Diagnosis and treatment of acute Achilles tendon rupture

A Case Report of Acute Achilles Tendon Rupture in a Patient With Multimorbidity Treated With Endoscopic Flexor Hallucis Longus Transfer

Acute Achilles tendon rupture (AATR) in patients with multimorbidity poses a significant therapeutic challenge to surgeons because of the increased risk for wound-healing-related complications. Thus, nonoperative management has been these individuals' most widely adopted treatment. We report a case of a 66-year-old patient with AATR who was treated with endoscopic flexor hallucis longus (FHL) transfer. His medical history was remarkable for recent stroke, hypertension, prediabetes, pemphigus under oral methylprednisolone, smoking, and recent pneumonia. The patient was evaluated up to two years postoperatively and was satisfied with the outcome since he was able to maintain his pre-traumatic activity level. No complications were noted. The Achilles tendon total rupture score was 92 out of a maximum of 100. This favorable outcome indicates that endoscopic FHL transfer may be a safe alternative treatment option for patients with an increased risk of surgical complications.

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.

Incidence and Time Course of Symptomatic Thromboembolic Outcomes After Lower Extremity Arthroscopic Surgery, Ankle Fracture Surgery, and Achilles Tendon Repair

BACKGROUND

The incidence and time course of acute venous thromboembolism (VTE) after ambulatory surgery for lower extremity orthopaedic conditions is not well-defined.

HYPOTHESIS

The purpose of this study was to analyze the incidence, the time course, and risk factors associated with clinically diagnosed acute deep vein thrombosis or pulmonary embolism within 3 months of surgery in patients undergoing specific operations for lower extremity injuries.

METHODS

Patients undergoing arthroscopic procedures of the knee, ankle fracture surgery, Achilles tendon repair, and ankle arthroscopy from January 1, 2005, to December 31, 2010, were identified in the California Ambulatory Surgery database with linkage to hospital discharge data, emergency department data, and a death registry. Outcomes were acute VTE and death within 90 days. Time courses were compared using Kaplan-Meier analysis, and risk factors were analyzed using proportional hazard modeling.

RESULTS

Analysis of data from 468,699 surgeries showed that the cumulative incidence of acute VTE was significantly higher after Achilles tendon repair (0.72%, P < 0.001) than ankle fracture surgery (0.33%), knee arthroscopy procedures (range, 0.29% to 0.41%), or ankle arthroscopy (0.24%). The time course of diagnosis of VTE was similar for all arthroscopic procedures (median postoperative day for diagnosis = 9 to 10; 80% by 22 to 36 days), whereas for Achilles tendon surgery, the time course was protracted (median postoperative day for diagnosis = 29 days; 80% by 51 days). Ninety-day mortality was low (<0.06%) after all procedures except ankle fracture (0.12%). Predictors of pulmonary embolism included age older than 60 years (HR, 3.1; 95% CI; 2.0 to 4.8, versus younger than 30 years), Achilles tendon repair (HR, 3.8; 95% CI; 2.8 to 5.3), and ankle fracture surgery (Hazard Ratio [HR], 2.1; 95% Confidence Interval [CI]; 1.5 to 2.8); Asian/Pacific Islander (HR, 0.3; 95% CI; 0.1 to 0.6) and Hispanic patients (HR, 0.5; 95% CI; 0.4 to 0.7) had significantly lower risk.

DISCUSSION

The incidence and time course of onset of acute VTE after lower extremity orthopaedic surgeries varies significantly depending on the surgical procedure. These findings have implications regarding the use and duration of pharmacologic thromboprophylaxis.

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

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.

Transforming the Management of Articular Fractures in the Foot: A Critical Examination of Current Methods and Future Directions: A Review

This study provides a comprehensive examination of the current methodologies and potential strategies for the treatment of articular fractures of the foot. In the field of orthopedic healthcare, these fractures present a significant challenge due to their complex nature and the fact that they affect the routines of patients. The motivation behind this study is based on two main concepts. The first one is represented by the use of emerging medical technologies and personalized medicine to bring a significant transformation in the management of foot fractures and give a better quality of treatment that is accepted by the patient. However, because there are inequities in the availability of the necessary medical care and equipment, as well as uneven incorporation in clinical settings, new technologies cannot be used to treat these types of fractures. Regarding the second concept behind this study, it is indicated that although current treatment methods are essential, they have a number of shortcomings when it comes to properly addressing these types of injuries. An approach is needed that takes into account the biomechanical points of view and the particularities of each patient. This approach could be applied in all hospital settings. Through this study, we want to highlight the progress made in recent years in surgical techniques such as 3D printing, minimally invasive surgery (MIS), and biological products. However, in the application of this new discovery, new obstacles have been discovered that prevent the efficient treatment of these types of injuries. This study examines the effectiveness and limitations of current treatments, as well as how differences in healthcare, such as available equipment, training of medical staff, and technological advances, affect patient outcomes in everyday life. This research wishes to emphasize that continuous innovation, interdisciplinary collaboration, and the use of an optimal approach that is appropriate for each patient, are essential. This study aims to provide new insights and useful recommendations for future research and clinical practice. The main role of this research is to improve the quality of life of patients and increase the standards of care in this complex field, which is in permanent evolution.

No difference in operative time, outcomes, cosmesis, or return to activity and/or sport after minimally invasive versus open repair of primary Achilles ruptures: a retrospective review

PURPOSE

To compare clinical outcomes and the rate of return to sport among patients that have undergone minimally invasive repair versus open approach of an acute Achilles tendon rupture.

METHODS

Patients who underwent surgical repair of acute Achilles tendon rupture at a single urban academic institution from 2017 to 2020 with minimum 2-year follow-up were reviewed retrospectively. Preinjury sport participation and preinjury work activity information, the Achilles tendon Total Rupture Score (ATRS), the Tegner Activity Scale, Patient-Reported Outcomes Measurement Information System for mobility and pain interference were collected.

RESULTS

In total, 144 patients were initially included in the study. Of these, 63 patients were followed with a mean follow-up of 45.3 ± 29.2 months. The mean operative time did not significantly differ between groups (p = 0.938). Patients who underwent minimally invasive repair returned to sport at a rate of 88.9% at a mean of 10.6 ± 5.8 months, compared to return rate of open procedures of 83.7% at 9.5 ± 5.5 months. There were no significant differences in ATRS (p = 0.246), Tegner (p = 0.137) or VAS pain (p = 0.317) scores between groups. There was no difference in cosmetic satisfaction between PARS and open repair groups (88.4 vs. 76.0; p = 0.244).

CONCLUSION

Patients who underwent minimally invasive repair of acute Achilles tendon ruptures demonstrate no significant differences with respect to cosmesis, operative time, patient-reported outcomes and the rate and level of return to activities when compared to an open approach.

LEVEL OF EVIDENCE

III.

An Early Functional Unsupervised Rehabilitation Protocol Allows Safe Return to Function After Achilles Tendon Repair

PURPOSE

Acute Achilles tendon tears in young active individuals are often treated surgically with prolonged rehabilitation, with the leg initially immobilized in plantar flexion in serial non-weight bearing casts and gradually progressing to full weight bearing. This study aimed to evaluate the safety of an early functional unsupervised rehabilitation protocol.

METHODS

The medical records of 25 patients treated with open repair were available for follow-up. In 10 patients, an early functional unsupervised rehabilitation protocol was used with a removable cast, active range of motion exercises of the ankle from the first postoperative day, and full weight bearing in a walking boot with the foot plantigrade after the second week. Another 15 patients who followed the classic rehabilitation protocol were used as controls. The patients were evaluated with the Victorian Institute of Sports Assessment-Achilles (VISA-A) and an ultrasound examination-based score. A Wilcoxon test was used to compare the scores between the groups.

RESULTS

The mean VISA-A score was 90.1 (SD = 9.87) for the early functional rehabilitation protocol group, while it was 83.8 (SD = 17.06, p = 0.624) for the control group. The mean ultrasound score was 7.75 (SD = 1.71) for the early functional rehabilitation protocol group, while it was 7.60 (SD = 3.05, p = 0.414) for the control group. There were no intra- or early postoperative complications in the groups, and all patients were satisfied with the results of their operation.

