Management of achilles tendon injury: A current concepts systematic review

Audit of a Revised Pathway Aimed at Expediting Diagnosis and Treatment for Suspected Achilles Tendon Rupture

Treatment outcomes for Achilles tendon ruptures depend upon prompt diagnosis and management. A local study in 2018 highlighted inefficiencies in patient management, and a revised protocol was introduced allowing investigation and referral to be initiated by other healthcare professionals. This retrospective audit evaluates the impact of this on the timescale from presentation to treatment. It analyzes all suspected Achilles tendon ruptures within one District General Hospital from April 2021 to March 2022. Data regarding patient timelines was compared to the 2018 study. Over 12 months, 99 patients were referred to Virtual Fracture Clinic, 87.8% (n = 87) of which had a complete or partial tear on ultrasound scan (USS). In comparison to 2018, the average time from presentation to USS request reduced from 2.9 to 1.1 days (p < .01). 95% were scanned within one week of USS request and 31.3% within 48 hours (81% and 18%, previously). The average time from USS request to scan went from 6.8 to 3.2 days (p < .01). The time from presentation to treatment decision reduced from 10.9 to 6.2 days (p < .01) and the percentage of patients with a definitive treatment plan within one week increased from 34.5% to 74.2% (p < .01). Patients required 0.8 fewer appointments (p < .01) giving an estimated total saving of $10,110 ($128 per patient) during the analyzed period. The Achilles Tendon Rupture Pathway has significantly improved the proportion of patients undergoing USS within 48 hours and receiving a treatment decision within one week. This study demonstrates an efficient, cost-saving and replicable pathway for Achilles tendon ruptures.

Ultrasound assessment of acute Achilles tendon rupture and measurement of the tendon gap

Achilles tendon rupture is a common sports-related injury which can carry significant morbidity to patients. Ultrasound remains the workhorse of imaging as it can confirm and localise the extent of Achilles tendon injury. The sonographic anatomy, both normal and ruptured sonographic appearances, as well as sonographic technique must be appreciated to accurately image and report findings, critical to patient management. Particular attention should be applied to the measurement of the diastasis between acutely ruptured tendon ends as this information can assist with informing the decision of conservative vs. operative management. Further work is necessary to standardise the measurement technique including correlating the degree of plantarflexion of the foot with the sonographic tendon gap measures.

Calcaneal tuberosity avulsion fractures - A review

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

iTRAQ-based proteomics reveals potential markers and treatment pathways for acute Achilles tendon rupture

BACKGROUND

Due to its limited blood supply and irregular mechanical loading, the Achilles tendon is the most frequently ruptured tendon. Despite the rising incidence of acute Achilles tendon rupture (AATR), the optimal treatment remains controversial. Missed diagnoses and delayed treatments lead to poor outcomes and limited treatment options. This study aimed to identify potential biomarkers for diagnosing and developing therapies for AATR.

METHODS

We employed the coupled isobaric tag for relative and absolute quantitation-liquid chromatography-electrospray ionization-tandem mass spectrometry approach to investigate protein expression in tissues from AATR patients. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were conducted to identify differentially expressed proteins (DEPs) between AATR patients and healthy individuals. A protein-protein interaction (PPI) network of DEPs was constructed using the Search Tool for the Retrieval of Interacting Genes. The screened hub genes were selectively verified by immunohistochemical staining.

RESULTS

We identified 410 DEPs between AATR patients and controls. The DEPs were significantly enriched in GO terms such as the extracellular region, extracellular region part, and defense response, as well as KEGG pathways, including complement and coagulation cascades, focal adhesion, and regulation of actin cytoskeleton. The main hub nodes in the PPI network comprised fibronectin 1 (FN1), major histocompatibility complex, class I, B (HLA-B), filamin A (FLNA), heat shock 27-kDa protein 1 (HSPB1), heat shock protein family A member 5 (HSPA5), apolipoprotein A4 (APOA4), and myosin IC (MYO1C). Although APOA4 and collagens I, II, and III were detectable in healthy tendons, immunohistochemical staining confirmed higher expression of these proteins in the acutely ruptured Achilles tendon.

CONCLUSIONS

Our findings lay a foundation for further molecular studies of AATR. Inflammation and age-related degeneration may contribute to the pathogenesis of AATR. Moreover, the identified DEPs could be potential biomarkers for AATR diagnosis and treatment.

Treatment outcome at 1 year did not differ between use of cast or walker in the first 3 weeks after an acute Achilles tendon rupture. A registry study of 1304 patients from the Danish Achilles tendon database

BACKGROUND

The best choice of orthosis in the treatment of acute Achilles tendon rupture is still under debate.

OBJECTIVE

To investigate if choice of orthosis in the first 3 weeks of treatment affected patient reported outcome (Achilles tendon Total Rupture Score (ATRS)), tendon elongation (Achilles Tendon Resting Angle (ATRA) and Heel Rise Height (HRH)) and re-rupture.

METHODS

Registry study in the Danish Achilles tendon Database. Patients treated with cast and patients treated with walker in the first 3 weeks of treatment were compared using a linear mixed-effects model adjusted for potential confounders.

RESULTS

1304 patients were included in the study. No clinically relevant difference was found: Adjusted mean difference (using walker the whole period as reference)(95% CI) ATRS after 1 year = 0.1(-3.0; 4.1), ATRS after 6 months = 2.0(-4.5; 5.8), ATRS after 2 years = 3.0(-0.7; 7.0), HRH difference = 0.6(-6.6; 8.2), ATRA difference = 0.03°(-1.5; 1.6), re-rupture(odds ratio) = 0.812(0.4; 1.61).

CONCLUSION

Patients treated with cast the first 3 weeks after acute Achilles tendon rupture did not have better treatment outcome than patients treated with walker.

Minimally Invasive Mid-Substance Achilles Tendon Repair Using the Percutaneous Achilles Repair System (PARS)

Achilles tendon ruptures commonly occur in physically active individuals and drastically alter the ability to perform recreational activities^1,2. Many patients want to continue participating in recreational activities, which can be facilitated by operatively treating the injury in a timely fashion, maximizing their functional recovery. The Percutaneous Achilles Repair System (PARS) Jig (Arthrex) can be utilized in patients with acute mid-substance Achilles tendon ruptures^3,4.

Description

Begin by positioning the patient prone with a thigh tourniquet on the operative side. Mark a 3-cm transverse incision 1 cm distal to the proximal Achilles stump and make the incision, taking care to protect the sural nerve laterally. Next, create a transverse paratenon incision and bluntly dissect it from the Achilles circumferentially. After gaining access to the proximal Achilles stump, clamp it with an Allis clamp and insert the PARS Jig between the Achilles tendon and paratenon, sliding it proximally to the myotendinous junction. To secure the jig to the proximal Achilles tendon, insert a guide pin into the jig position-1 hole. To pass sutures through the Achilles tendon, insert pins with their respective sutures into positions 2 through 5 and insert the FiberTape suture (Arthrex) in position 1. Remove the jig from the transverse incision, pulling the suture ends out of the incision. Once they are out, reorient the sutures on the medial and lateral sides to match their positions when initially placed. On both sides, wrap the blue suture around the 2 striped green-and-white sutures twice, and pull the blue suture through the looped green-and-white suture on the ipsilateral side. After doing that, fold the blue suture on itself to create a shuttling suture with the green-and-white suture. Next, pull on the medial non-looped green-and-white suture until it has been pulled out medially, and repeat that with the lateral non-looped green-and-white suture until it has been pulled out laterally, to create a locking stitch. Group the medial sutures together and the lateral sutures together, and utilize a free needle to further incorporate both bundles of sutures into the Achilles tendon. Next, create bilateral mini-incisions 1.5 cm proximal to the calcaneal tuberosity. Insert a rigid cannulated suture-passing device into each mini-incision, pass it through the distal Achilles tendon, load the ipsilateral suture bundle into the Nitinol wire, and pull the suture-passing device out the distal mini-incision to approximate the Achilles. To prepare the calcaneus, drill calcaneal tunnels toward the midline bilaterally, taking care to avoid convergence of the tunnels. Place a suture-passing needle in the tunnels to assist with placing the anchors. Next, tension the sutures, cycling them 5 to 10 times to remove any slack in the system. With the ankle in 15° of plantar flexion, anchor the sutures with cortical bioabsorbable interference screws, following the angle that the suture-passing needles are in. After confirming function of the Achilles tendon, close the peritenon, deep tissues, and superficial tissues, and place the ankle in a splint in 15° of plantar flexion.

