Rep Orthop 2020; 2020:6694968. [PMID: 33343955 PMCID: PMC7728476 DOI: 10.1155/2020/6694968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/23/2020] [Accepted: 11/27/2020] [Indexed: 12/05/2022] Open
Abstract
In this report, we describe a rare case of open rerupture of an Achilles tendon following primary surgical repair. The rerupture occurred 12 weeks postoperatively and was associated with a transverse open wound perpendicular to the original surgical incision. This complication was successfully managed utilizing the preexisting transverse wound and a minimally invasive repair technique, minimizing further risk to the soft tissues overlying the tendon. This rare complication has only been described a few times in the literature and is likely associated with adhesions between the tendon repair and the subcutaneous tissues.
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23
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Achilles tendon elongation after acute rupture: is it a problem? A systematic review. Knee Surg Sports Traumatol Arthrosc 2020; 28:4011-4030. [PMID: 32363475 DOI: 10.1007/s00167-020-06010-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Rupture of the Achilles tendon (AT) is a common injury. Strength deficits may persist over the long term, possibly owing to elongation of the tendon or inferior mechanical properties. This study aimed to provide a systematic review of the literature on the prevalence and consequences of tendon elongation in patients after acute AT rupture treatment. It was hypothesized that an elongated tendon would be associated with a worse clinical outcome. METHODS The databases for MEDLINE, CENTRAL and Web of Science were searched. Clinical studies related to AT rupture reporting tendon elongation and clinical or functional outcomes, with a minimum follow-up of 6 months, were eligible for inclusion. Only studies testing for statistical correlations (SCs) between AT elongation and other outcomes were eligible, with the exception of biomechanical studies in which statistically significant AT elongation was found to be a generalized finding in the study group. For these studies to be eligible, the study group had to be compared with a healthy control group, or the injured limb compared with the uninjured limb, regarding biomechanical parameters. RESULTS Twenty-eight papers were selected for inclusion. Mean AT elongation measured with imaging techniques ranged from 0.15 to 3.1 cm (n = 17). Ten studies investigated SCs with Patient Reported Outcome Measures (PROMs), in which two found SCs with tendon elongation. Five studies reported strength and power evaluations and their correlation with AT elongation, with two having found SCs between decreased strength and tendon elongation. In ten studies reporting data on biomechanical tests, nine found influence of tendon elongation. In this group, four out of five studies found SCs with biomechanical parameters. CONCLUSION Fair evidence of the influence of tendon elongation in biomechanical parameters was found. In a general population, evidence of a detrimental effect of tendon elongation on PROMs or functional strength at follow-up was not found in this review. LEVEL OF EVIDENCE Level IV.
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24
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Smith CS, Mollon B, Vannabouathong C, Fu JM, Sales B, Bhandari M, Whelan DB. An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013. J Bone Joint Surg Am 2020; 102:e116. [PMID: 33086352 DOI: 10.2106/jbjs.18.00653] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials. METHODS A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted. RESULTS A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment. CONCLUSIONS The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.
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Affiliation(s)
| | - Brent Mollon
- Soldiers' Memorial Hospital, Orillia, Ontario, Canada
| | | | - Joyce M Fu
- Department of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | | | - Mohit Bhandari
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daniel B Whelan
- University of Toronto Orthopaedic Sports Medicine, St. Michael's and Women's College Hospitals, Toronto, Ontario, Canada
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25
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Hales S, Tokita E, Neupane R, Ghosh U, Elder B, Wirthlin D, Kong YL. 3D printed nanomaterial-based electronic, biomedical, and bioelectronic devices. NANOTECHNOLOGY 2020; 31:172001. [PMID: 31805540 DOI: 10.1088/1361-6528/ab5f29] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The ability to seamlessly integrate functional materials into three-dimensional (3D) constructs has been of significant interest, as it can enable the creation of multifunctional devices. Such integration can be achieved with a multiscale, multi-material 3D printing strategy. This technology has enabled the creation of unique devices such as personalized tissue regenerative scaffolds, biomedical implants, 3D electronic devices, and bionic constructs which are challenging to realize with conventional manufacturing processes. In particular, the incorporation of nanomaterials into 3D printed devices can endow a wide range of constructs with tailorable mechanical, chemical, and electrical functionalities. This review highlights the advances and unique possibilities in the fabrication of novel electronic, biomedical, and bioelectronic devices that are realized by the synergistic integration of nanomaterials with 3D printing technologies.
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Affiliation(s)
- Samuel Hales
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT 84112, United States of America
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26
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Carmont MR, Zellers JA, Brorsson A, Nilsson-Helander K, Karlsson J, Grävare Silbernagel K. Age and Tightness of Repair Are Predictors of Heel-Rise Height After Achilles Tendon Rupture. Orthop J Sports Med 2020; 8:2325967120909556. [PMID: 32232072 PMCID: PMC7097876 DOI: 10.1177/2325967120909556] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Achilles tendon rupture leads to weakness of ankle plantarflexion. Treatment of Achilles tendon rupture should aim to restore function while minimizing weakness and complications of management. Purpose: To determine the influence of factors (age, sex, body mass index [BMI], weight, time from injury to operative repair, and tightness of repair) in the initial surgical management of patients after an acute Achilles tendon rupture on 12-month functional outcome assessment after percutaneous and minimally invasive repair. Study Design: Cohort study; Level of evidence, 3. Methods: From May 2012 to January 2018, patients sustaining an Achilles tendon rupture receiving operative repair were prospectively evaluated. Tightness of repair was quantified using the intraoperative Achilles tendon resting angle (ATRA). Heel-rise height index (HRHI) was used as the primary 12-month outcome variable. Secondary outcome measures included Achilles tendon total rupture score (ATRS) and Tegner score. Stepwise multiple regression was used to create a model to predict 12-month HRHI. Results: A total of 122 patients met the inclusion criteria for data analysis (mean ± SD age, 44.1 ± 10.8 years; 78% male; mean ± SD BMI, 28.1 ± 4.3 kg/m2). The elapsed time to surgery was 6.5 ± 4.0 days. At 12-month follow-up, patients had an HRHI of 82% ± 16% and performed 82% ± 17% of repetitions compared with the noninjured side. Participants had a mean ATRS of 87 ± 15 and a median Tegner score of 5 (range, 1-9), with a reduction in Tegner score of 2 from preinjury levels. The relative ATRA at 12 months was –4.8° ± 3.9°. Multiple regression identified younger age (B = ±0.006; P < .001) and greater intraoperative ATRA (B = 0.005; P = .053) as predictors of more symmetrical 12-month HRHI (R2 = 0.19; P < .001; n = 120). Conclusion: Age was found to be the strongest predictor of outcome after Achilles tendon rupture. The most important modifiable risk factor was the tightness of repair. It is recommended that repair be performed as tight as possible to optimize heel-rise height 1 year after Achilles tendon rupture and possibly to reduce tendon elongation.
