Surgical versus non-surgical treatment for acute Achilles' tendon rupture. A systematic review of literature and meta-analysis

Decellularised amniotic membrane-TDSCs composite promotes Achilles tendon healing

Adhesions and poor healing are major complications after Achilles tendon injury, and there is no effective solution to this problem. The purpose of this study is to determine whether the biomimetic peritoneurosis can solve the above problems in the process of Achilles tendon healing; This study investigated the adhesion and proliferation of tendon-derived stem cells (TDSCs) on dAM in vitro, as well as their tenogenic differentiation. The effects of Achilles tendon rupture on tendon regeneration were assessed in vivo by using an Achilles tendon rupture model in rats; Finally, from in vitro mRNA transcriptome sequencing combined with in vivo Achilles tendon protein to omics analysis to explore the repair mechanism of Achilles tendon rupture. Student's t-tests were used to assess the significance of observed differences between the two experimental groups. Multiple groups were compared using one-way analysis of variances (ANOVAs), followed by post hoc Bonferroni comparisons. The main findings of this study are that cell adhesion, proliferation, and differentiation of TDSCs were enhanced by dAM. Implanted dAM + TDSCs significantly accelerated tendon regeneration in vivo. In addition, extracellular matrix-related differential genes and proteins were screened by mRNA transcriptometry in vitro and proteomic analysis of Achilles tendon in vivo, and ERK signaling pathway was further explored to participate in the repair of Achilles tendon rupture. The dAM-TDSCs composite biomimetic peritendinous membrane material can effectively promote the healing of Achilles tendon. It provides a new direction for the development of biomimetic peritendinous membrane materials.

Validation of a Composite Outcome Score for Assessing Return to Sports After Achilles Tendon Repair

BACKGROUND

The Ankle-GO is a composite outcome score based on 4 functional tests and 2 patient-reported outcome measures. It was initially described and validated for its ability to predict return to sports (RTS) at the same level of play after lateral ankle sprains.

PURPOSE/HYPOTHESIS

The main aim of this study was to assess the psychometric properties of the Ankle-GO in patients after Achilles tendon repair. The second objective was to evaluate its ability to predict RTS at the same level of play. It was hypothesized that this composite outcome score is a valid and reliable tool that is able to discriminate and predict the level of RTS at 9 months after Achilles tendon repair.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This was a prospective multicenter study. Patients who were active in sports and underwent primary acute Achilles tendon repair between April 2021 and December 2022 were included. A control group comprising 30 participants with no history of lower limb injuries was also evaluated. After standard rehabilitation for the first 2 months, the Ankle-GO was administered at 6 and 9 months after repair by the same experienced physical therapist. During testing, the patients were asked whether they were able to practice their main sport again and, if so, whether at the same or a lower level of play. A comparison between control participants and patients at 9 months after surgery was performed.

RESULTS

A total of 50 patients (24 women and 26 men), with a mean age of 38.3 ± 10.1 years, were included. No patients were lost to follow-up at 9 months. The Ankle-GO score at 6 months was 10.7 ± 4.8. At 9 months, the score had risen by 4.8 points. All participants scored above the minimum threshold. The minimum score achieved was 3 points (n = 5 [10%]). Only 1 patient (2%) obtained the maximum score (25 points). There was a significant difference in the Ankle-GO score between patients at 6 and 9 months and between control participants and patients at 9 months after Achilles tendon repair. Of the 50 patients included in the study, 14 (28%) returned to their preinjury level of sport at 9 months. The ability of the Ankle-GO score at 6 months to predict RTS at the preinjury level at 9 months was good (area under the curve = 0.71 [95% CI, 0.56-0.85]; P < .01). A Youden index of 0.42 was observed for a cut-off score of 8 points, which corresponds to a sensitivity of 81.8% and a specificity of 41.2%.

CONCLUSION

The Ankle-GO is a valid tool to evaluate and discriminate patients during the RTS continuum after Achilles tendon repair and to predict RTS at the same level at 9 months after surgery. This composite outcome score assesses ankle function and the patient's psychological readiness to avoid premature RTS and worsening of the injury. Further studies are needed to assess its value in identifying and predicting patients at risk of a recurrence.

Achilles Tendon Rupture Treatment Systematic Review and Meta-analysis

Background

Acute Achilles tendon rupture (ATR) has increased in recent decades, reflecting the longer life expectancy and higher levels of activity. Surgical intervention has been the main treatment, but recently there has been growing interest in nonoperative approaches. Study compares surgical and conservative treatment of acute ATR, examining demographic data, rerupture rate, complications, and functional scale Achilles Total Tendon Rupture Score (ATRS).

Methods

A literature review was conducted including randomized clinical trials and prospective cohorts. RevMan software was employed to ascertain the I² heterogeneity, with a view to determining whether a fixed or random effects model should be used for meta-analysis. The results were expressed as either the mean difference or relative risk (RR), as appropriate, with 95% CI.

Results

Ten studies, published after 2010, were included in the analysis. Of the total 1327 participants, 57.8% received surgical treatment and 42.2% nonsurgical treatment. The follow-up was between 12-24 months. The rerupture rate was lower in surgical treatment (RR 0.28, 95% CI 0.15-0.50; P < .0001), although this was accompanied by a higher risk of complications (RR 2.39, 95% CI 1.57-3.63; P < .0001). The patient satisfaction was comparable between the 2 treatment groups, with no statistically significant difference on the ATRS scale (MD 0.87, 95% CI -1.18 to 2.92; P = .40).