Alternatives

Acute Achilles ruptures can be treated operatively or nonoperatively^1,2. Operative techniques include open, percutaneous, or minimally invasive Achilles tendon repair. Open Achilles tendon repair involves making a 10-cm posteromedial incision to perform a primary repair⁵, while percutaneous Achilles tendon repair involves the use of medial and lateral mini-incisions to pass needles and sutures into the Achilles tendon to repair it⁶. Minimally invasive Achilles tendon repair involves the use of a small 3 to 4-cm incision to introduce instrumentation such as modified ring forceps or an Achillon device (Integra)^7,8, along with a percutaneous technique, to repair the Achilles tendon. Nonoperative treatment can be utilized in patients with <5 mm of gapping between the ruptured tendon edges on dynamic ultrasound in 30° of plantar flexion⁹, in patients with limited activity, or in patients whose comorbidities make them high-risk surgical candidates. Nonoperative treatment includes a below-the-knee rigid cast in 30° of plantar flexion or the use of a functional splint in 30° of plantar flexion with gradual progression to a neutral position, along with early rehabilitation according to the postoperative protocol described in the present article.

Rationale

This technique allows patients to begin early postoperative rehabilitation, limits wound and soft-tissue complications such as superficial and deep infections, and protects neurovascular structures such as the sural nerve that may be injured if utilizing other techniques. These benefits are achieved through the use of a minimally invasive knotless approach that places nearly all of the suture material into the Achilles tendon, reducing friction within the paratenon and potentially facilitating improved gliding. Additionally, securing the sutures into the calcaneus minimizes postoperative Achilles tendon elongation and facilitates early postoperative rehabilitation.

Expected Outcomes

Patients undergoing this procedure can expect to return to their baseline physical activities by 5 months³, with the best functional results observed at ≥12 months postoperatively⁴. One retrospective cohort study compared the results of 101 patients who underwent Achilles repair with use of the PARS Jig and 169 patients who underwent open Achilles repair, and found that 98% of PARS patients returned to baseline activities in 5 months compared with 82% of patients undergoing open Achilles repair (p = 0.0001)³. Another retrospective chart review assessed the results of 19 patients who underwent Achilles repair with the PARS Jig⁴ and found that patients began to return to sport as early as 3 months postoperatively and that functional scores in patients increased as time progressed, with significant increases observed at 12 months and longer postoperatively.

Important Tips

Locate the Achilles tendon rupture site prior to marking the transverse incision.Bluntly dissecting the paratenon during closure stimulates healing and reduces scarring, thereby maintaining the integrity of the tissue¹⁰.When advancing the PARS Jig, ensure that the proximal Achilles tendon remains inside the device.Maintaining meticulous suture management and organization prevents tangles and improves suture shuttling.Ensure that the Achilles tendon is tensioned with the ankle in 15° of plantar flexion prior to distal anchor fixation.

Acronyms and Abbreviations

MRI = magnetic resonance imagingUS = ultrasoundBID = twice dailyPRN = as neededDVT = deep vein thrombosis.

New frontiers of tendon augmentation technology in tissue engineering and regenerative medicine: a concise literature review

Tissue banking programs fail to meet the demand for human organs and tissues for transplantation into patients with congenital defects, injuries, chronic diseases, and end-stage organ failure. Tendons and ligaments are among the most frequently ruptured and/or worn-out body tissues owing to their frequent use, especially in athletes and the elderly population. Surgical repair has remained the mainstay management approach, regardless of scarring and adhesion formation during healing, which then compromises the gliding motion of the joint and reduces the quality of life for patients. Tissue engineering and regenerative medicine approaches, such as tendon augmentation, are promising as they may provide superior outcomes by inducing host-tissue ingrowth and tendon regeneration during degradation, thereby decreasing failure rates and morbidity. However, to date, tendon tissue engineering and regeneration research has been limited and lacks the much-needed human clinical evidence to translate most laboratory augmentation approaches to therapeutics. This narrative review summarizes the current treatment options for various tendon pathologies, future of tendon augmentation, cell therapy, gene therapy, 3D/4D bioprinting, scaffolding, and cell signals.

Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison

BACKGROUND

the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy.

METHODS

33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery.

RESULTS

At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups.

CONCLUSIONS

fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.

Photobiomodulation Associated With Conservative Treatment for Achilles Tendon Rupture: A Double-Blind, Superiority, Randomized Controlled Trial

Objective

To investigate the effects of photobiomodulation on Achilles tendon rupture (ATR) treated conservatively.

Design

Prospective, patient- and assessor-blinded, parallel, randomized controlled trial.

Setting

Patients with acute ATR treated conservatively.

Participants

Thirty-four male individuals with acute unilateral ATR treated conservatively (N=34), equally divided in 2 groups: photobiomodulation group (PBMG) and sham group, with mean age of 45.5±9.47 and 48.7±8.38 years, respectively.

Intervention

All participants underwent through an immobilization period, followed by rehabilitation sessions (2 d/wk for 12 weeks) comprising strengthening, range of motion, and balance/weightbearing exercises. In PBMG, the tendon was irradiated with a photobiomodulation cluster (1 904 nm/50 mW infrared laser, 4 858 nm/50 mW infrared diodes, and 4 658 nm/40 mW red diodes; power density of 105 mW/cm² per cluster area) during the immobilization period (2 d/wk for 8 weeks) and the sham group received a simulation of the procedure with no irradiation. Outcomes were assessed at the removal of the immobilization 12 and 16 weeks after tendon rupture.

Main Outcome Measures

Primary outcome was the Achilles Tendon Rupture Score. Secondary outcomes included Numerical Pain Rating Scale at rest and during effort, plantar flexor strength, and ankle range of motion.

Results

Both groups demonstrated an increase in the Achilles Tendon Rupture Score and improvements in range of motion, plantar flexor strength, and pain. There were no significant differences in outcomes between the 2 groups (P>.05) except in pain during walking, which was significantly lower in the PBMG in week 12 (P<.01, effect size=0.56) and week 16 (P<.01, effect size=0.55).

Conclusion

Photobiomodulation associated with conservative treatment is not superior to conservative treatment alone for improving function in patients with acute ATR.

A retrospective audit of the timescales involved in the diagnosis and management of suspected Achilles tendon ruptures at a single National Health Service trust: A quality service improvement and redesign project

Introduction

The Achilles tendon is the most frequently ruptured tendon. Prompt diagnosis of this injury ensures optimal management decisions are instituted early ensuring the best outcome and patient experience, at minimal cost to the United Kingdom National Health Service. Despite this, regional and national variations to diagnosis and management exist, with anecdotal evidence of inefficiencies in the local patient pathway. To explore this further, a retrospective departmental audit of timescales from presentation to ultrasound diagnosis and definitive treatment decision was undertaken.