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Affiliation(s)
- Michael R Carmont
- Department of Trauma and Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
| | - Jennifer A Zellers
- Program in Physical Therapy, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Annelie Brorsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson-Helander
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jón Karlsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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27
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Walker J, Nicholson G, Jongerius N, Parelkar P, Harris N, Bissas A. Commonly reported isokinetic parameters do not reveal long-term strength deficits of the Triceps surae complex following operative treatment of Achilles tendon rupture. J Biomech 2020; 101:109630. [DOI: 10.1016/j.jbiomech.2020.109630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/04/2020] [Accepted: 01/12/2020] [Indexed: 10/25/2022]
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28
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Hürmeydan ÖM, Demirel M, Valiyev N, Sahinkaya T, Kılıçoğlu Öİ. Relationship of Postoperative Achilles Tendon Elongation With Plantarflexion Strength Following Surgical Repair. Foot Ankle Int 2020; 41:140-146. [PMID: 31595790 DOI: 10.1177/1071100719879659] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little data exist regarding the adverse effects of Achilles tendon (AT) elongation after rupture repair on plantarflexion strength. This study aimed to investigate the effect of AT elongation measured using AT resting angle (ATRA) on the plantarflexion strength in patients with surgically treated acute AT rupture. METHODS A retrospective chart review was performed on 40 patients (15 female and 25 female) who underwent open operative repair due to an acute AT rupture. At the final follow-up, AT elongation was assessed using ATRA. Plantarflexion strength (peak torques and angle-specific torques) was measured using an isokinetic dynamometer. All variables were obtained from the operated and unoperated contralateral ankles of the patients. RESULTS The mean ATRA was greater in the operated ankles (mean, 57 degrees; range, 39-71 degrees) compared with the unoperated ones (mean, 52 degrees; range, 36-66 degrees; P = .009). Except the plantarflexion torque at 20 degrees of plantarflexion (P = .246), all the other angle-specific torques were lower in the operated ankles (P < .05). Peak flexion torque at 30 degrees/s was lower in the operated ankle (P = .002). A negative correlation was found between operated/unoperated (O/N) ATRA and O/N plantarflexion torque ratios at 0 degrees (r = -0.404; P = .01), 10 degrees (r = -0.399; P= .011), and 20 degrees (r = -0.387; P = .014). CONCLUSION Postoperative AT elongation measured using ATRA may have a deleterious effect on the plantarflexion strength in patients with surgically treated acute AT rupture. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Önder Murat Hürmeydan
- Department of Orthopaedics and Traumatology, Bakirkoy Training and Research Hospital, School of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Mehmet Demirel
- Department of Orthopaedics and Traumatology, Haseki Training and Research Hospital, School of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Natig Valiyev
- Department of Orthopaedics, Acibadem Hospital, Maslak, Istanbul, Turkey
| | - Turker Sahinkaya
- Department of Sports Medicine, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Önder İsmet Kılıçoğlu
- Department of Orthopaedics and Traumatology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
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29
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McHugh MP, Orishimo KF, Kremenic IJ, Adelman J, Nicholas SJ. Electromyographic Evidence of Excessive Achilles Tendon Elongation During Isometric Contractions After Achilles Tendon Repair. Orthop J Sports Med 2019; 7:2325967119883357. [PMID: 31763342 PMCID: PMC6854752 DOI: 10.1177/2325967119883357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Weakness in end-range plantarflexion has been demonstrated after Achilles tendon repair and may be because of excessive tendon elongation. The mean frequency (MNF) of surface electromyogram (EMG) data during isometric maximum voluntary contraction (MVC) increases with muscle fiber shortening. Hypothesis During isometric plantarflexion, MNF during MVCs will be higher on the involved side compared with the uninvolved side after Achilles tendon repair because of excessive tendon elongation and greater muscle fiber shortening. Study Design Case series; Level of evidence, 4. Methods Isometric plantarflexion MVC torque was measured at 20° and 10° dorsiflexion, neutral, and 10° and 20° plantarflexion in 17 patients (15 men, 2 women; mean age, 39 ± 9 years) at a mean 43 ± 26 months after surgery. Surface EMG signals were recorded during strength tests. MNF was calculated from fast Fourier transforms of medial gastrocnemius (MG), lateral gastrocnemius (LG), and soleus (SOL) EMG signals. Results Patients had marked weakness on the involved side versus the uninvolved side in 20° plantarflexion (deficit, 28% ± 18%; P < .001) but no significant weakness in 20° dorsiflexion (deficit, 8% ± 15%; P = .195). MNF increased when moving from dorsiflexion to plantarflexion (P < .001), but overall, it was not different between the involved and uninvolved sides (P = .195). However, differences in MNF between the involved and uninvolved sides were apparent in patients with marked weakness. At 10° plantarflexion, 8 of 17 patients had marked weakness (>20% deficit). MNF at 10° plantarflexion was significantly higher on the involved side versus the uninvolved side in patients with weakness, but this was not apparent in patients with no weakness (side by group, P = .012). Mean MNF at 10° plantarflexion across the 3 muscles was 13% higher on the involved side versus the uninvolved side in patients with weakness (P = .012) versus 3% lower in patients with no weakness (P = .522). Conclusion Higher MNF on the involved side versus the uninvolved side in patients with significant plantarflexion weakness is consistent with greater muscle fiber shortening. This indicates that weakness was primarily because of excessive lengthening of the repaired Achilles tendon. If weakness was simply because of atrophy, a lower MNF would have been expected and patients would have had weakness throughout the range of motion. Surgical and rehabilitative strategies are needed to prevent excessive tendon elongation and weakness in end-range plantarflexion after Achilles repair.