Conclusion

Surgical repair of acute ATR significantly reduces the risk of rerupture but it is associated with a higher rate of complications. Furthermore, there are no significant differences in the various functional scales in terms of patient satisfaction between the 2 treatments.

Level of Evidence

II, meta-analysis.

Achilles Tendon Surgical Repair Partially Restores Early Plantar Flexor Structure and Function in a Rat Model

Achilles tendon ruptures significantly impair long-term patient function, with two-thirds of patients experiencing persistent functional deficits. Although nonsurgical treatment has gained popularity due to its perceived lower risk of complications, the specific effects of this approach on tendon healing, muscle function, and overall performance remain poorly understood. Directly comparing surgical and nonsurgical treatment options in a clinical population is challenging given the diverse nature of the patient population. Preclinical models are essential to isolate the mechanisms underlying these treatments, enabling a detailed examination of the structural and functional outcomes that are difficult to assess in human studies. Here, we surgically induced Achilles tendon ruptures in 20 adult male Sprague Dawley rats and repaired the rupture in half of these animals. Then, functional outcomes were assessed by measuring plantar flexor torque across the ankle's range of motion using a custom-developed small animal dynamometer, and structural changes were evaluated through measurements of Achilles tendon elongation and plantar flexor muscle mass. We found that surgical treatment led to 11%-35% increased functional plantar flexor torque outcomes compared to nonsurgical treatment. Additionally, plantar flexor muscle mass decreased by 21% in nonsurgically treated animals compared to only 12% in the surgically treated group. Our results suggest that surgically repairing a tendon rupture restores plantar flexor function more effectively than nonsurgical treatment; however, persistent functional deficits in both groups indicate that enhanced rehabilitation strategies are necessary for full functional restoration.

Advancements in biomaterials and scaffold design for tendon repair and regeneration

Tendon injuries present a significant clinical challenge due to their limited natural healing capacity and the mechanical demands placed on these tissues. This review provides a comprehensive evaluation of the current strategies and advancements in tendon repair and regeneration, focusing on biomaterial innovations and scaffold design. Through a systematic literature search of databases such as PubMed, Scopus, and Web of Science, key studies were analyzed to assess the efficacy of biocompatible materials like hydrogels, synthetic polymers, and fiber-reinforced scaffolds in promoting tendon healing. Emphasis is placed on the role of collagen fiber architecture, including fiber diameter, alignment, and crimping, in restoring the mechanical strength and functional properties of tendons. Additionally, the review highlights emerging techniques such as electrospinning, melt electrowriting, and hybrid textile methods that allow for precise scaffold designs mimicking native tendon structures. Cutting-edge approaches in regenerative medicine, including stem cell therapies, bioelectronic devices, and bioactive molecules, are also explored for their potential to enhance tendon repair. The findings underscore the transformative impact of these technologies on improving tendon biomechanics and functional recovery. Future research directions are outlined, aiming to overcome the current limitations in scaffold mechanical properties and integration at tendon-bone and tendon-muscle junctions. This review contributes to the development of more effective strategies for tendon regeneration, advancing both clinical outcomes and the field of orthopedic tissue engineering.

Long-Term Outcomes Following Surgical Intervention for Achilles Tendon Rupture: A Systematic Review With a Minimum Five-Year Follow-Up

Achilles tendon (TA) rupture is a common injury. However, there is limited evidence on the long-term outcomes following surgical repair. This systematic review aims to evaluate the efficacy and complications associated with surgical management of TA rupture with a minimum five-year follow-up duration. A literature search of Medline OVID, EMBASE, and Cochrane databases was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The outcomes measured focused on postoperative complications, rates of re-rupture, contralateral rupture, and revision surgery. Six studies including 806 patients were included. Surgical repair demonstrated low re-rupture rates (4.2%) and revision rates (3.7%) at five years follow-up. Contralateral ruptures were uncommon (N=5), and 30 patients required revision surgery. However, complications such as deep vein thrombosis (6.3%) and wound infections (3.6%) were observed. Surgical repair of TA rupture demonstrates excellent long-term outcomes, including low rates of re-rupture and revision over a minimum of five years. While complications such as deep vein thrombosis and wound infections are observed, this systematic review highlights the reliability, durability, and overall success of surgical intervention in effectively treating this condition.

Achilles Rupture Repair: Modified Gift-Box With a Proximal Myotendinous Backup Fixation Technique

Achilles tendon tears are not an uncommon injury, with a predominance in explosive athletes and weekend warriors in the third to fifth decade of life. Consideration of operative intervention is commonplace in young athletes, whereas less active and older individuals may opt for nonsurgical treatment. Surgical treatment is reported to improve functional outcomes in high-demand individuals and demonstrates increased plantarflexion power, better return to sports rates, and a reduced rerupture rate. Traditionally, a primary end-to-end repair of the Achilles tendon was the surgical treatment of choice. More recently, alternative advanced techniques and minimally invasive constructs have been proposed in an effort to improve repair construct while reducing soft tissue complications. This technical note describes a technique that combines a modified gift-box primary repair with backup fixation using calcaneal anchors. This technique is performed with a small, medially based incision that reduces wound and nerve complications, while promoting end-to-end tendon healing by reducing tension across the repair site through the calcaneal backup fixation.