CONCLUSIONS

An early unsupervised functional rehabilitation protocol after open Achilles repair may allow for safe early mobilization and minimize the need for physiotherapy. The small number of participants is a limitation of this study, and further evaluation with more patients is necessary to document the efficacy.

Percutaneous cruciate repair of ruptured Achilles tendon

Percutaneous repair is a safe and reliable method to restore continuity after acute Achilles tendon ruptures, with a lower incidence of wound complications compared to open techniques. We describe a novel percutaneous cruciate suture performed through 5 stab skin incisions, four of which are longitudinal and parallel to the course of the sural nerve to minimize the risk of injury and one transverse incision at the site of rupture, with a total of 16 suture threads and the knot outside the tendon body, increasing the tensile strength of the suture and minimizing the risk of re-rupture. Clinical studies are necessary to ascertain whether the theoretical advantages of the cruciate suture technique translate into better clinical outcomes compared to established percutaneous techniques.

Diagnostic Value of Lateral Ankle Radiography in Achilles Tendon Rupture

INTRODUCTION

Achilles tendon rupture (ATR) is a common sports injury, but approximately 20% of acute ATR cases are misdiagnosed as ankle sprains at first presentation. This study aimed to investigate the diagnostic value of lateral ankle radiography in the diagnosis of acute ATR.

METHODS

This was a retrospective case-control study in which the lateral ankle radiographs of patients who presented to the emergency department between January 1, 2015 and December 31, 2019 were examined. The study included a total of 154 patients with acute ATR, who underwent lateral ankle radiography at the presentation and were surgically or magnetic resonance imaging (MRI) confirmed to have ATR in our hospital. The lateral ankle radiographs of the patients were examined by 2 clinicians blinded to clinical data for the following 3 findings: Kager's fat pad sign, tibio-first metatarsal angle, and tibiocalcaneal angle. The same procedure was repeated for 308 controls who underwent lateral ankle radiography and were diagnosed with ankle sprain.

RESULTS

Kager's fat pad sign was detected in 133 (86.4%) of the 154 patients with ATR and 26 (8.4%) of the 308 patients in the control group. The Kager's fat pad sign, tibio-first metatarsal angle, and tibiocalcaneal angle sensitivity values for the diagnosis of ATR were 86.4%, 61.7%, and 65.6%, respectively, and their specificity values were 91.6%, 78.9%, and 56.2%, respectively. Interobserver reliability was determined to be good for all 3 radiographic findings.

CONCLUSION

Clinicians should be particularly aware of Kager's fat pad sign when examining lateral ankle radiographs for ankle injury.

LEVELS OF EVIDENCE

Level IV: Case control study.

Bioinductive Collagen Implant Augmentation for Myotendinous Achilles Rupture in a Teenage Competitive Gymnast: A Case Report

CASE

A 16-year-old female competitive gymnast presented to our orthopaedic clinic with an acute Achilles tendon rupture at the myotendinous junction. Direct end-to-end repair was performed and augmented with a bioinductive collagen patch. The patient had increased tendon thickness at 6 months postoperatively, as well as significant improvements in strength and range of motion at 12 months.

CONCLUSION

Bioinductive collagen patch augmentation of Achilles tendon repair may be a useful adjunct for myotendinous junction Achilles ruptures, particularly in high-demand patients including competitive gymnasts.

Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position

Background

The mini-open approach with supine patient positioning is a useful technique to consider for acute Achilles rupture repair, ideally performed within 2 weeks from the time of injury. The traditional surgical approach is completed with the patient in the prone position with an extensile midline incision. Here we describe a mini-open approach with supine positioning that utilizes a single incision measuring approximately 3 to 4 cm in length and avoids the pitfalls of prone positioning, which include greater operative time and potential difficult airway management, vision loss, and brachial plexus palsies1.

Description

When positioning the patient supine, lower-extremity bolsters are placed beneath the contralateral hip and the operative ankle in order to allow for exaggerated external rotation of the ankle and improved medial visualization. A thigh tourniquet is then applied on the operative side in a standard sterile fashion.After appropriate draping, begin by palpating the tendon rupture site and mark a 3 to 4-cm incision line just medial to the tendon. Sharp dissection through the skin to the level of the paratenon is then performed. Incise the paratenon with a knife, separate the paratenon from the underlying Achilles tendon with a Freer elevator or scissors, subsequently remove any hematoma formation, and cut the paratenon proximally and distally with scissors or a knife. Debride any damaged tendon thoroughly.The steps of the procedure are performed under direct visualization. If the sural nerve is encountered, it is noted and retracted, and extra care is taken to avoid damaging it with instruments or suture.Now that the proximal and distal ends of the Achilles tendon are free, utilize a 4-stranded double Krackow locking stitch with two #2 FiberWires (Arthrex) on both the proximal and the distal stump. The stumps of the ruptured tendon are approximated by tying the free suture ends together with use of a simple surgeon's knot. A running epitendinous repair is performed with use of number-0 Vicryl (Ethicon) suture in a cross-stich weave technique to provide additional strength to the repair. Finally, test the integrity of the repair via an intraoperative Thompson test. The postoperative protocol includes non-weight-bearing with the operative limb in a posterior splint for 2 weeks. At the 2-week follow-up, stitches are removed and the limb is placed in a tall CAM (controlled ankle motion) walker boot with 2 heel wedges measuring 6.35 mm (0.25 inches) apiece. The patient can begin partial weight-bearing with crutches at 2 weeks postoperatively. At 4 weeks postoperatively, 1 heel wedge is removed, and at 6 weeks postoperatively, the second heel wedge is removed. Patients are instructed to begin gentle range-of-motion exercises at 2 weeks, with formal physical therapy scheduled to begin at 6 weeks. Most patients are out of the boot at 8 to 10 weeks postoperatively.

Alternatives

Nonoperative treatment of Achilles rupture includes functional bracing or casting with the foot resting in the equinus position and early weight-bearing and rehabilitation. As mentioned earlier, the traditional operative approach with prone positioning is a viable option but is associated with a higher incidence of procedural and anesthesia-related complications, as well as potentially increased cost1.

Rationale

Recent studies have shown that a mini-open approach will produce a repair that is comparable with the traditional open approach, while also minimizing the anesthesia and postural complications associated with prone positioning1. Previous studies focusing on supine positioning have generally utilized a larger incision more comparable with that of the traditional prone approach6. Other studies have utilized a minimally invasive approach but require >1 incision and often utilize specialized instrumentation, which may limit the technique to certain facilities7. The technique described in the present article utilizes a single 3 to 4-cm incision that requires no specialized instrumentation, has a minimal learning curve, and can be performed at any facility.

Expected Outcomes

McKissack et al. demonstrated that the overall complication rate of the mini-open supine approach (7.7%) was lower than that of the traditional prone approach (9.3%), while the average cost of the prone approach exceeded that of the supine approach by $1,8231. This increased cost, although not significant, may be attributable to longer operating room and post-anesthesia care unit times. Additionally, no patient in either cohort experienced tendon rerupture within the first year after repair, further proving the effectiveness of this technique. We have utilized this mini-open supine technique for acute Achilles ruptures for over 9 years now, with good patient outcomes and satisfaction. Throughout this duration we have not had a single patient experience rerupture of the repaired tendon. In our experience, we find this technique to be effective, with fewer complications than prone positioning. Additionally, this approach may be associated with decreased financial and anesthesia burdens.

Important Tips

Always palpate the tendon rupture site to determine the best incision placement.With ruptures close to the tendon insertion site, it can be notoriously difficult to mobilize the distal tendon stump, so extended incisions may be required.Test the integrity of the repair with use of the intraoperative Thompson test.This technique does not utilize any special equipment and thus can be performed at any facility.This supine approach decreases operating room turnover time, anesthesia burden, and complications associated with prone positioning.

Acronyms & Abbreviations

AP = anteroposteriorMRI = magnetic resonance imagingUS = ultrasoundDVT = deep vein thrombosisVAS = visual analog scaleNWB = non-weight-bearingCAM = controlled ankle motionPWB = partial weightbearingROM = range of motionPT = physical therapyOR = operating room.