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Affiliation(s)
- Malachy P McHugh
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA.,Department of Sport, Exercise & Rehabilitation, Northumbria University, Newcastle Upon Tyne, UK
| | - Karl F Orishimo
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Ian J Kremenic
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Julia Adelman
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Stephen J Nicholas
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
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30
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Manent A, López L, Corominas H, Santamaría A, Domínguez A, Llorens N, Sales M, Videla S. Acute Achilles Tendon Ruptures: Efficacy of Conservative and Surgical (Percutaneous, Open) Treatment-A Randomized, Controlled, Clinical Trial. J Foot Ankle Surg 2019; 58:1229-1234. [PMID: 31679677 DOI: 10.1053/j.jfas.2019.02.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 02/03/2023]
Abstract
There is controversy regarding the best treatment for acute ruptures of the Achilles tendon. Multiple treatments present good results in the short and long term, none being superior to the other if a protocol of rehabilitation with full early weightbearing rehabilitation is followed. The objective of this study was to provide evidence on the efficacy and safety of conservative or surgical (percutaneous or open) treatment for acute Achilles tendon rupture. A randomized, controlled, parallel-groups, pilot clinical trial was performed in patients aged ≥18 years who arrived at the emergency room of our center experiencing acute Achilles tendon rupture. Patients were randomized via a computer-generated list to receive 1 of 3 treatments (conservative, percutaneous surgery, or open surgery). All patients followed the same protocol of rehabilitation with early weightbearing. A responder (i.e., successful treatment) was defined as capable of standing heelrise mono- and bipodally for 3 seconds, having a pain score ≤2 (verbal numerical rating scale) after walking, and having returned to active previous life (sport) at 1-year follow-up. From 2014 to 2017, 34 consecutive patients (median age, 41 years [range 18 to 59]; 32 male [94%]) were included: 11 conservative treatment, 11 percutaneous surgery, and 12 open surgery. At 1-year follow-up, the proportion of responders was 100% (11/11, 95% confidence interval [CI] 74% to 100%), 82% (9/11, 95% CI 52% to 95%), and 83% (10/12, 95% CI 55% to 95%), respectively. There was no case of total rerupture. Similar efficacy was found for conservative, percutaneous, and open surgery treatments for acute Achilles tendon rupture at 1-year follow-up with an early weightbearing rehabilitation program.
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Affiliation(s)
- Andrea Manent
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain.
| | - Laia López
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Hèctor Corominas
- Medical Doctor, Rheumatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Alejandro Santamaría
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Alejandro Domínguez
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Natalia Llorens
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Miquel Sales
- Surgeon, Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral, Sant Joan Despí, Barcelona, Catalonia, Spain
| | - Sebastián Videla
- Associate, Clinical Research Support Unit, Clinical Pharmacology Department, Bellvitge University Hospital/Bellvitge Biomedical Research Institute/University of Barcelona, L'Hospitalet del Llobregat, Barcelona, Catalonia, Spain
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31
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Abstract
The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.
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Affiliation(s)
- Henrik C Bäcker
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Adrian J Yenchak
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - David P Trofa
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - J Turner Vosseller
- Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY
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32
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Svensson RB, Couppé C, Agergaard A, Ohrhammar Josefsen C, Jensen MH, Barfod KW, Nybing JD, Hansen P, Krogsgaard M, Magnusson SP. Persistent functional loss following ruptured Achilles tendon is associated with reduced gastrocnemius muscle fascicle length, elongated gastrocnemius and soleus tendon, and reduced muscle cross‐sectional area. TRANSLATIONAL SPORTS MEDICINE 2019. [DOI: 10.1002/tsm2.103] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- René B. Svensson
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Christian Couppé
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
- Department of Physical Therapy Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - Anne‐Sofie Agergaard
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
- Department of Physical Therapy Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - Christian Ohrhammar Josefsen
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Mikkel Holm Jensen
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Kristoffer Weisskirchner Barfod
- Department of Orthopedic Surgery, Sports Orthopedic Research Center–Copenhagen Copenhagen University Hospital Amager‐Hvidovre Denmark
| | - Janus D. Nybing
- Department of Radiology, Musculoskeletal Imaging Research Unit Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - Philip Hansen
- Department of Radiology, Musculoskeletal Imaging Research Unit Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology, Department of Orthopedic Surgery Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
| | - S. Peter Magnusson
- Department of Orthopedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg‐Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
- Department of Physical Therapy Bispebjerg‐Frederiksberg Hospital Copenhagen Denmark
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Hullfish TJ, O’Connor KM, Baxter JR. Gastrocnemius fascicles are shorter and more pennate throughout the first month following acute Achilles tendon rupture. PeerJ 2019; 7:e6788. [PMID: 31065459 PMCID: PMC6485203 DOI: 10.7717/peerj.6788] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/14/2019] [Indexed: 12/28/2022] Open
Abstract
The purpose of this study was to characterize the short-term effects of Achilles tendon ruptures on medial gastrocnemius. We hypothesized that the fascicles of the medial gastrocnemius muscle of the injured Achilles tendon would be shorter and more pennate immediately following the injury and would persist throughout 4 weeks post-injury. B-mode longitudinal ultrasound images of the medial gastrocnemius were acquired in 10 adults who suffered acute Achilles tendon ruptures and were treated non-operatively. Ultrasound images were acquired during the initial clinical visit following injury as well as 2 and 4 weeks following this initial clinical visit. Resting muscle structure was characterized by measuring fascicle length, pennation angle, muscle thickness, and muscle echo intensity in both the injured and contralateral (control) limbs. Fascicle length was 15% shorter (P < 0.001) and pennation angle was 21% greater (P < 0.001) in the injured muscle compared to the uninjured (control) muscle at the presentation of injury (week 0). These differences in fascicle length persisted through 4 weeks after injury (P < 0.002) and pennation angle returned to pre-injury levels. Muscle thickness changes were not detected at any of the post-injury visits (difference < 4%, P > 0.026). Echo intensity of the injured limb was 8% lower at the presentation of the injury but was not different compared to the contralateral muscle at 2 and 4 weeks post-injury. Our results suggest that Achilles tendon ruptures elicit rapid changes in the configuration of the medial gastrocnemius, which may explain long-term functional deficits.