Re-rupture rate and complications after percutaneous Tenolig® repair in acute midsubstance rupture of Achilles tendon

PURPOSE

Acute midsubstance Achilles tendon ruptures are the most common tendon injuries in adults and the choice of surgical technique is still debated. The objective of this study is to evaluate the rate of iterative ruptures and postoperative complications at a minimum follow-up of one year of percutaneous sutures of the Achilles tendon, as well as to investigate the risk factors for rupture.

METHODS

In this single-center retrospective study, 142 patients (119 men and 23 women, mean age of 46 years) were reviewed at a mean follow-up of 24 (12-38) months. Percutaneous sutures with the Tenolig® device was performed by several senior surgeons. We studied the rate of re-ruptures, scar-related complications, sural nerve damage, and thromboembolic complications. The mechanism leading to the rupture was also identified, as were the risk factors.

RESULTS

3 patients (2.11%) presented a re-rupture. No damage of the sural nerve was found. Three superficial skin ulcerations were identified, and three patients presented superficial venous thrombosis of the lower limb. Football was the highest risk activity (34.51%). The risk factors for a first episode of rupture were smoking and a BMI over than 25 kg/m2. Nevertheless, no statistically significant risk factors could be identified for re-ruptures.

CONCLUSION

Percutaneous sutures of the Achilles tendon using Tenolig® provides a low risk of re-rupture, a low complication rate, particularly scar-related complications, and a respect for tendon vascularization.

LEVEL OF CLINICAL EVIDENCE

3.

Optimizing Achilles Tendon Rupture Care: The Efficacy of Physiotherapy-Led Conservative Management in a District General Hospital

Introduction Achilles tendon rupture (ATR) represents a significant musculoskeletal injury that can affect many patients' mobility and quality of life. Treatment of ATR consists of both conservative and surgical options, with the traditional belief being that surgical intervention reduces the risk of re-rupture. However, with the introduction of physiotherapy-led functional rehabilitation strategies with early mobilization, it has been shown that re-rupture rates are equal among surgical and non-surgical patients. This study focuses on evaluating the effectiveness of non-surgical, physiotherapy-led management, specifically within the context of patients at a district general hospital. The rationale for investigating this approach lies in the growing interest and adoption of conservative management strategies for ATR across orthopaedic practices within the National Health Service (NHS). Methods This is a retrospective cross-sectional study assessing the efficacy of the physiotherapy-led treatment pathway in our district general hospital. Data were retrospectively collected from Hive, which is the trust's electronic patient record (EPR) and has comprehensive access to all patients' history, notes, images, investigations, and previous letters. We looked at all patients treated by physiotherapists for ATR from September 2022 to December 2023. Results In total, 76 patients were treated along the physiotherapy-led pathway for ATR between September 2022 and December 2023. The ages ranged from 22 to 82 years, with a mean age of 47 years. Of the patients, 48.6% (n = 37) were in the 40-60 years age range. The gender distribution was 69.7% (n = 53) males and 30.3% (n = 23) females (total = 76). The injury characteristics revealed a predominance of complete ATR, with 88.1% (n = 67) of cases being complete ATR, and 11.9% (n = 9) being partial ATR. Patients experiencing re-ruptures ranged from 34 to 64 years old, with three males and one female. Re-escalation to a consultant in only 14.5% of cases (n = 11) reflects successful initial management, minimizing the need for further interventions. Based on the available data, on average, younger patients (≤49 years) returned to work approximately 5.7 weeks post injury (n = 32). Conversely, older patients (above the average age) took 13.5 weeks on average to return to work. The dataset revealed that, on average, patients under the physiotherapy-led pathway returned to sports activities in about 29.9 weeks. Thromboprophylaxis was prescribed for 93.5% (n = 71) of patients with ATR. The data revealed a low incidence rate of deep vein thrombosis with only 4% (n = 3) of patients experiencing this complication post rupture. Conclusion This audit offers insight into physiotherapy-led ATR management at Wythenshawe Hospital, evaluating treatment results and challenges. The findings suggest that a conservative approach is effective in promoting patient recovery, with low re-rupture rates and successful return-to-function outcomes. While limitations such as sample size and retrospective design exist, the findings underscore the need for tailored rehabilitation protocols and continued research to optimize patient care in ATR management.

Surgical vs. nonoperative treatment for acute Achilles' tendon rupture: a meta-analysis of randomized controlled trials

Background

Acute Achilles tendon rupture (AATR) is common among young individuals. There are various management options available, including conservative treatment, open surgical repair, and minimally invasive treatments. However, the optimal treatment approach remains controversial.

Purpose

In this study, we conducted a thorough analysis of the existing literature to compare the clinical outcomes of surgical and nonoperative treatments for patients with AATR by conducting a meta-analysis of randomized controlled trials.

Study design

Meta analysis; Level of evidence, 1.

Methods

Eligible trials randomly assigned adults with AATR to surgical or conservative treatment and assessed by three independent reviewers. We searched in PubMed, Embase, and The Cochrane Library. The assessment of risk of bias was conducted by entering the data from each included study into the Revman computer program. Extracted data were meta-analyzed. Heterogeneity was evaluated using the I2 test. Pooled results were expressed as odds ratios, risk ratios (OR), and mean differences (MD).