The Relationship Between Patient Demographics, Tear Locations, and Operative Techniques on the Surgical Treatment of Acute Achilles Tendon Ruptures

Introduction

Achilles tendon ruptures (ATRs) have classically been thought to affect the middle-aged “weekend warrior” participating in basketball, volleyball, soccer, or any ground sport; however, with a more active elderly population, these tears are becoming more common in older patients. We sought to examine the role of demographics, tear location, and operative technique for acute Achilles tendon ruptures treated surgically.

Methods

A retrospective query was performed to identify patients who presented with Achilles tendon ruptures. Inclusion data were primary end-to-end repairs, augmented repairs with flexor hallucis longus (FHL) transfers, augmented repairs with graft, augmented repairs with both FHL transfer and graft use, isolated FHL transfers, and revision Achilles tendon procedures. Demographics and tear locations were collected and analyzed.

Results

Midsubstance tears were the most common tear location occurring in 237 of 286 (82.9%) patients. Distal insertional tears of the Achilles tendon were treated in 35 (12.2%) patients, while 14 (4.9%) patients had a more proximal tear located at the myotendinous junction. Older patients (average age: 53.3±12.5) had significantly more distal insertional tears (p<0.001), while younger patients (average age: 35.1±7.4) presented with significantly more tears at the myotendinous junction (p<0.001). The average BMI was significantly higher (average BMI: 32.2±6.6; p<0.001) in patients with distal insertional tears compared to midsubstance and proximal tears (28.5±4.6 and 28.5±5.3, respectively). There was a higher percentage of diabetic patients who underwent operative treatment for distal insertional tears (20%) compared to midsubstance tears (7.2%).

Conclusion

The findings of our study suggest that a subset of patients, particularly those with advanced age and higher BMI, is more likely to present with a distal Achilles tendon rupture. Additionally, patients in our series who had distal tears more commonly required an augmented repair technique. Our results highlight the need for future research to further define the relationship between increasing age and higher BMI patients sustaining distal tears more often than midsubstance tears.

Supervised Physiotherapy Improves Three-Dimensional (3D) Gait Parameters in Patients after Surgical Suturing of the Achilles Tendon Using an Open Method (SSATOM)

BACKGROUND

The aim of this study was to assess the effectiveness of 38 supervised postoperative physiotherapy (SVPh) visits conducted between 1 and 20 weeks after SSATOM on the values of 3D gait parameters measured at 10 and 20 weeks after surgery.

MATERIAL

Group I comprised male patients (n = 22) after SSATOM (SVPh x = 38 visits) and Group II comprised male patients (n = 22) from the control group.

METHODS

A non-randomized, open-label, controlled clinical trial was performed in the two groups to obtain the following values: Step length (cm), stride length (cm), step width (cm), next stance phase (%), swing phase (%), double support (%), gait velocity (m/s), and walking frequency (step/min). The measurements were carried out using the BTS SMART system (Italy).

RESULTS

Orthopedic examination showed no pain, a negative result of Thompson and Matles tests, and proper healing of Achilles tendon (ultrasound image). In Group I, between 10 and 20 weeks after SSATOM, there was a statistically significant improvement in all tested gait parameter values (p ≤ 0.001 to 0.009).

CONCLUSIONS

Conducting 38 SVPh visits significantly improved the values of the analyzed kinematic and spatiotemporal gait parameters in patients in the twentieth week after SSATOM, which were mostly close to the non-operated side and the results of the control group. However, the gait speed and stride length were not close to the results of the control group.

Immediate Weightbearing and Ankle Motion Exercise After Acute Achilles Tendon Rupture Repair

The incidence of Achilles tendon rupture is increasing. Postoperative rehabilitation after repairing acute Achilles tendon rupture is very important because the choice of treatment during the rehabilitation period can influence the results. Moreover, the method of functional rehabilitation varies and is developing steadily. Recent studies recommend a functional rehabilitation protocol, and this approach is accepted widely. This study aimed to introduce our most accelerated functional rehabilitation protocol following surgery for acute Achilles tendon rupture and to review the results retrospectively. From July 2014 to July 2016, 67 patients underwent surgery for acute Achilles tendon rupture by one surgeon. Age, sex, body mass index, injury mechanism, rehabilitation method and progress, time to return to previous physical activity, and complications were evaluated. The mean time to be able to squat fully was 10 ± 4.7 (4-20) weeks. Full squatting was possible in 92.8% (52 patients). The mean time to perform a single-limb heel rise and repetitive single-limb heel rise was 12.6 ± 3.9 (6-24) and 23.3 ± 7.7 (8-40) weeks, respectively. The mean time to return to sports was 20.6 ± 5.2 (12-32) weeks. The major complication rate was 3.5% (one re-rupture and one tendon elongation). The mean pre- and postoperative Achilles Tendon Total Rupture Score was 29.5 ± 3.7 (20-38) and 79.3 ± 18.5 (20-98) points, respectively. The increase was significant (p < .01). In conclusion, immediate full weightbearing and ankle motion exercise after repair of acute Achilles tendon rupture can provide a good rehabilitation option with a low re-rupture rate and satisfactory functional results.

Achilles Injury and Access to Care in South Florida

Introduction. Despite the amount of orthopaedic research evaluating access to care based on insurance status, no study quantifies the effects of insurance status on the care of acute Achilles tendon ruptures. Methods. Using Current Procedural Terminology codes, we identified all patients who underwent surgical management of Achilles tendon rupture between December 31, 2013, and December 31, 2018, and followed-up at either a county hospital-based orthopaedic surgery clinic and/or private university-based clinic. Inclusion criteria included patients who (1) underwent surgical management of an Achilles tendon rupture during this time period and (2) were at least 18 years of age at the time of surgery. A univariate 2-tailed t test was used to compare various groups. Statistical significance was set at P < 0.05. Results. When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of injury to first clinic visit (14.5 days vs 5.2 days, P < .001), first clinic visit to surgery (34.6 days vs 4.8 days, P < .002), injury to surgery date (48.9 days vs 9.8 days, P < .001), initial presentation to when magnetic resonance imaging was obtained (48.1 days vs 1.9 days, P < .002). Conclusions. Disparities in access to care for Achilles tendon ruptures are intimately related to insurance status. Uninsured and Medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance.Levels of Evidence: Level III: Prognostic, retrospective.

Biomechanical comparison of new Achilles tendon rupture repair technique the "Giftbox" versus the Krackow technique in New Zealand white rabbits: An experimental animal study

INTRODUCTION

To compare the strength between the Achilles tendons repaired with the "Giftbox" and the Krackow techniques in New Zealand white rabbits post six weeks of tendon healing.

MATERIALS AND METHODS

Eight rabbits were randomized into Giftbox and Krackow groups. Tenotomy was performed on the Achilles tendon of one side of the lower limb and repaired with the respective techniques. The contralateral limb served as control. Subjects were euthanized six weeks post-operative, and both repaired and control Achilles tendons were harvested for biomechanical tensile test.

RESULTS

The means of maximum load to rupture and tenacity in the Giftbox group (156.89 ± 38.49 N and 159.98 ± 39.25 gf/tex) were significantly different than Krackow's (103.55 ± 27.48 N and 104.91 ± 26.96 gf/tex, both p = 0.043).

CONCLUSION

The tendons repaired with Giftbox technique were biomechanically stronger than those repaired with Krackow technique after six weeks of tendon healing.

Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes

Pain management is a crucial issue for athletes who train and compete at the highest performance levels. There are still evidence gaps for the use of analgesics for sports injuries despite the growing interest in training and competition settings. However, high-quality research is needed to determine the most appropriate and optimal timing and formulations in non-steroidal anti-inflammatory drug and opioid management, particularly given the strictness of anti-doping regulations. Indeed, the role of pharmacological therapy in reducing acute traumatic pain in athletes should still be addressed to minimize the timing of return to sport. Therefore, the aim of this comprehensive review was to summarize the current evidence about pain management in the setting of acute injury in elite athletes, providing the most informed strategy for pain relief and performance recovery.