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Affiliation(s)
- Todd J. Hullfish
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathryn M. O’Connor
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Josh R. Baxter
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Zellers JA, Marmon AR, Ebrahimi A, Silbernagel KG. Lower extremity work along with triceps surae structure and activation is altered with jumping after Achilles tendon repair. J Orthop Res 2019; 37:933-941. [PMID: 30816587 PMCID: PMC6470019 DOI: 10.1002/jor.24260] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/12/2019] [Indexed: 02/04/2023]
Abstract
Achilles tendon rupture leads to long term plantar flexor deficits. The purpose of this study was to describe changes in jumping biomechanics along with triceps surae structure and activation in individuals after Achilles repair. Eleven individuals 1-3 years following Achilles repair and 10 healthy controls were included. Kinetics and kinematics, analyzed using a constituent lower extremity work (CLEW) approach, and muscle activity using surface electromyography (EMG) were collected during a unilateral hopping task. Triceps surae myotendinous structure was assessed using ultrasound imaging. There were no differences in jump height, absolute limb work, or cost of transport between groups. During takeoff, the knee did more (p < 0.001) and ankle did less concentric work (p < 0.001), and lateral gastrocnemius rate of rise was higher (p = 0.02) on the ruptured side. During landing, the knee did more eccentric work (p = 0.033) and lateral gastrocnemius (p = 0.003) and soleus (p = 0.02) activation amplitude prior to landing was higher on the ruptured side. Individuals after Achilles tendon repair shift work toward the knee and alter muscle recruitment. Differences in lateral gastrocnemius activity may indicate that it is well-situated to generate power during takeoff and assist in landing with the soleus. The lack of change in muscle activity and decreased cross sectional area of the medial gastrocnemius may suggest that this muscle atrophies and does not accommodate to the hopping task. Clinical Significance: Proximal lower extremity strengthening along with emphasizing medial gastrocnemius and soleus activation during the recovery of patients with Achilles tendon repair may be rehabilitative targets for improved jumping performance. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Jennifer A. Zellers
- Department of Physical Therapy, University of Delaware, 540 S. College Ave, Newark, DE 19713, USA,
| | - Adam R. Marmon
- Department of Physical Therapy, University of Delaware, 540 S. College Ave, Newark, DE 19713, USA,
| | - Anahid Ebrahimi
- Department of Mechanical Engineering, University of Wisconsin-Madison, 1513 University Ave, Madison, WI, 53706, USA,
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Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Bosma E, van Raaij TM, Munzebrock AV, Zijlstra WP, Zwerver J, Reininga IHF. The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study. BMC Musculoskelet Disord 2019; 20:69. [PMID: 30744626 PMCID: PMC6371453 DOI: 10.1186/s12891-019-2437-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 01/28/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Achilles tendon rupture (ATR) is a common sports injury, with a rising incidence and significant impairments. Due to the lack of treatment guidelines, there is no consensus about diagnostic methods, primary treatment (non-surgical or surgical) and rehabilitation. It is hypothesized that this lack of consensus and guidelines leads to sub-optimal recovery and higher societal costs. The primary aim of this study is to give a broad insight into the recovery after ATR. Secondarily this study aims to explore factors contributing to recovery and gain insight into the cost-effectiveness of ATR management. METHODS This multicenter prospective cohort study will include all adult (≥ 18 years) patients with an ATR treated at the three main hospitals in the Northern Netherlands: University Medical Center Groningen, Martini Hospital Groningen and Medical Center Leeuwarden. All subjects will be invited for three visits at 3, 6 and 12 months post-injury. The following data will be collected: patient-reported outcome measures (PROMs), physical tests, imaging and economic questionnaires. At 3 months post-injury personal, injury, and treatment data will be collected through a baseline questionnaire and assessment of the medical file. The PROMs concern the Dutch version of the Achilles Tendon Total Rupture Score, EQ-5D-5 L, Oslo Sport Trauma Research Center Overuse Injury Questionnaire, Injury Psychological Readiness Return to Sport Scale, Tampa Scale of Kinesiophobia, Expectations, Motivation and Satisfaction questionnaire and a ranking of reasons for not returning to sport. The administered physical tests are the heel-rise test, standing dorsiflexion range of motion, resting tendon length and single leg hop for distance. Ultrasound Tissue Characterization will be used for imaging. Finally, economic data will be collected using the Productivity Cost Questionnaire and Medical Consumption Questionnaire. DISCUSSION This prospective cohort study will contribute to optimal decision making in the primary treatment and rehabilitation of ATRs by providing insight into (1) ATR recovery (2) novel imaging for monitoring recovery (3) (barriers to) return to sport and (4) cost-effectiveness of management. The analysis of these data strives to give a broad insight into the recovery after ATR as well as provide data on novel imaging and costs, contributing to individualized ATR management. TRIAL REGISTRATION Trialregister.nl. NTR6484 . 20/06/2017. 20/07/2017.
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Affiliation(s)
- Olivier C. Dams
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ron L. Diercks
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaus W. Wendt
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eelke Bosma
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Tom M. van Raaij
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Arvid V. Munzebrock
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Wierd P. Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Johannes Zwerver
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Baxter JR, Farber DC, Hast MW. Plantarflexor fiber and tendon slack length are strong determinates of simulated single-leg heel raise height. J Biomech 2019; 86:27-33. [PMID: 30722935 DOI: 10.1016/j.jbiomech.2019.01.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
Achilles tendon ruptures have been linked with detrimental changes in muscle-tendon structure, which may help explain long-term functional deficits. However, the causal effects of muscle-tendon structure on joint function have not been tested in a controlled setting. Therefore, the purpose of this study was to test the implications of muscle-tendon unit parameters on simulated single-leg heel raise height. We hypothesized that muscle fiber length and resting ankle angle - a clinical surrogate measure of tendon slack length - would predict single-leg heel raise height more strongly than other parameters. To test this hypothesis, we developed a two-part simulation paradigm that recreated clinically relevant muscle-tendon scenarios and then tested these parameters on single-leg heel raise height. We found that longer muscle fibers had the greatest positive effect on single-leg heel raise height. However, tendon slack length, determined by simulating resting ankle angles in a secondary analysis, revealed a stronger negative correlation with heel raise height. Our findings support previous clinical observations that both muscle fascicle length and resting tendon length are important muscle-tendon parameters for patient function. In addition to minimizing tendon elongation following rupture, treatment plans should focus on preserving plantarflexor muscle structure to mitigate functional loses following Achilles tendon ruptures.