Results

The meta-analysis included a total of 14 studies and 1,399 patients, with 696 patients receiving surgical intervention and 703 patients undergoing non-surgical treatment. The follow- up duration ranged from 12 to 30 months. The surgical group was found to have a significantly lower re-rupture rate (OR: 0.30, 95% CI: 0.18-0.54; P < 0.00001), but also had a higher risk of other complications (OR: 3.28, 95% CI: 1.56-6.93, P = 0.002). The surgical group also had significantly abnormal calf (OR: 0.45, 95% CI: 0.26-0.76, P = 0.03). There was no statistically significant difference between the two groups in terms of returning to sports, ATRS, abnormal motion of foot and ankle, unable heel-rise, and torque for plantar flexion.

Conclusion

The meta-analysis results indicate that surgical intervention for AATR is associated with a lower re-rupture rate, but a higher risk of other complications. Our assessment of life-quality and functional outcomes also suggests that surgery leads to significantly better outcomes in terms of sick leave, abnormal calf, and torque for plantar flexion. Based on these findings, we recommend that surgery is a preferable option for patients who have a higher risk of re-rupture and require a quick rehabilitation.

Recent developments in Achilles tendon risk-analyzing rupture factors for enhanced injury prevention and clinical guidance: Current implications of regenerative medicine

Background

In recent years, many countries have actively implemented programs and strategies to promote physical education and sports. Despite these efforts, the increase in physical activity has been accompanied by a significant rise in muscle and tendon-ligament injuries, with Achilles tendon rupture being the most prevalent, accounting for 47 % of such injuries. This review aims to summarize all significant factors determining the predisposition of the Achilles tendon to rupture, to develop effective personalized prevention measures.

Objective

To identify and evaluate the risk factors contributing to Achilles tendon rupture and to develop strategies for personalized prevention.

Methods

This review utilized data from several databases, including Elsevier, Global Health, PubMed-NCBI, Embase, Medline, Scopus, ResearchGate, RSCI, Cochrane Library, Google Scholar, eLibrary.ru, and CyberLeninka. Both non-modifiable and modifiable risk factors for Achilles tendon injuries and ruptures were analyzed.

Results

The analysis identified several non-modifiable risk factors, such as genetic predisposition, anatomical and functional features of the Achilles tendon, sex, and age. These factors should be considered when selecting sports activities and designing training programs. Modifiable risk factors included imbalanced nutrition, improper exercise regimens, and inadequate monitoring of Achilles tendon conditions in athletes. Early treatment of musculoskeletal injuries, Achilles tendon diseases, foot deformities, and metabolic disorders is crucial. Long-term drug use and its risk assessment were also highlighted as important considerations. Furthermore, recent clinical advancements in both conventional and surgical methods to treat Achilles tendon injuries were described. The efficacy of these therapies in enhancing functional outcomes in individuals with Achilles injuries was compared. Advancements in cell-based and scaffold-based therapies aimed at enhancing cell regeneration and repairing Achilles injuries were also discussed.

Discussion

The combination of several established factors significantly increases the risk of Achilles tendon rupture. Addressing these factors through personalized prevention strategies can effectively reduce the incidence of these injuries. Proper nutrition, regular monitoring, timely treatment, and the correction of metabolic disorders are essential components of a comprehensive prevention plan.

Conclusion

Early identification of Achilles tendon risk factors allows for the timely development of effective personalized prevention strategies. These measures can contribute significantly to public health preservation by reducing the incidence of Achilles tendon ruptures associated with physical activity and sports. Continued research and clinical advancements in treatment methods will further enhance the ability to prevent and manage Achilles tendon injuries.

The translational potential of this article

This study identifies key modifiable and non-modifiable risk factors for Achilles tendon injuries, paving the way for personalized prevention strategies. Emphasizing nutrition, exercise, and early treatment of musculoskeletal issues, along with advancements in cell-based therapies, offers promising avenues for improving recovery and outcomes. These findings can guide clinical practices in prevention and rehabilitation, ultimately reducing Achilles injuries and enhancing public health.

[Surgical or non-operative treatment of acute Achilles tendon rupture : What does the current literature say?]

BACKGROUND

The Achilles tendon is the strongest tendon in humans and is frequently injured, especially in the physically active young to middle-aged population. An increasing frequency of Achilles tendon ruptures (ATR) has been reported in several studies. However, there is no international consensus regarding possible non-operative (N-OP) or operative (surgical) treatment (OP).

OBJECTIVES

The aim of this article is to semi-quantitatively compare both treatment options for ATR by analyzing the results reported in the literature.

MATERIAL AND METHODS

For this purpose, relevant categories were identified, and the literature was then evaluated in a PubMed analysis. Ten meta-analyses and two cost analyses were included. The data was extracted according to the categories and evaluated comparatively.

RESULTS

OP and N‑OP for acute ATR can lead to equally good restitution of clinical function if early functional rehabilitation is applied. The lower re-rupture rate is an advantage of OP, whereas the lower general complications speak in favor of N‑OP. The minimally invasive or percutaneous surgical technique (M-OP) appears to be advantageous over the open surgical technique (O-OP), although studies show an increased rate of lesions of the sural nerve.

CONCLUSION

There is no consensus regarding the superiority of OP or N‑OP for acute ATR, as several studies conducted since the introduction of early mobilization protocols have shown similar results for these two interventions. Results and complications of M‑OP and O‑OP are also comparable. Considering the available data on the various surgical procedures, the authors prefer the M‑OP technique with adequate sural nerve protection for repair of acute ATR, combined with an early mobilization protocol.