Safety and Efficacy of Achilles Repair Using the Mini-Open Approach in Supine Versus Prone Position: A Retrospective Study

Purpose

Surgical repair of the Achilles tendon is a common procedure in cases of acute rupture. Open Achilles tendon surgery with a traditional extensile approach is most often performed in the prone position, but this can lead to numerous complications. The mini-open approach for repair in the supine position may avoid the risks of the prone position. The purpose of this study is to compare perioperative outcomes and differences in cost between patients undergoing acute Achilles rupture repair with mini-open approach, incision of approximately 3 cm, in the supine position versus traditional approach in the prone position.

Methods

Patients who underwent surgical repair of acute Achilles rupture at a single institution were retrospectively identified using Current Procedural Terminology (CPT) code 27650. Complication rates and the total cost charged to the insurance companies of both the supine and prone groups were calculated.

Results

A total of 80 patients were included for analysis, 26 supine and 54 prone. The difference in average total time in the operating room was statistically significant. The prone position took approximately 15% more time (118.7 minutes) compared to the supine position (100 minutes) (p = 0.001). While not statistically significant, the total cost for the supine group ($19,889) was less than the for the prone group ($21,722) (p = 0.153) Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and deep vein thrombosis (DVT) rate were also similar between the two groups. No patient in either group experienced re-rupture of the Achilles tendon within the first year of primary repair.

Conclusion

The mini-open approach in the supine position may be advantageous in the repair of acute Achilles rupture in that it reduces total time in the operating room and total cost while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.

What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Simultaneous comparison of the multiple treatment options using traditional study designs is problematic; multiarm clinical trials often are logistically constrained to small sample sizes, and traditional meta-analyses are limited to comparisons of only two treatments that have been compared in head-to-head trials. Network meta-analyses allow for simultaneous comparison of all existing treatments utilizing both direct (head-to-head comparison) and indirect (not previously compared head-to-head) evidence.

QUESTIONS/PURPOSES

We performed a network meta-analysis of randomized controlled trials (RCTs) to answer the following questions: Considering open repair, minimally invasive surgery (MIS) repair, functional rehabilitation, or primary immobilization for acute Achilles tendon ruptures, (1) which intervention is associated with the lowest risk of rerupture? (2) Which intervention is associated with the lowest risk of complications resulting in surgery?

METHODS

This study was conducted with methods guided by the Cochrane Handbook for Systematic Reviews of Interventions and is reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for incorporating network meta-analysis. Five databases and grey literature sources (such as major orthopaedic meeting presentation lists) were searched from inception to September 30, 2019. Included studies were RCTs comparing treatment of acute Achilles tendon ruptures using two or more of the following interventions: primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. We excluded studies enrolling patients with chronic ruptures, reruptures, and preexisting Achilles tendinopathy as well as studies with more than 20% loss to follow-up or less than 6 months of follow-up. Nineteen RCTs (1316 patients) were included in the final analysis. The mean number of patients per study treatment arm was 35 ± 16, mean age was 41 ± 5 years, mean sex composition was 80% ± 10% males, and mean follow-up was 22 ± 12 months. The four treatment groups were compared for the main outcomes of rerupture and complications resulting in operation. The analysis was conducted using random-effects Bayesian network meta-analysis with vague priors. Evidence quality was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation methodology. We found risk of selection, attrition, and reporting bias to be low across treatments, and we found the risk of performance and detection bias to be high. Overall risk of bias between treatments appeared similar.

RESULTS

We found that treatment with primary immobilization had a greater risk of rerupture than open surgery (odds ratio 4.06 [95% credible interval {CrI} 1.47 to 11.88]; p < 0.05). There were no other differences between treatments for risk of rerupture. Minimally invasive surgery was ranked first for fewest complications resulting in surgery and was associated with a lower risk of complications resulting in surgery than functional rehabilitation (OR 0.16 [95% CrI 0.02 to 0.90]; p < 0.05), open surgery (OR 0.22 [95% CrI 0.04 to 0.93]; p < 0.05), and primary immobilization (OR < 0.01 [95% CrI < 0.01 to 0.01]; p < 0.05). Risk of complications resulting in surgery was no different between primary immobilization and open surgery (OR 1.46 [95% CrI 0.35 to 5.36]). Data for patient-reported outcome scores and return to activity were inappropriate for pooling secondary to considerable clinical heterogeneity and imprecision associated with small sample sizes.

CONCLUSION

Faced with acute Achilles tendon rupture, patients should be counseled that, based on the best-available evidence, the risk of rerupture likely is no different across contemporary treatments. Considering the possibly lower risk of complications resulting in surgery associated with MIS repair, patients and surgeons must balance any benefit with the potential risks of MIS techniques. As treatments continue to evolve, consistent reporting of validated patient-reported outcome measures is critically important to facilitate analysis with existing RCT evidence. Infrequent but serious complications such as rerupture and deep infection should be further explored to determine whether meaningful differences exist in specific patient populations.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Photobiomodulation therapy increases collagen II after tendon experimental injury

A tendon is a mechanosensitive tissue that transmits muscle-derived forces to bones. Photobiomodulation (PBM), also known as low-level laser therapy (LLLT), has been used in therapeutic approaches in tendon lesions, but uncertainties regarding its mechanisms of action have prevented its widespread use. We investigated the response of PBM therapy in experimental lesions of the Achilles tendon in rats. Thirty adult male Wistar rats weighing 250 to 300 g were surgically submitted to bilateral partial transverse section of the Achilles tendon. The right tendon was treated with PBM, whereas the left tendon served as a control. On the third postoperative day, the rats were divided into three experimental groups consisting of ten rats each, which were treated with PBM (Konf, Aculas - HB 750), 780 nm and 80 mW for 20 seconds, three times/week for 7, 14 and 28 days. The rats were sacrificed at the end of the therapeutic time period. The Sca-1 was examined by immunohistochemistry and histomorphometry, and COLA1, COLA2 and COLA3 gene expression was examined by qRT-PCR. COLA2 gene expression was higher in PBM treated tendons than in the control group. The histomorphometric analysis coincided with increased number of mesenchymal cells, characterized by Sca-1 expression in the lesion region (p<0.001). PBM effectively interferes in tendon tissue repair after injury by stimulating mesenchymal cell proliferation and the synthesis of collagen type II, which is suggested to provide structural support to the interstitial tissues during the healing process of the Achilles tendon. Further studies are needed to confirm the role of PBM in tendon healing.

Resistance Exercises in Early Functional Rehabilitation for Achilles Tendon Ruptures Are Poorly Described: A Scoping Review

OBJECTIVES

To (1) describe which resistance exercises are used in the first 8 weeks of treatment for acute Achilles tendon rupture and (2) assess the completeness of reporting of the exercise descriptions.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the MEDLINE, Embase, CINAHL, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases.

STUDY SELECTION CRITERIA

Randomized controlled trials, cohort studies, and case series (10 or more participants) that reported using resistance exercise in the immobilization period in the first 8 weeks of treatment for acute Achilles tendon rupture were included.

DATA SYNTHESIS

Completeness of exercise description was assessed with the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier exercise descriptor framework.

RESULTS

Thirty-eight studies were included. Fifty-one resistance exercises were extracted and categorized as isometric exercises (n = 20), heel raises (n = 6), strengthening with external resistance (n = 13), or unspecified (n = 12). A median of 8 (interquartile range, 6-10) of a possible 19 CERT items was reported. The amount of items described of the 13 Toigo and and Boutellier exercise descriptors ranged from 0 to 11.

CONCLUSION

A variety of resistance exercises targeted at the ankle plantar flexors were used as part of early functional rehabilitation after Achilles tendon rupture. However, most studies provided inadequate description of resistance exercise interventions. J Orthop Sports Phys Ther 2020;50(12):681-691. Epub 23 Oct 2020. doi:10.2519/jospt.2020.9463.

Achilles Tendinosis Injuries-Tendinosis to Rupture (Getting the Athlete Back to Play)

Recreational athletes are susceptible to experiencing pain in the Achilles tendon, affecting their ability to complete daily activities. Achilles tendinosis is a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation, which can be categorized by location into insertional and noninsertional tendinosis. This condition is one that can be treated conservatively with great success or surgically for refractory cases. Currently, there is a lack of consensus regarding the best treatment options. This review aims to explore both conservative and operative treatment options for Achilles tendinopathy and Achilles tendon rupture.