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Affiliation(s)
- Josh R Baxter
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Daniel C Farber
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael W Hast
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Objectives The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development. Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2.
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Affiliation(s)
- X Yang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - H Meng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Q Quan
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - J Peng
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - S Lu
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - A Wang
- Department of Orthopedic Surgery, Key Laboratory of Musculoskeletal Trauma & War Injuries PLA, Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China
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Eliasson P, Agergaard AS, Couppé C, Svensson R, Hoeffner R, Warming S, Warming N, Holm C, Jensen MH, Krogsgaard M, Kjaer M, Magnusson SP. The Ruptured Achilles Tendon Elongates for 6 Months After Surgical Repair Regardless of Early or Late Weightbearing in Combination With Ankle Mobilization: A Randomized Clinical Trial. Am J Sports Med 2018; 46:2492-2502. [PMID: 29965789 DOI: 10.1177/0363546518781826] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment strategies for Achilles tendon rupture vary considerably, and clinical outcome may depend on the magnitude of tendon elongation after surgical repair. The aim of this project was to examine whether tendon elongation, mechanical properties, and functional outcomes during rehabilitation of surgically repaired acute Achilles tendon ruptures were influenced by different rehabilitation regimens during the early postsurgical period. HYPOTHESIS Restricted early weightbearing that permits only limited motion about the ankle in the early phase of tendon healing limits tendon elongation and improves functional outcome. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS 75 consecutive patients with an acute Achilles tendon rupture were included. They underwent surgical repair, and tantalum beads were placed in the distal and proximal parts of the tendon; thereafter, the patients were randomized into 3 groups. The first group was completely restricted from weightbearing until week 7. The second group was completely restricted from weightbearing until week 7 but performed ankle joint mobilization exercises. The first and second groups were allowed full weightbearing after week 8. The third group was allowed partial weightbearing from day 1 and full weightbearing from week 5. All patients received the same instructions in home exercise guidelines starting from week 9. RESULTS The rehabilitation regimen in the initial 8 weeks did not significantly influence any of the measured outcomes including tendon elongation. Achilles tendon elongation and tendon compliance continued for up to 6 months after surgery, and muscle strength, muscle endurance, and patient-reported functional scores did not reach normal values at 12 months. CONCLUSION Differences in rehabilitation loading pattern in the initial 8 weeks after the repair of an Achilles tendon rupture did not measurably alter the outcome. The time to recover full function after an Achilles tendon rupture is at least 12 months. Registration: NCT02422004 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Pernilla Eliasson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Anne-Sofie Agergaard
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Christian Couppé
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - René Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Rikke Hoeffner
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Susan Warming
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Nichlas Warming
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Christina Holm
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Mikkel Holm Jensen
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Michael Krogsgaard
- Section for Sports Traumatology, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg-Frederiksberg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Denmark
- Department of Physical Therapy, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
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Manent A, Lopez L, Vilanova J, Mota T, Alvarez J, Santamaría A, Oliva XM. Assessment of the Resistance of Several Suture Techniques in Human Cadaver Achilles Tendons. J Foot Ankle Surg 2018; 56:954-959. [PMID: 28842104 DOI: 10.1053/j.jfas.2017.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Indexed: 02/03/2023]
Abstract
Many treatments are available for acute Achilles tendon ruptures, conservative and surgical, with none superior to another. For surgical treatment, one can use various techniques. Recent studies have shown that double stitches are superior to simple sutures. Therefore, in the present study, we sought to determine the suture technique that is the most resistant to rupture. We performed an experimental anatomic study with 27 fresh-frozen human cadaveric Achilles tendons obtained through the body donation program of the University of Barcelona, testing the maximum strength. We simulated a rupture by performing resection in the middle portion of the tendon, 4 cm proximal to the calcaneus insertion. We then evaluated the double Kessler, double Bunnell, Krackow, and percutaneous Ma and Griffith technique. We used absorbable suture (polydioxanone no. 1) with all the techniques. Traction was performed using a machine that pulls the tendon at 10 to 100 N in 1000 repetitive cycles. Statistical analysis was performed using the χ2 test and analysis of variance, with the 95% confidence intervals (p < .05). All repairs failed at the site of the suture knots, with none pulling out through the substance of the tendon. We found no significant differences among the different open suture techniques (p > .05). The Krackow suture presented with superior resistance, with a rupture rate 16.70% but with a mean elongation of 7.11 mm. The double Bunnell suture had the same rupture rate as the Krakow suture (16.70%) but with an inferior mean elongation of 4.53 mm. The Krackow and Bunnell suture were superior in endurance, strength of failure, and primary stability compared with the other suture types. However, the former presented with greater tendon elongation, although the difference was not statistically significant. Therefore, according to our findings and the published data, we recommend double Bunnell sutures for the surgical treatment of acute Achilles tendon rupture.
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Affiliation(s)
- Andrea Manent
- Orthopaedic Surgeon, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain.