Methods

All suspected Achilles tendon ruptures in 2018 were identified through electronic and written patient records, and information on timescales involved in the diagnosis and management of each compiled. Descriptive statistics were used to map each step of the pathway and timescales involved, with performance assessed against local departmental standards and the Swansea Morriston Achilles Rupture Treatment (SMART) protocol.

Results

In total, 119 patients were identified, of which 113 received an ultrasound examination. Local departmental standards were met in the majority of cases, with 78% (n = 88) diagnosed by ultrasound within one week of the request and 83% (n = 91) given a treatment decision within two weeks of presentation. However, this was suboptimal when compared with timeframes utilised for developing the SMART protocol, with only 7% (n = 8) scanned within 48 hours of presentation.

Conclusions

Key areas of the patient pathway were identified for quality service improvement and redesign, with multidisciplinary discussion resulting in the development of a revised patient pathway which expedites diagnosis and treatment for these injuries.

A Pop from a Shock: A Case Report of an Unusual Cause of Achilles Tendon Rupture

Introduction

Achilles tendon ruptures often occur during physical activity where the tendon is frequently stressed. Although rare, rupture can also result from electric shock.

Case Report

We present the case of a 63-year-old female who presented with pain in the lower leg after enduring an electric shock. She was diagnosed with a ruptured Achilles tendon based on physical exam and ultrasound.

Conclusion

This case highlights an uncommon mechanism for a relatively common injury. Because Achilles tendon ruptures are frequently misdiagnosed, clinicians need to be aware of unusual causes and use tools at their disposal to ensure timely and accurate diagnosis.

Generation of a tendon-like tissue from human iPS cells

Tendons and ligaments are essential connective tissues that connect the muscle and bone. Their recovery from injuries is known to be poor, highlighting the crucial need for an effective therapy. A few reports have described the development of artificial ligaments with sufficient strength from human cells. In this study, we successfully generated a tendon-like tissue (bio-tendon) using human induced pluripotent stem cells (iPSCs). We first differentiated human iPSCs into mesenchymal stem cells (iPSC-MSCs) and transfected them with Mohawk (Mkx) to obtain Mkx-iPSC-MSCs, which were applied to a newly designed chamber with a mechanical stretch incubation system. The embedded Mkx-iPSC-MSCs created bio-tendons and exhibited an aligned extracellular matrix structure. Transplantation of the bio-tendons into a mouse Achilles tendon rupture model showed host-derived cell infiltration with improved histological score and biomechanical properties. Taken together, the bio-tendon generated in this study has potential clinical applications for tendon/ligament-related injuries and diseases.

Achilles Tendon Ruptures in Middle-Aged Rats Heal Poorly Compared With Those in Young and Old Rats [Formula: see text]

BACKGROUND

Achilles tendon ruptures are painful and debilitating injuries and are most common in middle-aged patients. There is a lack of understanding of the underlying causes for increased rupture rates in middle-aged patients and how healing outcomes after a rupture might be affected by patient age. Therefore, the objective of this study was to define age-specific Achilles tendon healing by assessing ankle functional outcomes and Achilles tendon mechanical and histological properties after a rupture using a rat model.

HYPOTHESIS

Rats representing the middle-aged patient population would demonstrate reduced healing capability after an Achilles tendon rupture, as demonstrated by a slower return to baseline ankle functional properties and inferior biomechanical and histological tendon properties.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fischer 344 rats were categorized by age to represent young, middle-aged, and old patients, and Achilles tendon ruptures were induced in the right hindlimb. Animals were allowed to heal and were euthanized at 3 or 6 weeks after the injury. In vivo functional assays and ultrasound imaging were performed throughout the healing period, and ex vivo tendon mechanical and histological properties were assessed after euthanasia.

RESULTS

Rats representing middle-aged patients displayed reduced healing potential compared with the other age groups, as they demonstrated decreased recovery of in vivo functional and ultrasound assessment parameters and inferior mechanical and histological properties after an Achilles tendon rupture.

CONCLUSION

These findings may help explain the increased rupture rate observed clinically in middle-aged patients by suggesting that there may be altered tendon responses to daily trauma.

CLINICAL RELEVANCE

The results provide novel data on age-specific healing outcomes after an Achilles tendon rupture, which underscores the importance of considering a patient's age during treatment and expectations for outcomes.

Limited Scar Resection for Chronic Achilles Tendon Repair: Use of a Rat Model

BACKGROUND

Achilles tendon rupture diagnosis is frequently missed, leading to the development of a chronic rupture that requires surgical intervention to remove scar tissue and return the elongated Achilles tendon to appropriate functional length. The limited scar resection (LSR) intervention strategy may provide an advantage over other techniques, as it is less invasive and nondestructive to other tissues, although there is little evidence comparing outcomes between intervention strategies.

HYPOTHESIS

The LSR technique would be a viable treatment option for chronic Achilles tendon ruptures and would perform comparably with a more clinically accepted procedure, the gastrocnemius fascial turndown (GFT), in postintervention functional outcome measures and tendon mechanical and histological properties.

STUDY DESIGN

Controlled laboratory study.

METHODS

Chronic Achilles tendon ruptures were induced in the right hindlimb of Sprague-Dawley rats by Achilles tendon transection without repair, immobilization in dorsiflexion, and 5 weeks of cage activity. Animals were randomly divided between the intervention strategy groups (LSR and GFT), received 1 week of immobilization in plantarflexion, and were sacrificed at 3 or 6 weeks postintervention. In vivo functional outcome measures (gait kinetics, passive joint function, tendon vascular perfusion) were quantified during healing, and tendon mechanical and histological properties were assessed postsacrifice.

RESULTS

When compared with the GFT, the LSR technique elicited a faster return to baseline in gait kinetics, although there were few differences between groups or with healing time in other functional outcome measures (passive joint function and vascular perfusion). Quasi-static mechanical properties were improved with healing in both surgical intervention groups, although only the LSR group showed an improvement in fatigue properties between 3 and 6 weeks postintervention. Histological properties were similar between intervention strategies, except for decreased cellularity in the LSR group at 6 weeks postintervention.

CONCLUSION

The LSR technique is a viable surgical intervention strategy for a chronic Achilles tendon rupture in a rodent model, and it performs similarly, if not better, when directly compared with a more clinically accepted surgery, the GFT.

CLINICAL RELEVANCE

This study supports the increased clinical use of the LSR technique for treating chronic Achilles tendon rupture cases.

Return to the original sport at only 3 months after an Achilles tendon rupture by a combination of intra-tissue injection of freeze-dried platelet-derived factor concentrate and excessively early rehabilitation after operative treatment in a male basketball player: A case report

Background

Achilles tendon rupture is one of the most common serious injuries in athletes. Various studies to accelerate the healing process of the Achilles tendon have been performed as it takes a longer time to repair the tissue compared to other tendons. Here, we report a case of an acute Achilles tendon rupture in a male basketball player treated by a combination of an intra-tissue injection of freeze-dried platelet-derived factor concentrate, which included a platelet-derived growth factor with an early rehabilitation protocol after the operative treatment to facilitate the biological healing of the injured tendon tissue. To the best of our knowledge, this case is the first instance that enabled the athlete to return to original sport activity at only 3-months after the injury.