A microfluidics-derived growth factor gradient in a scaffold regulates stem cell activities for tendon-to-bone interface healing

Treatment of tendon-to-bone interface injury has long been challenging in sports medicine. The major obstacle lies with the complicated three-layer structure of the tissue that consists of a bone region with osteocytes, a tendon region with tenocytes and a transitional region with chondrocytes. Conventional tissue engineering approaches using simply biomaterial scaffolds, stem cells and combinations of them had limited abilities to reconstruct the gradient structure with normal biomechanical properties. We herein aim to construct a three-layer structure with bone marrow-derived stem cells and tendon stem cells cultured in a decellularized tendon scaffold, through application of a gradient of biological cues in the longitudinal direction of the scaffold that guides the stem cells to differentiate and remodel the extracellular matrix in response to different medium concentrations in different regions. A microfluidic chip, on which a tree-like flow pattern was implemented, was adopted to create the concentration gradient in a dichotomous manner. We screened for an optimized seeding ratio between the two stem cell types before incubation of the scaffold in the medium concentration gradient and surgical implantation. Histology and immunohistochemistry assessments, both qualitatively and semi-quantitatively, showed that the microfluidic system provided desired guidance to the seeded stem cells that the healing at 8-week post-implantation presented a similar structure to that of a normal tendon-to-bone interface, which was outstanding compared to treatments without gradient guidance, stem cells or scaffolds where chaotic and fibrotic structures were obtained. This strategy offers a potentially translational tissue engineering approach for better outcomes in tendon-to-bone healing.

Treatment of Acute Achilles Tendon Rupture

There is no clear consensus on the optimal treatment of acute Achilles tendon rupture. Recently, studies have demonstrated the critical role of functional rehabilitation in the treatment of ruptured Achilles tendons. Hence, conservative treatment is preferred by a growing number of surgeons seeking to treat the condition without the risk of complications from surgery. However, operative treatment is still considered as a more reliable treatment option for acute Achilles tendon rupture. In this review article, we provide an overview of recent treatment strategies for acute rupture of the Achilles tendon.

Repair of Combined Insertional and Midsubstance Achilles Tendon Ruptures

Complex combined tears of the insertion and midsubstance of the Achilles tendon are rare injuries that are challenging to diagnose and treat. The author describes a novel technique for combined insertional and midsubstance Achilles repair that decreases proximal soft tissue dissection, restores musculotendinous length, and directly fixes tendon to bone in a strong, knotless fashion to allow for early mobilization and functional recovery. [Orthopedics. 2020; 43(1):e57-e64.].

Treatment modalities for hip and knee osteoarthritis: A systematic review of safety

Current guidelines on the management of hip and knee osteoarthritis (OA) do not compare safety of treatment modalities. We therefore systematically reviewed 20 studies investigating mortality and serious complications of both medical and surgical treatments for hip and knee OA using PubMed, Scopus, Web of Knowledge and Google Scholar. Mortality was the highest for naproxen (hazard ratio (HR) = 3 (1.9, 4.6)) and lowest for total hip replacement (relative risk (RR) = 0.7 (0.7, 0.7)). Highest gastrointestinal complications were reported for diclofenac (odds ratio (OR) = 4.77 (3.94, 5.76)) and lowest for total knee replacement (HR = 0.6 (0.49, 0.75)). Ibuprofen had the highest renal complications (OR = 2.32 (1.45, 3.71)), whereas celecoxib had the highest cardiovascular risk (OR = 2.26 (1, 5.1)) and lowest was for tramadol (RR = 1.1 (0.87, 1.4)). Results show that medical management of hip and knee OA, particularly with non-steroidal anti-inflammatory drugs, may carry higher mortality compared to surgery. Careful consideration should be given to medical management taking into account known co-morbidities.

Quantitative comparison of three rat models of Achilles tendon injury: A multidisciplinary approach

The Achilles tendon, while the strongest and largest tendon in the body, is frequently injured. Inconclusive evidence exists regarding treatment strategies for both complete tears and partial tears. Well-characterized animal models of tendon injury are important for understanding physiological processes of tendon repair and testing potential therapeutics. Utilizing three distinct models of rat Achilles tendon injury, the objective of this study was to define and compare the effects and relative impact on tendon properties and ankle function of both tear severity (complete tear versus partial tear, both with post-operative immobilization) and immobilization after partial tear (partial tear with versus without immobilization). We hypothesized that a complete tear would cause inferior post-injury properties compared to a partial tear, and that immediate loading after partial tear would improve post-injury properties compared to immobilization. All models were reproducible and had distinct effects on measured parameters. Injury severity drastically influenced tendon healing, with complete tear causing decreased ankle mobility and tendon mechanics compared to partial tears. One week of plantarflexion immobilization had a strong effect on animals receiving a partial tear. Tendons with partial tears and immobilization failed early during fatigue cycling three weeks post-injury. Partial tear without immobilization had no effect on ankle range of motion through dorsiflexion at any time point compared to the pre-surgery value, while partial tear with immobilization demonstrated diminished function at all post-injury time points. All three models of Achilles injury could be useful for tendon healing investigations, chosen based on the prospective applications of a potential therapeutic.

Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines

PURPOSE

This study aimed to describe and analyse usual care of Achilles tendon ruptures (ATRs) by orthopaedic surgeons and trauma surgeons in the Netherlands.

METHODS

A nationwide online survey of ATR management was sent to all consultant orthopaedic and trauma surgeons in the Netherlands, requesting participation of those involved in ATR management. Data on individual characteristics and the entire ATR management (from diagnosis to rehabilitation) were gathered. Consensus was defined as ≥ 70% agreement on an answer.

RESULTS

A total of 91 responses (70 orthopaedic surgeons and 21 trauma surgeons) were analysed. There was consensus on the importance of the physical examination in terms of diagnosis (> 90%) and a lack of consensus on diagnostic imaging (ultrasound/MRI). There was consensus that non-surgical treatment is preferred for sedentary and systemically diseased patients and surgery for patients who are younger and athletic and present with larger tendon gap sizes. There was consensus on most of the non-surgical methods used: initial immobilisation in plaster cast with the foot in equinus position (90%) and its gradual regression (82%) every 2 weeks (85%). Only length of immobilisation lacked consensus. Surgery was generally preferred, but there was a lack of consensus on the entire followed protocol. Orthopaedic and trauma surgeons differed significantly on their surgical (p = 0.001) and suturing techniques (p = 0.002) and methods of postoperative immobilisation (p < 0.001). Orthopaedic surgeons employed open repair and Bunnell sutures more often, whereas trauma surgeons used minimally invasive approaches and bone anchors. Rehabilitation methods and advised time until weight-bearing and return to sport varied. Orthopaedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment (p = 0.001) and surgery (p = 0.002) than trauma surgeons.

CONCLUSION

This is the first study to describe the entire ATR management. The results show a lack of consensus and wide variation in management of ATRs in the Netherlands. This study shows that especially the methods of the perioperative and rehabilitation phases were inconclusive and differed between orthopaedic and trauma surgeons. Further research into optimal ATR management regimens is recommended. In addition, to achieve uniformity in management more multidisciplinary collaboration between Dutch and international surgeons treating ATRs is needed.

LEVEL OF EVIDENCE

Cross-sectional survey, Level V.

Protocol for treatment of Achilles tendon ruptures; a systematic review with network meta-analysis

BACKGROUND

Achilles tendon ruptures are a common injury and are increasing in incidence. Several management strategies exist for both non-operative and operative care, with each strategy offering unique risks and benefits. Traditional pairwise meta-analyses have been performed to compare management strategies; however, all treatment options have never been integrated in a single analysis. Network meta-analysis (NMA) is a generalization of pairwise meta-analysis, which allows for the comparison of multiple interventions based on all available direct and indirect evidence. The objectives of this review are to synthesize the evidence on the management options for acute Achilles tendon rupture and identify which treatment gives the best functional outcomes.