| | - Laia Lopez
- Orthopaedic Surgeon, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Vilanova
- Surgeon in Practice, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain
| | - Tiago Mota
- Intern, Department of Anatomy, Universitat de Barcelona (H. Clinic), Barcelona, Spain
| | - Jordi Alvarez
- Orthopaedic Surgeon, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain
| | - Alejandro Santamaría
- Orthopaedic Surgeon, Consorci Sanitari Integral, Sant Joan Despí y Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Martí Oliva
- Orthopedic Surgeon and Professor, Department of Anatomy, Universitat de Barcelona, Barcelona, Spain
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Zhang YJ, Zhang C, Wang Q, Lin XJ. Augmented Versus Nonaugmented Repair of Acute Achilles Tendon Rupture: A Systematic Review and Meta-analysis. Am J Sports Med 2018; 46:1767-1772. [PMID: 28467100 DOI: 10.1177/0363546517702872] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although simple end-to-end repair of the Achilles tendon is common, many augmented repair protocols have been implemented for acute Achilles tendon rupture. However, whether augmented repair is better than nonaugmented repair of an acute Achilles tendon rupture is still unknown. PURPOSE To conduct a meta-analysis to determine whether augmented surgical repair of an acute Achilles tendon rupture improved subjective patient satisfaction without an increase in rerupture rates. Secondary outcomes assessed included infections, ankle range of motion, calf muscle strength, and minor complications. STUDY DESIGN Meta-analysis. METHODS A systematic literature search of peer-reviewed articles was conducted to identify all randomized controlled trials (RCTs) comparing augmented repair and nonaugmented repair for acute Achilles tendon rupture from January 1980 to August 2016 in the electronic databases of PubMed, Web of Science (SCI-E/SSCI/A&HCI), and EMBASE. The keywords (Achilles tendon rupture) AND (surg* OR operat* OR repair* OR augment* OR non-augment* OR end-to-end OR sutur*) were combined, and results were limited to human RCTs and controlled clinical trials published in the English language. Four RCTs involving 169 participants were eligible for inclusion; 83 participants were treated with augmented repair and 86 were treated with nonaugmented repair. RESULTS Augmented repair led to similar responses when compared with nonaugmented repair for acute Achilles tendon rupture (93% vs 90%, respectively; P = .53). The rerupture rates showed no significant difference for augmented versus nonaugmented repair (7.2% vs 9.3%, respectively; P = .69). No differences in superficial and deep infections occurred in augmented (7 infections) and nonaugmented (8 infections) repair groups during postoperative follow-up ( P = .89). The average incisional infection rate was 8.4% with augmented repair and 9.3% with nonaugmented repair. No significant differences in other complications were found between augmented (7.2%) and nonaugmented (8.1%) repair ( P = .80). CONCLUSION Augmented repair, when compared with nonaugmented repair, was not found to improve patient satisfaction or reduce rerupture rate or infection rate. These conclusions are based on 4 trials with small sample sizes, and larger randomized trials are required to confirm these results.
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Affiliation(s)
- Yi-Jun Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chi Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Quan Wang
- Department of Orthopedic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiang-Jin Lin
- Department of Orthopedic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Abstract
BACKGROUND Open Achilles tendon surgery with the patient in the supine position potentially avoids the complications of the prone position, but the safety and viability of the supine position for this procedure are not known. The aim of this study was to test the hypothesis that supine positioning for open repair of acute Achilles tendon ruptures would be safe, with low wound and neurologic complication rates. METHODS Supine position safety in acute Achilles tendon repair was investigated. Consecutive cases of supine Achilles tendon surgical repair performed by one surgeon from 2010 to 2015 were retrospectively reviewed. Patients were included if they were surgically treated with primary repair in the supine position within 15 days of injury and did not undergo concomitant surgery. A paramedian incision 1 cm medial to the Achilles sheath was used. Initial chart review identified 161 patients who underwent any type of Achilles tendon surgery in the supine position, of whom 45 patients met the inclusion criteria. This group included 39 men and 6 women with an average age of 41 years (range, 20-66 years). Median length of follow-up was 116 days (range, 25-1,589 days). Average body mass index was 29 kg/m2 (range, 23-36 kg/m2). RESULTS There were no infections, sural nerve injuries, or reruptures. CONCLUSIONS The supine position was safe for primary open Achilles tendon repair, with no wound or neurologic complications. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- John J Marcel
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Katherine Sage
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gregory P Guyton
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Orishimo KF, Schwartz-Balle S, Tyler TF, McHugh MP, Bedford BB, Lee SJ, Nicholas SJ. Can Weakness in End-Range Plantar Flexion After Achilles Tendon Repair Be Prevented? Orthop J Sports Med 2018; 6:2325967118774031. [PMID: 29845085 PMCID: PMC5967157 DOI: 10.1177/2325967118774031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Disproportionate end-range plantar flexion weakness, decreased passive stiffness, and inability to perform a heel rise on a decline after Achilles tendon repair are thought to reflect increased tendon compliance or tendon lengthening. Since this was first noted, we have performed stronger repairs and avoided stretching into dorsiflexion for the first 12 weeks after surgery. Hypothesis Using stronger repairs and avoiding stretching into dorsiflexion would eliminate end-range plantar flexion weakness and normalize passive stiffness. Study Design Case series; Level of evidence, 4. Methods Achilles repairs with epitendinous augmentation were performed on 18 patients. Plantar flexion torque, dorsiflexion range of motion (ROM), passive joint stiffness, and standing single-legged heel rise on a decline were assessed at 43 ± 24 months after surgery (range, 9 months to 8 years). Maximum isometric plantar flexion torque was measured at 20° and 10° of dorsiflexion, neutral position, and 10° and 20° of plantar flexion. Passive dorsiflexion ROM was measured with a goniometer. Passive joint stiffness was computed from the increase in passive torque from 10° to 20° of dorsiflexion. Tendon thickness was measured by use of digital calipers. Plantar flexion electromyographic (EMG) data were recorded during strength and functional tests. Analysis of variance and chi-square tests were used to assess weakness and function. Results Marked weakness was evident on the involved side at 20° of plantar flexion (deficit, 26% ± 18%; P < .001), with no weakness at 20° of dorsiflexion (deficit, 6% ± 17%; P = .390). Dorsiflexion ROM was decreased 5.5° ± 8° (P = .015), and tendon width was 8 ± 3 mm greater on the involved side (P < .001). Passive joint stiffness was similar between the involved and noninvolved sides. Only 2 of 18 patients could perform a decline heel rise on the involved side compared with 18 of 18 on the noninvolved side (P = .01). No difference in EMG amplitude was found between the involved and noninvolved sides during the strength or heel rise tests. Conclusion The use of stronger repair techniques and attempts to limit tendon elongation by avoiding dorsiflexion stretching did not eliminate weakness in end-range plantar flexion. EMG data confirmed that end-range weakness was not due to neural inhibition. Physiological changes that alter the force transmission capability of the healing tendon may be responsible for this continued impairment. This weakness has implications for high-demand jumping and sprinting after Achilles tendon repair.
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Affiliation(s)
- Karl F Orishimo
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Sidse Schwartz-Balle
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Timothy F Tyler
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Malachy P McHugh
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Benjamin B Bedford
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Steven J Lee
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
| | - Stephen J Nicholas
- Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, USA
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Abstract
Chronic Achilles tendon ruptures are debilitating injuries and are often associated with large tendon gaps that can be challenging for the foot and ankle surgeon to treat. Preoperative evaluation should include the patient's functional goals, medical comorbidities, MRI assessment of gastrocsoleus muscle viability, condition of adjacent flexor tendons, and size of the tendon defect. Although several surgical techniques have been described, the surgeon must formulate an individualized treatment plan for the patient. This article reviews the principles of diagnosis, treatment options, and clinical outcomes, and outlines the authors' preferred techniques.