Case report

A 23-year-old male basketball player who belonged to a university basketball team sustained an Achilles tendon rupture during running in a training match. The remaining time period until the final tournament of the university league as a senior player was only 3 months. The patient received a combination of an intra-tissue injection of freeze-dried platelet-derived factor concentrate and early rehabilitation protocol after operative treatment. Surgery was performed 4 days after the injury and the early rehabilitation protocols were applied postoperatively. A freeze-dried platelet-derived factor concentrate was injected into the ruptured site of the Achilles tendon under ultrasound guide at 4 weeks postoperatively. The patient could return to play at the pre-injury level without any symptoms and disfunctions at 3 months after surgery. At two years postoperatively, the patient could play basketball without symptoms or rerupture.

Conclusions

We reported a case of an Achilles tendon rupture which was treated by a combination of intra-tissue injection of freeze-dried platelet-derived factor concentrate and an early rehabilitation protocol after the operative treatment. The patient could return to play basketball at the pre-injury activity level at only 3-months after the injury, suggesting that the role of applying excessively early rehabilitation of mechanical loading could facilitate tendon tissue healing when combined with an intra-tissue injection of freeze-dried platelet-derived factor concentrate.

•

FD-PFC has rich growth factors such as PDGF-BB, which is a part of the PDGF growth family.

•

An achilles tendon rupture was treated by a combination of injection of FD-PFC and excessively postoperative rehabilitation.

•

The patient could return to play basketball at the pre-injury activity level at only 3-months after the injury.

Health service use and costs associated with fluoroquinolone-related tendon injuries

The aim of this study was to assess costs and health service use associated with tendon injuries after the use of fluoroquinolone antimicrobials in Finland during 2002-2012. This retrospective observational study included data from the Finnish Pharmaceutical Insurance Pool's pharmaceutical injury claims. In total, 145 compensated claimants aged ≥18 years presenting tendon injuries after the use of fluoroquinolones (FQs) were included in the study. Outcomes of interest were the number of outpatient visits to primary, secondary, tertiary, and private healthcare services, hospital days, rehabilitation and their costs. Regression models were used to analyze the impact of patient characteristics on hospital days, as well as the relationship between patient characteristics and tendon ruptures. Direct costs of a tendon injury averaged 14,800€ and indirect costs were estimated to be 9,077€ for employed claimants. Fifty-one percent of the claimants were hospitalized, with an average duration of 21 days. Hospitalization was the costliest form of health service use with an average of 9,915€ per hospital episode. Hospital days and direct costs increased with the severity of the injury. Tendon ruptures, in particular bilateral ruptures, required substantially more hospital days and their direct costs were significantly higher than those of uncomplicated tendinitis. Concurrent use of oral corticosteroids and increasing age were associated with a higher likelihood of tendon ruptures. Although rare, FQ-related tendon injuries can result in considerable costs and health service use. Medical staff should remain vigilant when prescribing FQs, especially in groups at increased risk for tendon injuries.

Do Geographic Region, Pathologic Chronicity, and Hospital Affiliation Affect Access to Care Among Medicaid- and Privately Insured Foot and Ankle Surgery Patients?

OBJECTIVES

Studies have shown that patients enrolled in Medicaid have difficulty obtaining access to care compared with patients with private insurance. Whether variables such as geographic location, state expansion versus nonexpansion, and private versus academic affiliation affect access to care among foot and ankle surgery patients enrolled in Medicaid has not been previously established. The purpose of this study was to assess the differences in access to care between patients who are privately insured and those with Medicaid in need of foot and ankle consultation. Secondary objectives include assessment of whether access to care for foot and ankle patients with Medicaid differs between those with acute and chronic conditions, Medicaid expanded and unexpanded states, geographic regions within the United States, and academic versus private practices.

METHODS

Twenty providers from each of five Medicaid-expanded and five nonexpanded states in different US geographic regions were randomly chosen via the American Orthopaedic Foot & Ankle Society directory. One investigator contacted each office requesting the earliest available appointment for their fictitious relative's acute Achilles tendon rupture or hallux valgus. Investigator insurance was stated to be Medicaid for half of the telephone calls and Blue Cross Blue Shield (BCBS) for the other half. Appointment success rate and average time to appointment were compared between private insurance and Medicaid. Results were further compared across geographic regions, between private and academic practices, and between urgent acute injury (Achilles rupture) and chronic nonurgent injury (hallux valgus).

RESULTS

Appointments were successful for all 100 (100%) calls made with BCBS as the insurer, in comparison to 73 of 100 calls (73%) with Medicaid (P < 0.001). Both acute and chronic injury had significantly higher success rates with BCBS than Medicaid (P < 0.001). The appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ 0.01) in all of the geographic regions. The success rate with Medicaid (66.7%) was significantly lower than with BCBS (100.0%, P < 0.001) for private practice offices, but not for academic practices.

CONCLUSIONS

Patients with Medicaid experience fewer options when obtaining appointments for common nonemergent foot and ankle problems and may experience less difficulty scheduling appointments at academic rather than private institutions. The medical community should continue to seek and identify potential interventions which can improve access to orthopedic care for all patients and increase the visibility of practices that accept Medicaid.

Bionic Silk Fibroin Film Induces Morphological Changes and Differentiation of Tendon Stem/Progenitor Cells

Purpose

Tendon injuries are common musculoskeletal system disorders, but the ability for tendon regeneration is limited. Silk fibroin (SF) film may be suitable for tendon regeneration due to its excellent biocompatibility and physical properties. This study is aimed at evaluating the application value of bionic SF film in tendon regeneration.

Methods

Tendon stem/progenitor cells (TSPCs) were isolated from rat Achilles tendon and characterized based on their surface marker expression and multilineage differentiation potential. SF films with smooth or bionic microstructure surfaces (5, 10, 15, 20 μm) were prepared. The morphology and mechanical properties of natural tendons and SF films were characterized. TSPCs were used as the seed cells, and the cell viability and cell adhesion morphology were analyzed. The tendongenesis-related gene expression of TSPCs was also evaluated using quantitative polymerase chain reaction.

Results

Compared to the native tendon, only the 10, 15, and 20 μm SF film groups had comparable maximum loading and ultimate stress, with the exception of the breaking elongation rate. The 10 μm SF film group had the highest percentage of oriented cells and the most significant changes in cell morphology. The most significant upregulations in the expression of COL1A1, TNC, TNMD, and SCX were also observed in the 10 μm SF film group.

Conclusion

SF film with a bionic microstructure can serve as a tissue engineering scaffold and provide biophysical cues for the use of TSPCs to achieve proper cellular adherence arrangement and morphology as well as promote the tenogenic differentiation of TSPCs, making it a valuable customizable biomaterial for future applications in tendon repair.

A Step in the Right Direction: Point-of-Care Ultrasound as an Evaluation Tool of Achilles Tendon Injuries in the Emergency Department

This report describes the diagnosis of an Achilles tendon tear in a female patient with an inconclusive physical exam, which was limited by the patient’s body habitus. Expedient use of point-of-care ultrasound supported the diagnosis of an Achilles tear with findings of a tendinous defect, fibrous stranding, and surrounding anechoic fluid, suggestive of localized hemorrhage. The patient was splinted in plantar flexion and had prompt orthopedic referral with MRI that verified Achilles tear.

Unusual Presentation of a Swelling in the Achilles Tendon After an Acute Rupture: A Case Report

Introduction

Achilles tendon rupture is common and most cases heal with appropriate treatment. However, complications in the treatment of this condition can be debilitating, especially for young, active individuals.

Case Report

We present the case of a 37-year-old man who presented with ongoing pain on weight-bearing and swelling in the left Achilles tendon area8 months after acute rupture treated with functional bracing and early rehabilitation. Magnetic resonance imaging showed intrasubstance thickening of the tendon with a large swelling. Successful decompression of the swelling was achieved using an arthroscopic technique and the patient returned to normal activities.