METHODS

A systematic review with NMA is planned. An electronic literature search will be performed in conjunction with an experienced information specialist in MEDLINE, EMBASE, CINAHL, PEDro, and the Cochrane Central Register of Controlled Trials. We will include randomized controlled trials with a minimum 6-month follow-up. Two independent reviewers will screen citations for eligibility, extract study data, and perform risk of bias assessments. The primary outcome will be disease-specific functional outcome scores (AOFAS, Leppilahti, modified Leppilahti) at 1 year. Secondary outcomes will include complications (re-rupture, sural nerve injury, wound complications, deep infection, secondary surgeries), strength, range of motion, return to work, return to sport, and quality-of-life measures (including the SF-36 questionnaire). Traditional pairwise meta-analyses will be performed for all direct comparisons where evidence is available, and NMAs will subsequently be performed where possible to compare all management strategies.

DISCUSSION

The data generated from this review will provide health-care providers with a clear evidence synthesis of all Achilles tendon rupture management strategies. Additionally, these data will be incorporated into the development of a patient decision aid to assist patients and clinicians in making a preference-based decision when faced with an Achilles tendon rupture.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018093033 .

Reliability and validity of the Polish version of the Achilles tendon Total Rupture Score

PURPOSE

The aim of this study was to perform the translation and cross-cultural adaptation of the Achilles tendon Total Rupture Score (ATRS) into Polish version, and to evaluate its reliability and validity.

METHODS

The ATRS was translated into Polish language according to the Beaton recommendations. A total number of 71 patients previously treated surgically (from 2011 to 2015), due to the Achilles tendon rupture, were enrolled in this study. ATRS-Polish was performed twice within a period of 5-10 days. To evaluate test-retest reliability, intra-rater coefficient (ICC) was calculated. Construct validity was determined by the Spearman's rank coefficient correlation between the ATRS-Polish and a Polish version of EQ-5D-5L questionnaire.

RESULTS

Test-retest reliability was found to be excellent (ICC 0.9). The mean and standard deviation of the first and second assessment amounted 87.4 ± 14.0 and 88.4 ± 13.2, respectively. Construct validity analysis showed a strong correlation between the ATRS and the EQ-5D-5L score (r = - 0.69.) and moderate correlation between ATRS and actual comfort (r = 0.47).

CONCLUSIONS AND PERSPECTIVES

Polish version of the Achilles tendon Total Rupture Score was found to be reliable and valid.

LEVEL OF EVIDENCE

Level II.

The biomechanical study of rupture of Achilles Tendon and repair by different suture techniques

Objective

To study the biomechanical properties of different suture methods, and to provide evidence for the clinical application of this suture methods in repairing acute Achilles tendon rupture.

Methods

Twenty four fresh frozen cadaver Achilles tendon specimens were collected and randomly divided into three groups (n=8), Group-A Bunnell suture method, Group-B Bosworth suture and Group-C anchor suture respectively. 5 N tensions were applied to tighten the tendon. The actual length of the tendon between the upper and lower clips was measured with a ruler. The length of the long axis and the short axis of the three sections of the tendon was measured by vernier caliper. The cross sectional area of the tendon was calculated according to the elliptical area formula and the mean value was obtained.

Results

There was no significant difference in the length and cross-sectional area of each tendon among three groups (F=0.26, P=0.86; F=0.09, P=0.96). There was no significant difference in the maximum load of tendon and failure displacement in Group A and B (P>0.05). The maximal load of Group-C was significantly larger than that of Group A and B (P<0.05), and there was no significant difference between the failure displacement and Group A and B (P>0.05).

Conclusion

Three suture methods can provide good biomechanical properties, but the anchor suture is more effective in solving the shortcomings of traditional methods. It is a safe and effective method, and is worthy of promotion.

Outcomes and Complications Following Endoscopically Assisted Percutaneous Achilles Tendon Repair

PURPOSE

To review functional and clinical outcomes as well as complications in patients who underwent endoscopically assisted percutaneous Achilles tendon repair using 4-strand core suture configuration via a 6-portal technique.

METHODS

A retrospective chart review with prospectively collected data was performed in 23 consecutive patients who underwent endoscopically assisted percutaneous Achilles tendon repair between 2008 and 2015. The minimum follow-up to be included in the study was 24 months. The primary outcome was Foot and Ankle Ability Measure (FAAM), Activities of Daily Living (ADL) and Sports subscales; Short Form-36 (SF-36), physical and mental component summaries (PCS and MCS); and visual analog scale (VAS). The secondary outcomes included tourniquet time, recovery time, and complications.

RESULTS

Twenty-three patients (18 males and 5 females, all unilateral) with the mean age of 36.7 years were included and 6 patients were repaired using an open technique because they did not meet the inclusion criteria owing to presenting late in the clinic (injury more than 2-3 weeks). The average time to final follow-up was 54.1 months. The average tourniquet time was 41.3 minutes. There was significant improvement of VAS (7.9/10 to 0.1/10), SF-36 (PCS, 32.5-44.7, and MCS, 47.9-51.4), and FAAM (ADL, 26.1.0-83.0, and Sports, 0-61.7). The average time to return to activities of daily living, work, and sports were 8.0 weeks, 8.8 weeks, and 5.7 months, respectively. The postoperative morbidity included superficial wound infection at the portal (1 patient with underlying type 2 diabetes, 4.3%) and there was no rerupture, deep vein thrombosis, sural nerve injury, and painful scar in this study.

CONCLUSIONS

Endoscopically assisted percutaneous Achilles tendon repair has significant improvement in terms of functional outcomes as measured with the FAAM, SF-36, and VAS. This technique is safe and feasible with minimal postoperative pain and morbidities, early return to activities, and satisfactory functional outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Treatment of Neglected Achilles Tendon Ruptures with Interpositional Allograft

Although most astute clinicians can diagnose Achilles tendon ruptures by physical examination alone, more than 20% are not accurately diagnosed in a timely fashion. The definition of a "chronic" Achilles tendon rupture in foot and ankle literature varies widely: from 4 to 10 weeks status after injury. Neglected or chronic Achilles tendon ruptures can be significantly disabling to patients if the muscle-tendon unit is stretched beyond its normal passive limit. There are a variety of treatment options that all have valid uses but have not been proven to be superior to one another.

Postoperative Foot and Ankle MR Imaging

MR imaging has an important role in the evaluation of the postoperative foot and ankle. In this article, a variety of operative techniques and postoperative findings in the foot and ankle are described, including tendon and ligament reconstruction, as well as the treatment of tarsal coalition and Morton neuroma. The role of MR imaging in the assessment of complications of foot and ankle surgery is also detailed.

Surgical Management of the Aging Athlete

Epidemiologic data show that the number of middle aged (>40 yr) and elderly (>65 yr) individuals continues to increase steadily, creating an expanding need for sports medicine care. Management of injuries in this subset of patients is expanding well beyond sustaining a patient's ability to perform activities of daily living. In fact, many older individuals increasingly expect to maintain reasonably high activity levels throughout their lifespan as well as after musculoskeletal injury. While a number of the emerging physiologic benefits of physical activity in older patients have been outlined, no recent review has outlined the current best surgical techniques, rehabilitation protocols, and return-to-sport recommendations for older athletes after soft-tissue repair or reconstruction as well as joint replacement. The goal of orthopaedic care in the elderly patient is shifting from simple pain relief toward return to athletic activity.

Mechanical, histological, and functional properties remain inferior in conservatively treated Achilles tendons in rodents: Long term evaluation

Conservative treatment (non-operative) of Achilles tendon ruptures is suggested to produce equivalent capacity for return to function; however, long term results and the role of return to activity (RTA) for this treatment paradigm remain unclear. Therefore, the objective of this study was to evaluate the long term response of conservatively treated Achilles tendons in rodents with varied RTA. Sprague Dawley rats (n=32) received unilateral blunt transection of the Achilles tendon followed by randomization into groups that returned to activity after 1-week (RTA1) or 3-weeks (RTA3) of limb casting in plantarflexion, before being euthanized at 16-weeks post-injury. Uninjured age-matched control animals were used as a control group (n=10). Limb function, passive joint mechanics, tendon properties (mechanical, histological), and muscle properties (histological, immunohistochemical) were evaluated. Results showed that although hindlimb ground reaction forces and range of motion returned to baseline levels by 16-weeks post-injury regardless of RTA, ankle joint stiffness remained altered. RTA1 and RTA3 groups both exhibited no differences in fatigue properties; however, the secant modulus, hysteresis, and laxity were inferior compared to uninjured age-matched control tendons. Despite these changes, tendons 16-weeks post-injury achieved secant stiffness levels of uninjured tendons. RTA1 and RTA3 groups had no differences in histological properties, but had higher cell numbers compared to control tendons. No changes in gastrocnemius fiber size or type in the superficial or deep regions were detected, except for type 2x fiber fraction. Together, this work highlights RTA-dependent deficits in limb function and tissue-level properties in long-term Achilles tendon and muscle healing.