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Affiliation(s)
- Brian D Steginsky
- Illinois Bone & Joint Institute, 720 Florsheim Drive, Libertyville, IL 60048, USA
| | - Bryan Van Dyke
- The Orthopedic Foot & Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082, USA
| | - Gregory C Berlet
- The Orthopedic Foot & Ankle Center, 300 Polaris Parkway, Suite 2000, Westerville, OH 43082, USA.
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Leigheb M, Guzzardi G, Pogliacomi F, Sempio L, Grassi FA. Comparison of clinical results after augmented versus direct surgical repair of acute Achilles tendon rupture. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:50-55. [PMID: 29083353 DOI: 10.23750/abm.v88i4 -s.6794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM OF THE WORK Achilles tendon rupture is frequent and can result in a disabling condition. The ideal method of management remains a matter of debate. We aimed to compare the clinical outcome of patients who underwent surgical repair of Achilles tendon rupture with Silfverskiöld augmentation technique with gastrocnemius fascia flap versus Krackow end-to-end stitching technique. METHODS We retrospectively studied all patients that were surgically treated for Achilles tendon rupture at our institution, between January 2000 and December 2015, using either Silfverskiöld or Krackow technique. We excluded all patients deceased or untreaceble, and those refusing the follow up interview. Disability, Quality-of-Life and functional restriction were evaluated using the Achilles-Tendon-total-Rupture-Score (ATRS) and Foot-and-Ankle-Disability-Index (FADI); means were compared by the Mann-Whitney test and correlations by the Spearman coefficient. RESULTS A total of 90 patients were included, with a mean age of 45.3±12.6 years. The augmented repair group-A included 33 patients and the simple repair group-B 57 patients. Follow-up averaged 8 years (1 to 16). FADI was 103.7±1.6 for group-A versus 100.3±15.6 for group-B. ATRS was 2.0±7.1 and 5.7±18.8, respecitvely. Differences were not significant. Age showed a low linear correlation with ATRS (R=0.41) and FADI (R=-0.40), indicating that clinical outcomes minimally tend to worsen in older patients. CONCLUSIONS We didn't find significative differences in the clinical outcomes between the two groups of patients. Acute uncomplicated Achilles tendon ruptures can be successfully treated with a direct suture technique. Augmentation with a fascial flap should be reserved to chronic or neglected cases with severe tendinosis or tissue defect.
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Heikkinen J, Lantto I, Piilonen J, Flinkkilä T, Ohtonen P, Siira P, Laine V, Niinimäki J, Pajala A, Leppilahti J. Tendon Length, Calf Muscle Atrophy, and Strength Deficit After Acute Achilles Tendon Rupture: Long-Term Follow-up of Patients in a Previous Study. J Bone Joint Surg Am 2017; 99:1509-1515. [PMID: 28926379 DOI: 10.2106/jbjs.16.01491] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In this prospective study, we used magnetic resonance imaging (MRI) to assess long-term Achilles tendon length, calf muscle volume, and muscle fatty degeneration after surgery for acute Achilles tendon rupture. METHODS From 1998 to 2001, 60 patients at our center underwent surgery for acute Achilles tendon rupture followed by early functional postoperative rehabilitation. Fifty-five patients were reexamined after a minimum duration of follow-up of 13 years (mean, 14 years), and 52 of them were included in the present study. Outcome measures included Achilles tendon length, calf muscle volume, and fatty degeneration measured with MRI of both the affected and the uninjured leg. The isokinetic plantar flexion strength of both calves was measured and was correlated with the structural findings. RESULTS The Achilles tendon was, on average, 12 mm (95% confidence interval [CI] = 8.6 to 15.6 mm; p < 0.001) longer (6% longer) in the affected leg than in the uninjured leg. The mean volumes of the soleus and medial and lateral gastrocnemius muscles were 63 cm (13%; p < 0.001), 30 cm (13%; p < 0.001), and 16 cm (11%; p < 0.001) lower in the affected leg than in the uninjured leg, whereas the mean volume of the flexor hallucis longus (FHL) was 5 cm (5%; p = 0.002) greater in the affected leg, indicating FHL compensatory hypertrophy. The median plantar flexion strength for the whole range of motion ranged from 12% to 18% less than that on the uninjured side. Finally, the side-to-side difference in Achilles tendon length correlated substantially with the strength deficit (ρ = 0.51, p < 0.001) and with medial gastrocnemius (ρ = 0.46, p = 0.001) and soleus (ρ = 0.42, p = 0.002) muscle atrophy. CONCLUSIONS Increased Achilles tendon length is associated with smaller calf muscle volumes and persistent plantar flexion strength deficits after surgical repair of Achilles tendon rupture. Strength deficits and muscle volume deficits are partly compensated for by FHL hypertrophy, but 11% to 13% deficits in soleus and gastrocnemius muscle volumes and 12% to 18% deficits in plantar flexion strength persist even after long-term follow-up. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Juuso Heikkinen
- 1Division of Orthopaedic and Trauma Surgery, Department of Surgery (J.H., I.L., J.P., T.F., P.O., A.P., and J.L.), Department of Physical Medicine and Rehabilitation (P.S. and V.L.), and Department of Diagnostic Radiology, Institute of Diagnostics (J.N.), Oulu University Hospital, Medical Research Center, University of Oulu, Oulu, Finland
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Carmont MR, Kuiper JH, Grävare Silbernagel K, Karlsson J, Nilsson-Helander K. Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures. J Exp Orthop 2017; 4:26. [PMID: 28733950 PMCID: PMC5520830 DOI: 10.1186/s40634-017-0101-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/14/2017] [Indexed: 12/28/2022] Open
Abstract
Background Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading. Methods Nineteen bovine Achilles tendons were repaired using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weight-bearing, before being loaded to failure. Results Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. Conclusion The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.