Conclusion

Physiotherapy and return to normal activities were limited in our patient due to high levels of discomfort and pain. Prolonged immobility following tendon rupture has been shown to cause increased scar tissue proliferation. This may have hindered functional rehabilitation progress and negatively impacted on the reparative process.

Achilles Tendon Rupture: Can the Tendon Gap on Ultrasound Scan Predict the Outcome of Functional Rehabilitation Program?

Background and objectives  There is a growing use of functional rehabilitation programs for the treatment of Achilles tendon rupture. Factors such as patient age and level of activity have been used to guide the decision. One of the debated indications is the gap size between the ruptured ends of the tendon. This study aims to define any correlation between the amount of the initial gap between tendon ends and patients outcome treated with the functional rehabilitation program. Method  A prospective case series study of all patients with acute Achilles tendon rupture treated non-surgically with the functional rehabilitation program between 2016 and 2018. The tendon gap was measured with an ultrasound scan on the initial presentation. Patients were followed for a minimum of 12 months and assessed for Achilles Tendon Rupture Score (ATRS), plantarflexion strength, and re-rupture rate.  Results  A total of 56 patients completed one-year follow-up, and 2 patients had re-ruptures. The mean plantar flexion gap was 13.7 mm. The mean ATRS at 12 months was 85.12. There was no statistically significant correlation between the final ATRS and the mean rupture gap. Conclusion  The outcome following non-operative functional rehabilitation treatment of rupture Achilles tendon did not correlate with the size of the tendon gap, and authors recommend that decision on functional rehabilitation should not be based on these criteria.

Biomechanical Study of a Multifilament Stainless Steel Cable Crimp System Versus a Multistrand Ultra-High Molecular Weight Polyethylene Polyester Suture Krackow Technique for Achilles Tendon Rupture Repair

Currently, Achilles tendon rupture repair is surgically addressed with an open or minimally invasive approach using a heavy, nonabsorbable suture in a locking stitch configuration. However, these sutures have low stiffness and a propensity to stretch, which can result in gapping at the repair site. Our study compares a new multifilament stainless steel cable-crimp repair method to a standard Krackow repair using multistrand, ultra-high molecular weight polyethylene polyester sutures. Eight matched pairs of cadavers were randomly assigned for Achilles tendon repair using either Krackow technique with polyethylene polyester sutures or the multifilament stainless steel cable-crimp technique. Each repair was cyclically loaded from 10 to 50 N for 100 loading cycles, followed by a linear increase in load until complete failure of the repair. During cyclic loading, 4 of the 8 Krackow polyethylene polyester suture repairs failed, whereas none of the multifilament stainless steel cable crimp repairs failed. Load to failure was greater for the multifilament stainless steel cable crimp repairs (321.03 ± 118.71 N) than for the Krackow polyethylene polyester suture repairs (132.47 ± 103.39 N, p = .0078). The ultimate tensile strength of the multifilament stainless steel cable crimp repairs was also greater than that of the Krackow polyethylene polyester suture repairs (485.69 ± 47.93 N vs 378.71 ± 107.23 N, respectively, p = .12). The mode of failure was by suture breakage at the crimp for all cable-crimp repairs and by suture breakage at the knot, within the tendon, or suture pullout for the polyethylene polyester suture repairs. The multifilament stainless steel cable crimp construct may be a better alternative for Achilles tendon rupture repairs.

Evaluation of a new collagen-based medical device (ElastiCo®) for the treatment of acute Achilles tendon injury and prevention of peritendinous adhesions: An in vitro biocompatibility and in vivo investigation

Tendon healing still represents a challenge for clinicians because it is slow and incomplete. The most injured is the Achilles tendon, and surgery is the therapeutic strategy often adopted because it provides a quicker functional recovery. Peritendinous adhesions are the main complication of surgery with hyperplasia and chemotaxis of fibroblasts. A biomaterial that blocks fibroblast migration, without interfering with the passage of cytokines and growth factors, might be useful. The present study evaluated the biocompatibility of a new Type I collagen-based scaffold (ElastiCo®) and its ability to promote Achilles tendon healing, inhibiting adhesion formation. After verifying in vitro biocompatibility, physical, and mechanical properties of the scaffold, an in vivo study was performed in 28 rats, operated to induce an acute lesion in both Achilles tendons. One tendon was treated with the suture only and the contralateral one with suture wrapped with ElastiCo® film. After 8 and 16 weeks, it was observed that ElastiCo® reduced internal and external peritendinous adhesions and Collagen III content and increased Collagen I. Elastic modulus increased with both treatments over time. Current results highlighted the clinical translationality of ElastiCo® that could improve the quality of life in patients affected by Achilles tendon lesions surgically treated.

Prognosis of elite basketball players after an Achilles tendon rupture

Objective

Professional Basketball players are at high risk of Achilles tendon rupture. Despite this, there remains limited research into the factors affecting rehabilitation and the long term outcomes of these players. Our aim is to quantify the effect of a player’s Achilles tendon rupture on their post-injury performance, and also to explore for correlations between their recovery timeline and pre-injury characteristics. Creation of an injury timeline of past incidents will allow injured players to better track their progress and also inform them about the probable impact on their careers.

Hypothesis

Players with Achilles tendon rupture injury will exhibit decreased performance compared to their pre-injury self and their non-injured peers after recovery.

Methods

Professional basketball players who sustained a unilateral Achilles tendon rupture from 1992 to 2016 were collected. 12 players met our inclusion criteria and their Player Efficiency Ratings (PER) were obtained as primary outcome measures; matched controls were chosen based on the PER, Age and playing position. The players’ index season PER was compared against the PER during the 10 games immediately following the players’ return and the PER of their post-injury peak performing season. The same data analysis was performed against their control group. To investigate the factors affecting the recovery and long-term consequences of their injury, we correlated the variables of Age, BMI, Time of Injury and pre-injury PER with the player’s time to return to play and their post-injury PER.

Results

2 out of 12 players failed to return to playing in the elite professional league following an Achilles Tendon Rupture, others returned after a mean recovery time of 10 months. When compared to players’ index PER, the mean PER reduction during the 10 games immediately following the players’ return was 7.15 (P < .000). Players on average took 1.8 seasons to reach their post-injury peak performance, with only 1 player returning to his pre-injury performance. Others suffered a mean PER reduction of 3.5 (P = .004) when compared to their index PER and 5.4 (P = .045) against their matched controls.

Conclusion

Achilles tendon rupture can be a career-ending injury for professional basketball players. They are expected to miss 10 months for rehabilitation and reach their post-injury peak performance level at the 2nd season back. The post-injury peak performance is significantly worse than the pre-injury level, but is similar to matched non-injured players.

Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis

BACKGROUND

While numerous clinical studies have compared the surgical and non-surgical treatment of acute Achilles tendon rupture (ATR), there are no studies that have performed a non-inferiority analysis between treatments.

METHODS

Data from patients who were included in five randomised controlled trials from two different centres in Sweden were used. Outcomes at 1 year after ATR consisted of the patient-reported Achilles tendon Total Rupture Score (ATRS) and the functional heel-rise tests reported as the limb symmetry index (LSI). The non-inferiority statistical 10% margin was calculated as a reflection of a clinically acceptable disadvantage in ATRS and heel-rise outcome when comparing treatments.

RESULTS

A total of 422 patients (350 males and 72 females) aged between 18 and 71 years, with a mean age of 40.6 (standard deviation 8.6), were included. A total of 363 (86%) patients were treated surgically. The ATRS (difference (Δ) = - 0.253 [95% confidence interval (CI); - 5.673;5.785] p = 0.36) and LSI of heel-rise height (difference = 1.43 [95% CI; - 2.43;5.59] p = 0.81), total work (difference = 0.686 [95% CI; - 4.520;6.253] p = 0.67), concentric power (difference = 2.93 [95% CI; - 6.38;11.90] p = 0.063) and repetitions (difference = - 1.30 [95% CI; - 6.32;4.13] p = 0.24) resulted in non-inferiority within a Δ - 10% margin for patients treated non-surgically.