Acute Rupture Open Repair Techniques

Achilles tendon injuries can be serious injuries requiring either operative or nonoperative management. For appropriate surgical candidates, operative intervention may provide lower rerupture rates and adequate end-to-end tendon healing. Our preference is an open Achilles tendon repair, specifically a limited open technique using the PARS device (Arthrex, Naples, FL). Postoperatively, we use functional rehabilitation and early range of motion. Although the current literature remains controversial regarding operative versus nonoperative management, the authors have obtained satisfactory results in appropriately chosen surgical candidates.

Management of acute Achilles tendon rupture with tendon-bundle technique

Objective * These authors contributed equally to this work. To explore tendon-bundle technique for treating Achilles tendon rupture with no defects. Methods Patients with full unilateral Achilles tendon rupture with no defects were included. The Achilles tendon medial edge surgical repair approach was used, revealing horsetail-like rupture bundles. Tendon bundles were anatomically realigned and repaired end-to-end using 5-0 sutures. Patients were followed-up for 1 year, and assessed for differences between the repaired versus healthy limb. Results Out of 24 patients (18 male, 6 female; aged 19-56 years) at 1 year following surgery, mean American Orthopaedic Foot and Ankle Society score was 92.4 ± 5.9; mean differences between the surgically repaired versus contralateral side in dorsiflexion and plantarflexion angle were 3.5 ± 2.3° and 5.6 ± 3.2°, respectively; mean difference in calf circumference between the two sides was 0.9 ± 0.5 cm; and mean increase in Achilles tendon width versus the healthy side was 0.8 ± 0.2 cm. By 1 year post-surgery, there were no significant between-side differences in dorsiflexion and plantarflexion angle, or calf circumference. Conclusions Tendon-bundle surgery resulted in good ankle function restoration and low complication rates. Tendon-bundle surgery may reduce blood supply destruction and maximally preserve Achilles tendon length, and may be effective for treating Achilles tendon rupture with no defects.

Nonsurgical treatment and early return to activity leads to improved Achilles tendon fatigue mechanics and functional outcomes during early healing in an animal model

Achilles tendon ruptures are common and devastating injuries; however, an optimized treatment and rehabilitation protocol has yet to be defined. Therefore, the objective of this study was to investigate the effects of surgical repair and return to activity on joint function and Achilles tendon properties after 3 weeks of healing. Sprague-Dawley rats (N = 100) received unilateral blunt transection of their Achilles tendon. Animals were then randomized into repaired or non-repaired treatments, and further randomized into groups that returned to activity after 1 week (RTA1) or after 3 weeks (RTA3) of limb casting in plantarflexion. Limb function, passive joint mechanics, and tendon properties (mechanical, organizational using high frequency ultrasound, histological, and compositional) were evaluated. Results showed that both treatment and return to activity collectively affected limb function, passive joint mechanics, and tendon properties. Functionally, RTA1 animals had increased dorsiflexion ROM and weight bearing of the injured limb compared to RTA3 animals 3-weeks post-injury. Such functional improvements in RTA1 tendons were evidenced in their mechanical fatigue properties and increased cross sectional area compared to RTA3 tendons. When RTA1 was coupled with nonsurgical treatment, superior fatigue properties were achieved compared to repaired tendons. No differences in cell shape, cellularity, GAG, collagen type I, or TGF-β staining were identified between groups, but collagen type III was elevated in RTA3 repaired tendons. The larger tissue area and increased fatigue resistance created in RTA1 tendons may prove critical for optimized outcomes in early Achilles tendon healing following complete rupture. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2172-2180, 2016.

Clinical Outcomes and Complications of Percutaneous Achilles Repair System Versus Open Technique for Acute Achilles Tendon Ruptures

BACKGROUND

Limited incision techniques for acute Achilles tendon ruptures have been developed in recent years to improve recovery and reduce postoperative complications compared with traditional open repair. The purpose of this retrospective cohort study was to analyze the clinical outcomes and postoperative complications between acute Achilles tendon ruptures treated using a percutaneous Achilles repair system (PARS [Arthrex, Inc, Naples, FL]) versus open repair and evaluate the overall outcomes for operatively treated Achilles ruptures.

METHODS

Between 2005 and 2014, 270 consecutive cases of operatively treated acute Achilles tendon ruptures were reviewed (101 PARS, 169 open). Patients with Achilles tendinopathy, insertional ruptures, chronic tears, or less than 3-month follow-up were excluded. Operative treatment consisted of a percutaneous technique (PARS) using a 2-cm transverse incision with FiberWire (Arthrex, Inc, Naples, FL) sutures or open repair using a 5- to 8-cm posteromedial incision with FiberWire in a Krackow fashion reinforced with absorbable sutures. Patient demographics were recorded along with medical comorbidities, activity at injury, time from injury to surgery, length of follow-up, return to baseline activities by 5 months, and postoperative complications.

RESULTS

The most common activity during injury for both groups was basketball (PARS: 39%, open: 47%). A greater number of patients treated with PARS were able to return to baseline physical activities by 5 months compared with the open group (PARS: 98%, open: 82%; P = .0001). There were no significant differences (P > .05) between groups in rates of rerupture (P = 1.0), sural neuritis (P = .16), wound dehiscence (P = .74), superficial (P = .29) and/or deep infection (P = .29), or reoperation (P = .13). There were no deep vein thromboses (DVTs) or reruptures in either group. In the PARS group, there were no cases of sural neuritis, 3 cases (3%) of superficial wound dehiscence, and 2 reoperations (2%) for superficial foreign-body reaction to FiberWire. In the open group, there were 5 cases (3%) of sural neuritis, 7 cases (4%) of superficial wound dehiscence, 3 cases (2%) of superficial infection, and 3 reoperations (2%) for deep infection.

CONCLUSION

The present study reports the largest single-center series of acute Achilles tendon ruptures in the literature with lower complication rates for operatively treated Achilles ruptures compared with previous reports. The overall complication rate for all operatively treated Achilles ruptures was 8.5% with no reruptures, and most patients (88%) were able to return to baseline activities by 5 months after surgery. There were no significant differences in rates of postoperative complications between PARS and open repair for acute Achilles tendon ruptures.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Turkish version of the Achilles tendon Total Rupture Score: cross-cultural adaptation, reliability and validity

PURPOSE

The Achilles tendon Total Rupture Score (ATRS) is a questionnaire designed to evaluate pain, symptoms, function and physical activity after Achilles tendon rupture. The purpose of this study was to translate and culturally adapt the ATRS into Turkish and to determine its reliability and validity.

METHODS

The ATRS was translated into Turkish in accordance with the stages recommended by Beaton. Seventy-four patients (73 male; average age: 42.3 ± 7.6; range 27-63 years) suffering from previous Achilles tendon ruptures were included for the study. The ATRS-Turkish was administered twice at 7-14 days intervals with 52 of the 74 patients (51 male, average age: 41.8 ± 7.8) to assess the test-retest reliability. Cronbach's α was used for internal consistency, and the inter-rater correlation coefficient (ICC) was used to calculate the test-retest reliability. The Turkish Short-Form-12 (SF-12) and the Foot and Ankle Outcome Score (FAOS) were employed for validity estimation.

RESULTS

The internal consistency (Cronbach's α = 0.95) and the test-retest reliability (ICC = 0.98) were excellent. The mean interval between the two tests was 7.1 ± 3.1 days. The mean and standard deviation of the first and second assessment of the ATRS were 78.1 ± 23.1 and 79.1 ± 22.5, respectively. The correlation coefficient between the ATRS-Turkish and the FAOS subscales (pain, symptoms, activities of daily living, sports and recreational activities, and quality of life) were determined (r = 0.82, r = 0.66, r = 0.79, r = 0.83 and r = 0.60, respectively, p < 0.0001). The ATRS-Turkish displayed good correlation with the SF-12 physical component score (r = 0.63, p < 0.001) and no correlation with the SF-12 mental component score (r = 0.22, p = 0.06).