Comparison of different immobilisation durations following open surgery for acute achilles tendon rupture: a prospective cohort study

BACKGROUND

In recent decades, early rehabilitation after Achilles tendon rupture (ATR) repair has been proposed. The aim of this prospective cohort study was to compare different immobilisation durations in order to determine the optimal duration after open surgery for ATR repair.

METHODS

This study included 1088 patients (mean age, 34.9 ± 5.9 years) who underwent open surgery for acute ATR repair. The patients were categorised into four groups (A, B, C, and D) according to postoperative immobilisation durations of 0, 2, 4, and 6 weeks, respectively. All patients received the same suture technique and a similar rehabilitation protocol after brace removal,; they were clinically examined at 2, 4, 6, 8, 10, 12, 14, and 16 weeks postoperatively, with a final follow-up at a mean of 19.0 months. The primary outcome was the recovery time for the one-leg heel-rise height (OHRH). Secondary outcomes included the time required to return to light exercise (LE) and the recovery times for the range of motion (ROM). Data regarding the surgical duration, complications, the visual analogue scale (VAS) score for pain, the Achilles tendon Total Rupture Score (ATRS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were also collected.

RESULTS

The recovery times for OHRH, LE, and ROM were significantly shorter in groups A and B than in groups C and D (P < 0.001). The VAS scores decreased over time, reaching 0 in all groups by 10 weeks. The mean scores in groups A and B were higher than those in the other groups at 2 and 4 weeks (P < 0.001), whereas the opposite was true at 8 weeks (P < 0.001). ATRS and the AOFAS Ankle-Hindfoot scale score increased across all groups over time, showing significant between-group differences from weeks 6 to 16 (P < 0.001) and weeks 6 to 12 (P < 0.001). The mean scores were better in groups A and B than in groups C and D. Thirty-eight complications (3.5%) were observed, including 20 re-ruptures and 18 superficial infections. All complications were resolved at the last follow-up, with no significant between-group differences.

CONCLUSIONS

Immobilisation for 2 weeks after open surgery for ATR repair may be the optimal strategy for early rehabilitation with relatively minimal pain and other complications.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04663542).

Paratenon preserving repair of the midsubstance acute Achilles tendon rupture: a systematic review and meta-analysis with best- and worst-case analyses for rerupture rates

INTRODUCTION

Paratenon preserving techniques to facilitate acute Achilles tendon rupture repair (AATR) functions by maintaining vascularity and biology for optimal healing response. Therefore, the purpose is to evaluate the outcomes following paratenon preserving repair of the midsubstance AATR. The hypothesis was that paratenon-preserving techniques demonstrate high return to play rates and low complication rates for the repair of the midsubstance AATR.

MATERIALS AND METHODS

A systematic review of the PubMed, Embase, and the Cochrane Library databases was performed by two authors using specific search terms and eligibility criteria. The assessment of the evidence was two-fold: level and quality of evidence. A meta-analysis of proportions for the various complication rates was performed using the restricted maximum likelihood method following the Freeman-Tukey double-arcsine transformation. Fixed effects models were employed if I2 < 25% (low heterogeneity), and random effects models were employed if I2 ≥ 25% (moderate to high heterogeneity).

RESULTS

The pooled return to play rate was 90.3%. The pooled rerupture rate as reported was 0.9% (best-case scenario 0.8% and worst-case scenario 6.8%). No meaningful subgroup analysis for rerupture rates could be performed based on the meta-regression. The pooled complication rate other than reruptures was 4.8%. The pooled infection rates were 0.3%, DVT rates were 1.6%, and sural nerve injury rates were 0.3%.

CONCLUSIONS

Paratenon preserving techniques that are minimally invasive in nature demonstrated safe and favorable outcomes with high return to play rates and low complication rates for the repair of the midsubstance AATR.

Acute Achilles tendon ruptures between 2002-2021: sustained increased incidence, surgical decline and prolonged delay to surgery-a nationwide study of 53 688 ruptures in Sweden

Introduction

Given the lack of consensus on optimal treatment strategies for acute Achilles tendon rupture (ATR), understanding temporal trends, treatment choice and demographic characteristics is important. Previous research suggests increasing incidence with declining surgical treatment. Current trends in Sweden are not known.

Hypothesis/purpose

To assess how incidence rates, treatment trends and time from injury to surgery (TTS) of ATR have changed between 2002 and 2021 in Sweden, with particular attention to changes since 2012.

Study design

Descriptive epidemiology study.

Methods

We conducted a nationwide register-based study including all inpatients and outpatients ≥18 years of age with an ATR between 2002 and 2021 in Sweden.

Results

53 688 ATRs (78.5% men) were identified during the study period. 15 045 patients (81.5% men) were surgically treated within 30 days. The long-term incidence rate for ATR injury increased by 45%, from 28.8 in 2002 to 41.7 in 2021 per 100 000 person-years (p<0.0001). In the last 5 years of the study, there was a significant, continuing increase in ATR incidence by 21%, from 34.4 in 2017 to 41.7 in 2021 per 100 000 person-years (p<0.0001). The surgical incidence rates decreased from 13.4 to 6.0 per 100 000 person-years (p<0.0001). TTS increased from 0.6 days in 2002 to 5.1 in 2021 (p<0.0001).

Conclusion

The observed increase in incidence rates and decrease in surgical treatment of ATR emphasise the need for evidence-based treatment and rehabilitation protocols for non-operated patients of all ages. A significant increase in time from injury to surgery was observed throughout the study period.