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Affiliation(s)
- Michael R Carmont
- Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital, Telford, UK. .,Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Jan Herman Kuiper
- Department of Biomechanical Engineering, The Robert Jones & Agnes Hunt District General Hospital, University of Keele, Keele, UK
| | | | - Jón Karlsson
- Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedic Surgery, Kungsbacka Hospital, Kungsbacka, Sweden
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Ho G, Tantigate D, Kirschenbaum J, Greisberg JK, Vosseller JT. Increasing age in Achilles rupture patients over time. Injury 2017; 48:1701-1709. [PMID: 28457569 DOI: 10.1016/j.injury.2017.04.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/11/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. METHODS Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. RESULTS The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. CONCLUSION Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. LEVEL OF EVIDENCE Level III; Retrospective cohort study.
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Affiliation(s)
- Gavin Ho
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Direk Tantigate
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Josh Kirschenbaum
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - Justin K Greisberg
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States
| | - J Turner Vosseller
- Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street, PH-11, New York, NY 10032, United States.
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Heikkinen J, Lantto I, Flinkkila T, Ohtonen P, Niinimaki J, Siira P, Laine V, Leppilahti J. Soleus Atrophy Is Common After the Nonsurgical Treatment of Acute Achilles Tendon Ruptures: A Randomized Clinical Trial Comparing Surgical and Nonsurgical Functional Treatments. Am J Sports Med 2017; 45:1395-1404. [PMID: 28282504 DOI: 10.1177/0363546517694610] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It remains controversial whether nonsurgical or surgical treatment provides better calf muscle strength recovery after an acute Achilles tendon rupture (ATR). Recent evidence has suggested that surgery might surpass nonsurgical treatment in restoring strength after an ATR. PURPOSE To assess whether magnetic resonance imaging (MRI) findings could explain calf muscle strength deficits and the difference between nonsurgical and surgical treatments in restoring calf muscle strength. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS From 2009 to 2013, 60 patients with acute ATRs were randomized to surgery or nonsurgical treatment with an identical rehabilitation protocol. The primary outcome measure was the volume of calf muscles assessed using MRI at 3 and 18 months. The secondary outcome measures included fatty degeneration of the calf muscles and length of the affected Achilles tendon. Additionally, isokinetic plantarflexion strength was measured in both legs. RESULTS At 3 months, the study groups showed no differences in muscle volumes or fatty degeneration. However, at 18 months, the mean differences between affected and healthy soleus muscle volumes were 83.2 cm3 (17.7%) after surgery and 115.5 cm3 (24.8%) after nonsurgical treatment (difference between means, 33.1 cm3; 95% CI, 1.3-65.0; P = .042). The study groups were not substantially different in the volumes or fatty degeneration of other muscles. From 3 to 18 months, compensatory hypertrophy was detected in the flexor hallucis longus (FHL) and deep flexors in both groups. In the nonsurgical treatment group, the mean difference between affected and healthy FHL muscle volumes was -9.3 cm3 (12%) and in the surgical treatment group was -8.4 cm3 (10%) ( P ≤ .001). At 18 months, Achilles tendons were, on average, 19 mm longer in patients treated nonsurgically compared with patients treated surgically ( P < .001). At 18 months, surgically treated patients demonstrated 10% to 18% greater strength results ( P = .037). Calf muscle isokinetic strength deficits for the entire range of ankle motion correlated with soleus atrophy (ρ = 0.449-0.611; P < .001). CONCLUSION Treating ATRs nonsurgically with a functional rehabilitation protocol resulted in greater soleus muscle atrophy compared with surgical treatment. The mean Achilles tendon length was 19 mm longer after nonsurgical treatment than after the surgical treatment of ATRs. These structural changes partly explained the 10% to 18% greater calf muscle strength observed in patients treated with surgery compared with those treated nonsurgically. Registration: NCT02012803 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Tapio Flinkkila
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Jaakko Niinimaki
- Research Unit of Medical Imaging, Physics and Technology, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Pertti Siira
- Department of Physical Medicine and Rehabilitation, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Vesa Laine
- Department of Physical Medicine and Rehabilitation, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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49
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Abstract
Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow-derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.
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50
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Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med 2016; 44:2406-14. [PMID: 27307495 DOI: 10.1177/0363546516651060] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment of acute Achilles tendon ruptures for active patients is under debate. PURPOSE To compare clinical outcomes and calf muscle strength recovery after the nonsurgical treatment and open surgical repair of acute Achilles tendon ruptures with identical accelerated rehabilitation programs. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS From 2009 to 2013, a total of 60 patients with an acute Achilles tendon rupture were randomized to surgery or nonsurgical treatment. Nonsurgical treatment included first a week of cast immobilization, followed by a functional orthosis for 6 weeks, allowing full weightbearing after week 1 and active plantar flexion after week 5. Surgery was simple end-to-end open repair, and postoperative treatment was identical to nonsurgical treatment. Outcome measures included the Leppilahti Achilles tendon performance score, isokinetic calf muscle strength, and RAND 36-Item Health Survey at 18-month follow-up. RESULTS At 18-month follow-up, the mean Leppilahti score was 79.5 and 75.7 for the surgically and nonsurgically treated groups, respectively (mean difference, 3.8; 95% CI, -1.9 to 9.5; P = .19). Angle-specific peak torque results of affected legs showed that surgery resulted in faster and better recovery of calf muscle strength over the entire range of motion of the ankle joint: at 6 months, the difference varied from 16% to 24% (P = .016), favoring the surgically treated group, whereas at 18 months, surgically treated patients had 10% to 18% greater strength results (P = .037). At 18 months, a 14% difference in the peak torque of the affected leg favored the surgical group versus the nonsurgical group (mean peak torque, 110.3 vs 96.5 N·m, respectively; mean difference, 13.6 N·m; 95% CI, 2.0-25.1 N·m; P = .022). The RAND 36-Item Health Survey indicated better results in the domains of physical functioning (P = .006) and bodily pain (P = .037) for surgically treated patients. CONCLUSION Surgical and nonsurgical treatments of acute Achilles tendon ruptures have similar results in terms of the Achilles tendon performance score, but surgery restores calf muscle strength earlier over the entire range of motion of the ankle joint, with a 10% to 18% strength difference favoring surgery at 18 months. Surgery may also result in better health-related quality of life in the domains of physical functioning and bodily pain compared with nonsurgical treatment. REGISTRATION NCT02012803 (ClinicalTrials.gov).
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Affiliation(s)
- Iikka Lantto
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Juuso Heikkinen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Tapio Flinkkila
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Pertti Siira
- Department of Physical and Rehabilitation Medicine, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Vesa Laine
- Department of Physical and Rehabilitation Medicine, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
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