CONCLUSION

The ATRS-Turkish was found to be reliable and valid for outcome evaluation after Achilles tendon ruptures.

LEVEL OF EVIDENCE

II.

The utility of clinical measures for the diagnosis of achilles tendon injuries: a systematic review with meta-analysis

OBJECTIVE

To summarize and evaluate the current diagnostic accuracy of clinical measures used to diagnose Achilles tendon injuries.

DATA SOURCES

A literature search of MEDLINE, CINAHL, and EMBASE databases was conducted with key words related to diagnostic accuracy and Achilles tendon injuries.

STUDY SELECTION

Original research articles investigating Achilles tendon injuries against an acceptable reference standard were included.

DATA EXTRACTION

Three studies met the inclusion criteria. Quality assessment was conducted using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects models were used to pool sensitivity (SN), specificity (SP), and diagnostic odds ratios with their 95% confidence intervals (CIs).

DATA SYNTHESIS

The SN and negative likelihood ratio (-LR) values for Achilles tendon rupture measures ranged from 0.73 (95% CI = 0.65, 0.81) and 0.30 (95% CI = 0.23, 0.40) to 0.96 (95% CI = 0.93, 0.99) and 0.04 (95% CI = 0.02, 0.10), respectively, whereas SP and positive likelihood ratio (+LR) values ranged from 0.85 (95% CI = 0.72, 0.98) and 6.29 (95% CI = 2.33, 19.96) to 0.93 (95% CI = 0.84, 1.00) and 13.71 (95% CI = 3.54, 51.24), respectively, with the highest SN and SP both reported in the calf-squeeze test. The SN and -LR values for Achilles tendinopathy measures ranged from 0.03 (95% CI = 0.00, 0.08) and 0.97 (95% CI = not reported) to 0.89 (95% CI = 0.75, 0.98) and 0.19 (95% CI = not reported), whereas SP and +LR values ranged from 0.58 (95% CI = 0.38, 0.77) and 2.12 (95% CI = not reported) to 1.00 (95% CI = 1.00, 1.00) and infinity, respectively, with the highest SN and SP reported for morning stiffness and palpation for crepitus. Pooled analyses demonstrated similar diagnostic properties in all 3 clinical measures (arc sign, palpation, and Royal London Hospital test), with SN and -LR ranging from 0.42 (95% CI = 0.23, 0.62) and 0.68 (95% CI = 0.50, 0.93), respectively, for the arc sign, to 0.64 (95% CI = 0.44, 0.81) and 0.48 (95% CI = 0.29, 0.80), respectively, for palpation. Pooled SP and +LR ranged from 0.81 (95% CI = 0.65, 0.91) and 3.15 (95% CI = 1.61, 6.18), respectively, for palpation, to 0.88 (95% CI = 0.74, 0.96) SP for the arc sign and 3.84 (95% CI = 1.69, 8.73) +LR for the Royal London Hospital test.

CONCLUSIONS

Most clinical measures for Achilles tendon injury have greater diagnostic than screening capability.

Is Operative Treatment of Achilles Tendon Ruptures Superior to Nonoperative Treatment?: A Systematic Review of Overlapping Meta-analyses

BACKGROUND

Multiple meta-analyses have been published in efforts to determine whether operative or nonoperative treatment of Achilles tendon ruptures affords superior outcomes.

PURPOSE

To perform a systematic review of overlapping meta-analyses comparing operative and nonoperative treatment of Achilles tendon ruptures to determine which meta-analyses provide the highest level of evidence for treatment recommendations.

STUDY DESIGN

Systematic review; Level of evidence, 3.

METHODS

A systematic review of the literature was performed to identify meta-analyses that fit the study inclusion criteria. Data were extracted from these meta-analyses regarding patient outcomes and reruptures. Meta-analysis quality was assessed using the Oxman-Guyatt and QUOROM (Quality of Reporting of Meta-analyses) systems. The Jadad algorithm was applied to determine the meta-analyses with the highest level of evidence.

RESULTS

Nine meta-analyses met the eligibility criteria, with all but 1 study including level 1 evidence. A total of 5842 patients were included. Seven studies found a higher rate of rerupture in the nonoperative group but a higher rate of complications in the operative group. One study found no differences in rerupture or complication rates, and 1 study found surgery decreased rerupture rates only when compared with nonoperative treatment without a functional brace. Three studies also identified an earlier return to work in the operative group. Almost all (8 of 9) of the meta-analyses had Oxman-Guyatt scores >3, indicating no major flaws.

CONCLUSION

Operative treatment of Achilles tendon ruptures decreases rerupture rates but increases the risk for minor complications when compared with nonoperative treatment. Additionally, surgical treatment may allow earlier return to work.

Achilles tendons from decorin- and biglycan-null mouse models have inferior mechanical and structural properties predicted by an image-based empirical damage model

Achilles tendons are a common source of pain and injury, and their pathology may originate from aberrant structure function relationships. Small leucine rich proteoglycans (SLRPs) influence mechanical and structural properties in a tendon-specific manner. However, their roles in the Achilles tendon have not been defined. The objective of this study was to evaluate the mechanical and structural differences observed in mouse Achilles tendons lacking class I SLRPs; either decorin or biglycan. In addition, empirical modeling techniques based on mechanical and image-based measures were employed. Achilles tendons from decorin-null (Dcn(-/-)) and biglycan-null (Bgn(-/-)) C57BL/6 female mice (N=102) were used. Each tendon underwent a dynamic mechanical testing protocol including simultaneous polarized light image capture to evaluate both structural and mechanical properties of each Achilles tendon. An empirical damage model was adapted for application to genetic variation and for use with image based structural properties to predict tendon dynamic mechanical properties. We found that Achilles tendons lacking decorin and biglycan had inferior mechanical and structural properties that were age dependent; and that simple empirical models, based on previously described damage models, were predictive of Achilles tendon dynamic modulus in both decorin- and biglycan-null mice.

Functional Treatment or Cast Immobilization After Minimally Invasive Repair of an Acute Achilles Tendon Rupture: Prospective, Randomized Trial

BACKGROUND

Operative repair of an acute Achilles tendon rupture (ATR) reduces the risk of re-rupture and has therefore gained popularity as a standard treatment for ATR, especially in the young and physically active patient. There is ongoing controversy over the best surgical technique and postoperative treatment. In this prospective, randomized trial, we compared cast immobilization and functional treatment with early mobilization and weightbearing after using a minimally invasive surgical technique in patients with ATR.

METHODS

All patients with ATR were included. Exclusion criteria were systemic immunosuppressive therapy, re-ruptures, and severe comorbidity. All included patients underwent minimally invasive surgery, after which a below-knee splint with the foot in 10 degrees of plantar flexion was applied for the first week. Patients were then randomized to the cast immobilization group (IG) for 6 weeks or to the functional group (FG) for 6 weeks. Sixty patients were included. Median age was 43 years (range, 19-65), and 78% were male. Most ATRs were sports related. Data were collected preoperatively and during the outpatient checks at 1, 3, and 6 weeks; 3 and 6 months; and 1 year. Outcome parameters were return to work or sport, complications including re-rupture, Achilles rupture performance score (ARPS), loss of strength, range of motion, subjective result, and quality-of-life (QoL) scores.

RESULTS

In our follow-up period, we did not see differences in strength, QoL scores, return to work or sports, or ARPS between the 2 treatment groups. The patients in the FG reported more complaints, mostly pain, in the first weeks after surgery, probably because of the exercise program starting 1 week postsurgery. The overall complication rate was low. In each group, we had 1 re-rupture; in the IG, however, 2 patients had a deep venous thrombosis, despite low-molecular-weight heparin.

CONCLUSION

The minimally invasive repair of ATR was a safe and reliable technique with good results. Early mobilization seemed to be as safe as more traditional postoperative immobilization with equal patient satisfaction. Although not significantly different, we saw more major complications in the IG.

LEVEL OF EVIDENCE

Level I, prospective randomized trial.