Effect of cilostazol on healing of achilles tendon ruptures: an experimental study on rats

PURPOSE

This study aimed to evaluate whether cilostazol (phosphodiesterase III inhibitor) could enhance the healing of Achilles tendon ruptures in rats.

MATERIALS AND METHODS

The Achilles tendons of 24 healthy male adult rats were incised and repaired. The rats were randomly allocated to cilostazol and control groups. The cilostazol group received daily intragastric administration of 50 mg/kg cilostazol for 28 days, while the control group did not receive any medication. The rats were sacrificed on the 30th day, and the Achilles tendon was evaluated for biomechanical properties, histopathological characteristics, and immunohistochemical analysis.

RESULTS

All rats completed the experiment. The Movin sum score of the control group was significantly higher (p = 0.008) than that of the cilostazol group, with means of 11 ± 0.63 and 7.50 ± 1.15, respectively. Similarly, the mean Bonar score was significantly higher (p = 0.026) in the control group compared to the cilostazol group (8.33 ± 1.50 vs. 5.5 ± 0.54, respectively). Moreover, the Type I/Type III Collagen ratio was notably higher (p = 0.016) in the cilostazol group (52.2 ± 8.4) than in the control group (34.6 ± 10.2). The load to failure was substantially higher in the cilostazol group than in the control group (p = 0.034), suggesting that the tendons in the cilostazol group were stronger and exhibited greater resistance to failure.

CONCLUSIONS

The results of this study suggest that cilostazol treatment significantly improves the biomechanical and histopathological parameters of the healing Achilles tendon in rats. Cilostazol might be a valuable supplementary therapy in treating Achilles tendon ruptures in humans. Additional clinical studies are, however, required to verify these outcomes.

The Use of Extracellular Vesicles in Achilles Tendon Repair: A Systematic Review

Achilles tendon (AT) pathologies are common musculoskeletal conditions that can significantly impair function. Despite various traditional treatments, recovery is often slow and may not restore full functionality. The use of extracellular vesicles (EVs) has emerged as a promising therapeutic option due to their role in cell signaling and tissue regeneration. This systematic review aims to consolidate current in vivo animal study findings on the therapeutic effects of EVs on AT injuries. An extensive literature search was conducted using the PubMed, Scopus, and Embase databases for in vivo animal studies examining the effects of EVs on AT pathologies. The extracted variables included but were not limited to the study design, type of EVs used, administration methods, efficacy of treatment, and proposed therapeutic mechanisms. After screening, 18 studies comprising 800 subjects were included. All but one study reported that EVs augmented wound healing processes in the AT. The most proposed mechanisms through which this occurred were gene regulation of the extracellular matrix (ECM), the enhancement of macrophage polarization, and the delivery of therapeutic microRNAs to the injury site. Further research is warranted to not only explore the therapeutic potential of EVs in the context of AT pathologies, but also to establish protocols for their clinical application.

Musculotendinous ruptures of the achilles tendon had greater heel-rise height index compared with mid-substance rupture with non-operative management: A retrospective cohort study

INTRODUCTION

Achilles tendon ruptures (ATRs) may occur at varying locations with ruptures at the mid-substance (MS) of the tendon most common, followed tears at the musculotendinous (MT) junction. There is scant literature about the outcome of MT ATR. This study compared the outcome of patients with a MT ATR with patients following a MS ATR.

METHODS

The diagnostic features and clinical outcome of 37 patients with a MT ATR were compared with a cohort of 19 patients with a MS ATR. Patients in both groups were managed non-operatively and received the same rehabilitation protocol with weight-bearing rehabilitation in protective functional brace.

RESULTS

From February 2009 to August 2023, 556 patients presented with an ATR. Of these, 37 (6.7 ​%) patients were diagnosed with a MT tear. At final follow-up, at 12 months following injury, the MT group reported an Achilles tendon total rupture score (ATRS) of mean (standard deviation (SD)) of 83.6 (3.5) (95 ​% confidence interval (CI) 81.8, 85.4) and median (inter-quartile range (IQR)) ATRS of 86 points (78-95.5) and the MS group mean (SD) of 80.3 (8.5) (95%CI) 76.1, 80.5) and median (IQR) of 87 points (59-95) (p ​= ​0.673). Functional evaluation, however, revealed statistically significant differences in mean (SD) heel-rise height index MT group 79 ​% (25) (95%CI 65.9, 92.1) and MS group 59 ​% (13) (95%CI 51.9, 67.1) (p ​= ​0.019). In the MT rupture group, there were considerably less complications than the MS rupture group.

CONCLUSIONS

When managed non-operatively, with only a 6 weeks period of brace protection, patients have little limitation although have some residual reduction of single heel-rise at the one-year following MT ATR.

LEVEL OF EVIDENCE

IV.

Conservative treatment outcome for Achilles tendon re-rupture occurring in the subacute phase after primary repair

INTRODUCTION

Until now, a treatment protocol for Achilles tendon re-rupture (ATRR) occurring in the postoperative period 5-12 weeks following primary Achilles tendon repair has not been established. We refer to this time frame as the subacute postoperative phase, and the objective of this study was to assess the efficacy of conservative treatment for subacute ATRR in this phase.