CONCLUSION

The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes.

Post-operative MRI and US appearance of the Achilles tendons

The Achilles tendon is one of the most commonly ruptured tendons in the human body. Minimally invasive and open surgical repairs are commonly undertaken to manage acute Achilles ruptures. This article describes the postoperative imaging findings and their evolution after surgery. Ultrasound and magnetic resonance imaging provide crucial information regarding the morphology, structure, vascularization and mobility of the Achilles tendon on the surrounding planes. Morphologically, a repaired tendon is physiologically larger and wider than an intact one, with a loss of its fibrillary structure; the presence of surgical material in the context of the tendon is normal after the rupture has been repaired. After surgery, the tendon is more vascularized in power-Doppler imaging. Elastography and diffusion tensor Imaging are innovative tools which allow for the visualization of microstructural abnormalities not apprehensible using conventional imaging techniques. A treated Achilles tendon is unlikely to regain a normal imaging appearance, and the health care professional must distinguish between postoperative findings and actual pathological features. In this context, clinical examination still reigns supreme.

Achilles tendon ruptures during summer show the lowest incidence, but exhibit an increased risk of re-rupture

PURPOSE

Achilles tendon rupture (ATR) is a common injury. The knowledge of seasonal factors´ impact is incomplete, but may provide means for preventive approaches for Achilles tendon related morbidity. The aim of this study was to investigate seasonal variations in ATR incidence in relation to injury mechanism, adverse events including risk of re-rupture, and patient-reported outcome in adults in Stockholm, Sweden.

METHODS

In total, 349 patients with unilateral acute Achilles tendon rupture, prospectively treated with standardized surgical techniques, were retrospectively assessed. Date of injury was assigned to one of the four internationally defined meteorological seasons in the northern hemisphere. Injury mechanism and the rate of adverse events; deep venous thrombosis, infection and re-rupture in relation to per-operative complications. Patient-reported outcome at 1 year was assessed with the validated Achilles tendon Total Rupture Score.

RESULTS

ATR incidence was significantly highest during winter and spring, and lowest during summer (p < 0.05). The most common sporting activities associated with ATR were badminton, floorball and soccer (> 50%). The rate of soccer-related ATR was highest during summer (p < 0.05). Patients sustaining an ATR during summer, compared to other seasons, exhibited more per-operative complications (p < 0.05), a significantly higher risk of re-rupture (p < 0.05) and a lower rate of good outcome (n.s.). The risk of other adverse events after ATR did not differ between the seasons.

CONCLUSION

Winter and spring are the high risk seasons for sports-related ATR and the risk sports are badminton, soccer and floorball. The reason for the higher risk of re-rupture after ATR repair during summer should be further investigated.

LEVEL OF EVIDENCE

III.

Expression of TGF-β1 and VEGF in patients with Achilles tendon rupture and the clinical efficacy

Expression of transforming growth factor-β1 (TGF-β1) and vascular endothelial growth factor (VEGF) in patients with Achilles tendon rupture, and the predictive values and significance in clinical efficacy were explored. Forty-two patients with Achilles tendon rupture, surgically treated in the First Affiliated Hospital of University of South China, were selected and the clinical efficacy was evaluated based on the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. RT-qPCR was adopted to detect the expression of serum TGF-β1 and VEGF in the patients before and after treatment, and Spearman's correlation was used to analyze the correlation of TGF-β1 and VEGF with the clinical efficacy after treatment. Patients were divided into an excellent efficacy group and a good/general efficacy group according to the predictive efficacy. In the two groups, the expression levels of TGF-β1 and VEGF before treatment were observed, and the predictive values of TGF-β1 and VEGF in clinical efficacy using the receiver operating characteristic (ROC) curves were obtained. The 42 patients showed significantly higher expression of TGF-β1 and VEGF at 3 months after treatment, and significantly decreased expression at 6 months after treatment, compared to the results before treatment (both P<0.001). After treatment, the efficacy was excellent in 11 patients, good in 25 and general in 6. Spearman's correlation analysis revealed that the expression of TGF-β1 and VEGF decreased with the improvement of efficacy after treatment (P<0.001), and the excellent efficacy group showed significantly lower expression of TGF-β1 and VEGF than that in the good/general efficacy group (P<0.01). Moreover, according to ROC curves, the areas under the curves (AUCs) of TGF-β1 and VEGF were 0.651 and 0.645, respectively. In conclusion, TGF-β1 and VEGF can be considered as observational indexes and predictors for clinical efficacy in patients with Achilles tendon rupture, before and after treatment.

Effects of immobilization angle on tendon healing after achilles rupture in a rat model

Conservative (non-operative) treatment of Achilles tendon ruptures is a common alternative to operative treatment. Following rupture, ankle immobilization in plantarflexion is thought to aid healing by restoring tendon end-to-end apposition. However, early activity may improve limb function, challenging the role of immobilization position on tendon healing, as it may affect loading across the injury site. This study investigated the effects of ankle immobilization angle in a rat model of Achilles tendon rupture. We hypothesized that manipulating the ankle from full plantarflexion into a more dorsiflexed position during the immobilization period would result in superior hindlimb function and tendon properties, but that prolonged casting in dorsiflexion would result in inferior outcomes. After Achilles tendon transection, animals were randomized into eight immobilization groups ranging from full plantarflexion (160°) to mid-point (90°) to full dorsiflexion (20°), with or without angle manipulation. Tendon properties and ankle function were influenced by ankle immobilization position and time. Tendon lengthening occurred after 1 week at 20° compared to more plantarflexed angles, and was associated with loss of propulsion force. Dorsiflexing the ankle during immobilization from 160° to 90° produced a stiffer, more aligned tendon, but did not lead to functional changes compared to immobilization at 160°. Although more dorsiflexed immobilization can enhance tissue properties and function of healing Achilles tendon following rupture, full dorsiflexion creates significant tendon elongation regardless of application time. This study suggests that the use of moderate plantarflexion and earlier return to activity can provide improved clinical outcomes. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

A quality improvement pilot assessment of the safety and associated outcomes of a viable cryopreserved umbilical tissue allograft as an adjunct surgical wrap in peroneus brevis tendon repair

Surgical tendon repairs of the lower extremity are frequently associated with post-operative (post-op) risks that result in poor patient outcomes. Initially, increased pain levels may contribute to extended post-op rehabilitation while the development of tissue adhesions and fibrosis limit long-term functionality through reduced range of motion. Several surgical methods describing incorporation of various augmentative graft materials in tendon repair exist. However, reports demonstrating technique and both short- and long-term patient outcomes are lacking. Recently, advances in tissue preservation technology have led to the commercialization of human placental allografts. Of these available allogeneic biomaterials, the components found in human placental membranes may provide anti-inflammatory, antimicrobial, anti-adhesive, and antifibrotic properties to benefit surgical outcomes.Here, the authors introduce and technically describe the use of a viable cryopreserved umbilical tissue (vCUT) (Stravix, Osiris Therapeutics, Inc., Columbia, MD) as a complementary surgical wrap in primary tendon repair, with particular focus on the peroneus brevis. A pilot study was undertaken to assess the safety and potential for secondary rehabilitative outcomes associated with the use of vCUT in 5 tendon repair cases. The use of vCUT as a surgical tendon wrap was evaluated via the following primary endpoints at post-op day 7:Secondary investigative endpoints included clinical and rehabilitative outcome measures for comparative pain reduction and transition times to both controlled ankle movement (CAM) boot and normal shoe ambulation.All patients were followed for an average of 24.15 months (range 16.75-26.5 months) after surgery. For primary safety measures, erythema, tenderness, drainage, heat, and swelling was absent in all 5 surgical sites. None of the patients required post-op use of narcotics past day 7. The potential for long-term rehabilitative improvement with adjunct use of vCUT was also demonstrated through reduced pain and reduced transition times to functional and non-assisted ambulation in normal shoewear as compared to historical controls managed without vCUT.This surgical technique is simple and safe for patients and preliminary findings have demonstrated favorable clinical and rehabilitative outcomes over historically observed controls.