MATERIALS AND METHODS

We conducted a retrospective review of 390 cases (385 patients) who had undergone primary Achilles tendon repair using the 4-strand Krachow method between January 2010 and August 2021. All patients were subjected to more than 12 months of follow-up and were categorized into two groups based on the presence of subacute ATRR: Group 1 comprised 370 cases without ATRR, while Group 2 comprised 20 cases with ATRR. Following confirmation of ATRR, we immediately applied a below-knee cast in an ankle plantar flexed position (25°-30°), followed by bracing according to the same rehabilitation plan used for the primary repair. After administering conservative treatment to the patients with ATRR, we compared several outcome parameters between the two groups, including isokinetic plantar flexion power measured using a dynamometer, time required for a single heel raise (t-SHR), time needed for ten repetitive SHRs (t-SHR10), Achilles Tendon Total Rupture Score (ATRS), and Foot and Ankle Ability Measure (FAAM) scores. The baseline timepoints for Groups 1 and 2 were the dates of the primary repair and the re-injury event.

RESULTS

After primary Achilles tendon repair, subacute ATRR occurred in 5.1% of patients. There were no significant differences between the groups in terms of t-SHR and t-SHR10 (P = 0.281, 0.486). Similarly, the isokinetic dynamometer measurements revealed no significant differences in peak torque for plantar flexion at angular velocities of 30°/s and 120°/s, both in absolute values and as a percentage of the contralateral side, between the groups (P > 0.05 for each). However, ATRSs were significantly lower in Group 2 compared to Group 1 before 6 months (P < 0.05), as were FAAM-Activities of Daily Living scores at 6 months (P < 0.05). After 12 months, there were no significant differences in these scores between the two groups (both P > 0.05).

CONCLUSION

Conservative treatment for subacute ATRR following primary Achilles tendon repair yields clinical outcomes comparable to those without ATRR. Therefore, we recommend that surgeons consider relying on the patient's natural healing capabilities rather than opting for aggressive surgical interventions, as expediting such operations may be unnecessary for subacute injuries.

The effect of smoking on 30-day complications following primary repair of Achilles tendon ruptures

PURPOSE

There exists a gap in the knowledge of the impact of smoking on Achilles tendon rupture repair. This study evaluates perioperative and postoperative complications associated with smoking to allow for a more informed evaluation and discussion with the patients when considering the surgical management of Achilles tendon repair in this patient population.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing Achilles tendon rupture repair from 2006 to 2019. Two patient cohorts were defined in this retrospective study: smokers and patients who did not smoke. The various patient demographics, medical comorbidities, and postoperative outcomes were compared using bivariate and multivariate analyses between the smoking and non-smoking groups.

RESULTS

Of 4209 patients who underwent Achilles tendon repair, 3662 patients (87%) did not smoke, whereas 547 patients (13%) were smokers. Patients who were smokers were more likely to be younger and have a higher body mass index. Following multivariate analyses, those who smoked had an increased risk of experiencing wound dehiscence (OR 3.57; p = 0.013) and urinary tract infections (OR 1.21; p = 0.033) compared to non-smoking patients.

CONCLUSION

Despite the rate of complications being relatively low in the short-term perioperative period, individuals who smoke should be counseled on the surgical risks they may experience following Achilles tendon repair, including wound dehiscence and urinary tract infections. Discussion preoperatively between the physician and patient who smoke can include ways in which postoperative care will be done to minimize the risk of adverse events, ultimately reducing costs for both the patient and the hospital.

Anti-Adhesive Resorbable Indomethacin/Bupivacaine-Eluting Nanofibers for Tendon Rupture Repair: In Vitro and In Vivo Studies

The treatment and surgical repair of torn Achilles tendons seldom return the wounded tendon to its original elasticity and stiffness. This study explored the in vitro and in vivo simultaneous release of indomethacin and bupivacaine from electrospun polylactide-polyglycolide composite membranes for their capacity to repair torn Achilles tendons. These membranes were fabricated by mixing polylactide-polyglycolide/indomethacin, polylactide-polyglycolide/collagen, and polylactide-polyglycolide/bupivacaine with 1,1,1,3,3,3-hexafluoro-2-propanol into sandwich-structured composites. Subsequently, the in vitro pharmaceutic release rates over 30 days were determined, and the in vivo release behavior and effectiveness of the loaded drugs were assessed using an animal surgical model. High concentrations of indomethacin and bupivacaine were released for over four weeks. The released pharmaceutics resulted in complete recovery of rat tendons, and the nanofibrous composite membranes exhibited exceptional mechanical strength. Additionally, the anti-adhesion capacity of the developed membrane was confirmed. Using the electrospinning technique developed in this study, we plan on manufacturing degradable composite membranes for tendon healing, which can deliver sustained pharmaceutical release and provide a collagenous habitat.

Methods of Immobilization after Achilles Tendon Rupture Repair: A Comparative Study in Rat Model

OBJECTIVE

The Achilles tendon (AT) is the most frequently ruptured in the human body. Literature describing different immobilization methods' impact on tendon healing after AT repair is lacking. We compare plaster cast, splint, and K-wire to determine which is the most stable and has the fewest complications.