Acute Achilles tendon rupture: Do cast boots produce adequate equinus when used for functional rehabilitation?

Acute Achilles tendon rupture is frequently treated conservatively using functional rehabilitation protocols in which the ankle is held in equinus. Equinus is achieved using a variety of means including equinus casts and rigid boots with heel wedges. Concerns have been raised that rigid boots with heel wedges do not achieve adequate equinus. Patients presenting to our institutions with an acute Achilles tendon rupture were randomised to treatment with an equinus cast or rigid boot with heel wedges. After application of these lateral radiographs of the hindfoot and ankle were taken, and these used to measure tibiotalar angle (TTA), tibio-1st metatarsal angle (TMA) and posterior malleolar to calcaneal tip height (PCH). 15 patients were randomised to a rigid boot and 14 to an equinus cast. The mean TTA was 124° in the rigid boot group and 136° in the equinus cast group (p<0.001). The mean TMA was 134° in the rigid boot group and 147° in the equinus cast group (p<0.001). The mean PCH was 25mm in the rigid boot group and 15mm in the equinus cast group (p<0.05). Our results demonstrate that the rigid boots with heel wedges used in our institutions produce significantly less equinus than an equinus cast. Whilst the clinical relevance of this remains uncertain, clinicians should be aware that rigid boots with wedges and equinus casts may not achieve the same degree of Achilles tendon shortening.

Knockdown of lncRNA KCNQ1OT1 suppresses the adipogenic and osteogenic differentiation of tendon stem cell via downregulating miR-138 target genes PPARγ and RUNX2

The study aimed to investigate the mechanism and biological roles of long noncoding RNA KCNQ1OT1 in adipogenic and osteogenic differentiation of tendon stem cell. In this study, tendon injury mice model was established to detect the expression of lncRNA KCNQ1OT1, miR-138, peroxisome proliferator-activated receptor gamma (PPARγ) and runt-related gene 2 (RUNX2) using quantitative real-time PCR (qRT-PCR) and western blot. Mechanical testing was carried out to assess tendon function. Adiponectin and Osterix were used to evaluate the adipogenic and osteogenic differentiation of tendon stem cells (TSCs). The interaction between lncRNA KCNQ1OT1 and miR-138 was detected by RNA immunoprecipitation (RIP) assay and RNA pull-down assay. We found that lncRNA KCNQ1OT1, PPARγ and RUNX2 expression were significantly upregulated, while miR-138 was suppressed in tendon tissue of injured group and the separated TSCs. lncRNA KCNQ1OT1 knockdown inhibited the adipogenic and osteogenic differentiation of TSCs. Further studies indicated that lncRNA KCNQ1OT1 functioned as a competing endogenous RNA (ceRNA) by sponging miR-138 in TSCs. Further investigations confirmed that lncRNA KCNQ1OT1 knockdown exerted anti-adipogenic and anti-osteogenic function via miR-138/PPARγ and miR-138/RUNX2 axis. Therefore, the lncRNA KCNQ1OT1/miR-138/PPARγ or RUNX2 axis modulated adipogenic and osteogenic differentiation of tendon stem cell, which might be a promising therapeutic target for tendon injuries.

Achillon versus open surgery in acute Achilles tendon repair

BACKGROUND

Open Achilles tendon repairs (OATR) are associated with high complication rates. Minimally invasive surgery (MIS) techniques like the Achillon Achilles tendon repair (AATR) were developed to reduce this. We performed a systematic review and meta-analysis to compare OATR with AATR.

METHODS

We performed an extensive literature search including all studies that compared the two techniques. Outcomes assessed included overall complication rate, re-rupture rate, sural nerve injury, wound length, The American Orthopaedic Foot and Ankle Scores (AOFAS) scores and return to sports.

RESULTS

Eight studies were suitable for inclusion totalling 210 patients in the AATR group vs 233 patients in the OATR group. Total complication rates were significantly reduced in the Achillon patients with odd ratio of 0.14 (CI 95%, 0.08-0.27, P<0.00001) in favour. There were no significant differences in re-rupture rate, sural nerve injury, return to sports and AOFAS scores following repair between the two groups.

CONCLUSIONS

AATR has fewer overall complications compared with OATR. It should be considered as an alternative to open surgical repair.

Point-of-Care Ultrasound in Trauma

The use of point-of-care ultrasound in trauma is widespread. Focused Assessment with Sonography for Trauma examination is a prototypical bedside examination used by the treating provider to quickly determine need for intervention and appropriate patient disposition. The role of bedside ultrasound in trauma, however, has expanded beyond the Focused Assessment with Sonography for Trauma examination. Advancements in diagnostics include contrast-enhanced ultrasound, thoracic, and musculoskeletal applications. Ultrasound is also an important tool for trauma providers for procedural guidance including vascular access and regional anesthesia. Its portability, affordability, and versatility have made ultrasound an invaluable tool in trauma management in resource-limited settings. In this review, we discuss these applications and the supporting evidence for point-of-care ultrasound in trauma.

Reliability and validation of the Dutch Achilles tendon Total Rupture Score

PURPOSE

Patient-reported outcome measures (PROMs) have become a cornerstone for the evaluation of the effectiveness of treatment. The Achilles tendon Total Rupture Score (ATRS) is a PROM for outcome and assessment of an Achilles tendon rupture. The aim of this study was to translate the ATRS to Dutch and evaluate its reliability and validity in the Dutch population.

METHODS

A forward-backward translation procedure was performed according to the guidelines of cross-cultural adaptation process. The Dutch ATRS was evaluated for reliability and validity in patients treated for a total Achilles tendon rupture from 1 January 2012 to 31 December 2014 in one teaching hospital and one academic hospital. Reliability was assessed by the intraclass correlation coefficients (ICC), Cronbach's alpha and minimal detectable change (MDC). We assessed construct validity by calculation of Spearman's rho correlation coefficient with domains of the Foot and Ankle Outcome Score (FAOS), Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A) and Numeric Rating Scale (NRS) for pain in rest and during running.

RESULTS

The Dutch ATRS had a good test-retest reliability (ICC = 0.852) and a high internal consistency (Cronbach's alpha = 0.96). MDC was 30.2 at individual level and 3.5 at group level. Construct validity was supported by 75 % of the hypothesized correlations. The Dutch ATRS had a strong correlation with NRS for pain during running (r = -0.746) and all the five subscales of the Dutch FAOS (r = 0.724-0.867). There was a moderate correlation with the VISA-A-NL (r = 0.691) and NRS for pain in rest (r = -0.580).

CONCLUSION

The Dutch ATRS shows an adequate reliability and validity and can be used in the Dutch population for measuring the outcome of treatment of a total Achilles tendon rupture and for research purposes.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

Effect of position, time in the season, and playing surface on Achilles tendon ruptures in NFL games: a 2009-10 to 2016-17 review

OBJECTIVES

Achilles tendon (AT) ruptures are a potentially career-altering and ending injury. Achilles tendon ruptures have a below average return-to-play rate compared to other common orthopaedic procedures for National Football League (NFL) players. The objective of this study was to monitor the incidence and injury rates (IR) of AT ruptures that occurred during the regular season in order to evaluate the influence of player position, time of injury, and playing surface on rupture rates.

METHODS

A thorough online review was completed to identify published injury reports and public information regarding AT ruptures sustained during regular season and post-season games in the National Football League (NFL) during the 2009-10 to 2016-17 seasons. Team schedules, player position details and stadium information was used to determine period of the season of injury and playing surface. IRs were calculated per 100 team games (TG). Injury rate ratios (IRR) were utilized to compare IRs.

RESULTS

During eight monitored seasons, there were 44 AT ruptures in NFL games. A majority of AT ruptures were sustained in the first eight games of the regular season (n = 32, 72.7%). There was a significant rate difference for the first and second four-game segments of the regular season compared to the last two four-game segments of the regular season. Defensive players suffered a majority of AT ruptures (n = 32, 72.7%). The IR on grass was 1.00 per 100 TG compared to 1.08 per 100 TG on artificial turf (IRR: 0.93, p = .80).

CONCLUSION

A significant increase in AT ruptures occurred in the first and second four game segments of the regular season compared to the last two-four game segments of the regular season. Defensive players suffered a majority of AT ruptures compared to offensive or specialist players. There was no difference between AT rupture rates and playing surface in games.

Advances of stem cell based-therapeutic approaches for tendon repair

Tendon injuries are significant clinical problems. Current treatments often result in incomplete repair or healing, which may lead to reduced function and rupture. Stem cell-based therapy is a promising intervention for tendon repair. In this article, we attempt to provide a brief overview on the recent progress in the field, current understanding of the underlying mechanisms of the approach, and the potential of stem cell-based therapies beyond cell implantation. We conclude the review by sharing our viewpoints on the challenges, opportunities, and future directions of this approach. The translational potential of this article: This paper reviews recent progress on stem cell-based therapeutic approaches for tendon repair, which highlights its translational potential and challenges.

Dual Fixation of Calcaneal Tuberosity Avulsion with Concomitant Achilles Tendon Rupture: A Novel Hybrid Technique

Fracture of the calcaneal tuberosity with a concomitant Achilles tendon rupture presents a difficult challenge for the treating surgeon. The ultimate goal of treatment is to restore function of both the gastrocnemius-soleus complex and the Achilles tendon. This particular subset of fractures occurs often in diabetics and elderly patients with osteoporosis making fixation of the displaced fragment rather complex. If the Achilles tendon disruption is only discovered later once the fracture is healed, subsequent management is difficult with surgical treatment being more morbid. While this is a rare injury, the consequences of a missed chronic Achilles tendon disruption are severe with significant dysfunction. It is therefore important to have a high index of suspicion for concomitant injury and to be prepared for dual fixation. We present a novel hybrid surgical fixation technique, which may be used in this instance.

Current concepts on tenogenic differentiation and clinical applications

Tendon is a tissue that transmits force from muscle to bone. Chronic or acute tendon injuries are very common, and are always accompanied by pain and a limited range of motion in patients. In clinical settings, management of tendon injuries still remains a big challenge. Cell therapies, such as the application of stem cells for tenogenic differentiation, were suggested to be an ideal strategy for clinical translation. However, there is still a lack of specific methods for tenogenic differentiation due to the limited understanding of tendon biology currently. This review focuses on the summary of current published strategies for tenogenic differentiation, such as the application of growth factors, mechanical stimulation, biomaterials, coculture, or induced pluripotent stem cells. Current clinical applications of stem cells for treatment of tendon injuries and their limitations have also been discussed in this review.

The Effect of Sodium Hyaluronate on Ligamentation and Biomechanical Property of Tendon in Repair of Achilles Tendon Defect with Polyethylene Terephthalate Artificial Ligament: A Rabbit Tendon Repair Model

The Achilles tendon is the most common ruptured tendon of human body. Reconstruction with polyethylene terephthalate (PET) artificial ligament is recommended in some serious cases. Sodium hyaluronate (HA) is beneficial for the healing of tendon injuries. We aimed to determine the effect of sodium hyaluronate in repair of Achilles tendon defect with PET artificial ligament in an animal tendon repair model. Sixteen New Zealand White rabbits were divided into two groups. Eight rabbits repaired with PET were assigned to PET group; the other eight rabbits repaired with PET along with injection of HE were assigned to HA-PET group. All rabbits were sacrificed at 4 and 8 weeks postoperatively for biomechanical and histological examination. The HA-PET group revealed higher biomechanical property compared with the PET group. Histologically, more collagen tissues grew into the HA-PET group compared with PET group. In conclusion, application of sodium hyaluronate can improve the healing of Achilles tendon reconstruction with polyethylene terephthalate artificial ligament.

The Double-Row Suture Technique: A Better Option for the Treatment of Haglund Syndrome

Purpose. The purpose of this study is to investigate whether double-row suture technique is a better option for the treatment of Haglund syndrome than single-row suture technique regarding the surgical outcomes. Methods. Thirty-two patients with Haglund syndrome were recruited in this study. Patients were divided into Group 1 (treated with single-row suture technique) and Group 2 (treated with double-row suture technique). There were 16 patients in each group. The AOFAS-ankle-hindfoot scale, VISA-A scores, and Arner-Lindholm standard were used to assess the clinical outcomes. The pre- and postoperative X-rays were used to assess the radiological outcome. Results. Both AOFAS-ankle-hindfoot scale score and VISA-A score had varying degrees of improvement in both groups. In latest follow-up assessment, the Arner-Lindholm standard investigation showed there were 7 excellent, 7 good, and 2 bad outcomes in Group 1 and 12 excellent and 4 good outcomes in Group 2. In Group 2 patients, there were no more posterosuperior bony prominence of the calcaneum in post-op X-rays and there were no recurrent cases. The ankle-related scale score was statistically significantly higher in Group 2 than in Group 1 (P = 0.029). Conclusion. The double-row suture technique seems to be a better option to treat Haglund syndrome than single-row suture technique.

Reconstruction of neglected achilles tendon ruptures with gastrocnemius flaps: excellent results in long-term follow-up

OBJECTIVE

Repair of the neglected achilles tendon ruptures can be challenging due to retraction of tendon stumps. Different repair and augmentation techniques were described. This study aims to investigate long-term results of neglected achilles tendon rupture repair with gastrocnemius flaps.

PATIENTS AND METHODS

Between 1995 and 2005, 21 neglected achilles tendon rupture reconstructions were performed with using gastrocnemius fascial flaps. Mean age was 32.1 years. Mean period between rupture and operation was 8.4 weeks. Ankle range of motion, calf circumference, heel raise test, Visual Analog Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and Foot and Ankle Disability Index (FADI) scores were checked.

RESULTS

The average gap length was 6.4 cm. Mean follow-up was 145.3 months. Median dorsiflexion/plantar flexion values for operated and uneffected sides were 18°/30° and 19°/30°, respectively. The mean values for AOFAS and FADI scores were 98.5 points and 98.9 %, respectively. VAS score was 0 point for all patients. With the numbers available, no significant difference could be detected in terms of ankle range of motion, calf circumference measures and dynamometric analysis. Mean time for return to daily activities was 11.1 (8-16) weeks after surgery. Prerupture activity level was achieved 14.1 months postoperatively. All patients were able to perform heel raise test.

CONCLUSION

Repair of neglected achilles tendon ruptures with gastrocnemius flaps has satisfactory long-term results.