METHODS

Sixty rats aged 5-6 months were selected to establish Achilles tendon injury in two hind legs model. After suturing the ends of the AT together with a modified "Kessler" method (Prolene 5-0). The skin incision was interrupted and sutured with 1-0 thread. Rats were divided into three immobilization methods (plaster cast group, splint group, and K-wire group). In plaster cast group, the hind leg was cast with plaster in the extended position of the hip and knee joints, and the ankle joint was at 150°. Splint and K-wire group used splints and 0.8-mm K-wires, separately. The fixed period was 4 weeks. The incidence of stability and complications (death, necrosis of the legs, necrosis of the skin, and incisional infection) were recorded. Differences were detected using the chi-square test.

RESULTS

Within 4 weeks observation, K-wires showed better stability (90%) compared with the other two ways (40% in plaster cast group, 65% in splint group; p < 0.05). Rats immobilized with K-wires (10%) suffered significantly lower complications compared with plaster cast and splint group (15%; p < 0.05).

CONCLUSION

K-wire has better stability, lower complication rate than other methods. Immobilization with K-wire may be a promising tool in future clinical Achilles tendon rupture applications.

Effect of the Copenhagen Achilles Rupture Treatment Algorithm (CARTA) on Calf Muscle Volume and Tendon Elongation After Acute Achilles Tendon Rupture: A Predefined Secondary Analysis of the First 60 Patients in a Randomized Controlled Trial

Background

Surgical treatment of acute Achilles tendon rupture (ATR) lowers the risk of rerupture and may reduce calf atrophy and elongation of the Achilles tendon. The Copenhagen Achilles Rupture Treatment Algorithm (CARTA) was developed to provide individualized treatment selection based on ultrasonographic evaluation of the rupture.

Purpose

In a randomized setup, the present study aimed to investigate whether treatment selection using the CARTA could reduce atrophy and tendon elongation compared with (1) patients treated surgically and (2) patients treated nonsurgically.

Study Design

Randomized controlled trial; Level of evidence, 2.

Methods

A total of 60 patients with an acute ATR were randomly assigned to receive treatment based on the CARTA (intervention), surgical treatment (control), or nonsurgical treatment (control) in a 1 to 1 to 1 ratio. After 1 year, magnetic resonance imaging of both calves was performed, and muscle volume and Achilles tendon length were measured. Results were presented as the ratio between the affected and the unaffected limbs (ie, limb symmetry index; %).

Results

A total of 156 patients were assessed for eligibility, 60 patients were randomized, and 54 patients provided data for the study-19 patients received treatment based on the CARTA (intervention group), 17 patients received nonsurgical treatment (control), and 18 patients received surgical treatment (control). No statistically significant differences were found between the intervention group and the 2 control groups regarding muscle volume and tendon length. No statistically significant differences were found between patients treated surgically and patients treated nonsurgically. Comparison between the affected and the unaffected limb showed statistically significant muscle atrophy (24%-30%) and tendon elongation (soleus, 59%-76%; gastrocnemius, 8%-14%) in the affected limb in all 3 groups.

Conclusion

Individualized treatment of acute ATR using an ultrasonographic selection algorithm did not reduce calf muscle atrophy or tendon elongation when compared with surgical and nonsurgical treatment. Surgical treatment did not reduce calf muscle atrophy or tendon elongation compared with nonsurgical treatment.

Is a Preoperative MRI Scan Necessary for Acute Achilles Tendon Rupture?

BACKGROUND

Different treatment methods have been developed for acute Achilles tendon rupture (ATR), including conservative treatment, minimally invasive or transdermal surgery, and open surgery, and there is no consensus about which method is superior. It is important to clarify the presence of Achilles tendon (AT) degeneration, the rupture site, and the rupture shape before surgery to determine whether minimally invasive or open surgery should be selected, thereby reducing the re-rupture rate following acute ATR. The aim of this study was to investigate the diagnostic value of MRI in identifying the presence of AT degeneration, the rupture site, and the rupture shape for acute closed ATR.

METHODS

From January 2016 to December 2019, patients with acute closed ATR who had undergone repair surgery were retrospectively enrolled. All patients received MRI examination, and the distance between the insertion site and broken end and the rupture shape (types I, II, and III) were independently determined by two observers. Then, the stump of the AT was exposed during the operation. The rupture site and rupture shape were recorded and compared and analyzed with the MRI results. Consistency analyses (using Cohen's kappa coefficient or intraclass correlation coefficient-ICC) and calculation of diagnostic performance indexes were, respectively, conducted to evaluate the diagnostic value of the MRI.

RESULTS

This study included 47 consecutive patients with acute ATR, with an average age of 38.4 years. Among them, 40 were male, and seven were female. The intraoperative exploration demonstrated a total of 34 (72.3%), 10 (21.3%), and three (6.4%) patients with type I, II, and III ruptures, respectively. The average distance between the insertion site and the proximal broken end measured intraoperatively was 4.07 ± 1.57 cm. High or excellent consistencies were found for ATR classifications (kappa: 0.739-0.770, p < 0.001) and rupture sites (ICC: 0.962-0.979, p < 0.001) between two observers and between observers 1 and 2 and intraoperative findings. Tendinopathy was identified in 22 patients by MRI and confirmed during surgery.

CONCLUSIONS

MRI scanning of acute closed ATR can help determine whether there is degeneration of the AT, as well as the location and shape of the rupture, which can guide the selection of the optimal operation method for orthopedic surgeons. Therefore, it is necessary to take preoperative MRI scans for patients with acute Achilles tendon ruptures.

Correlation between the Coaptation and Regeneration of Tendon Stumps in Endoscopic Assisted Achilles Tendon Rupture Repair

OBJECTIVE

When the endoscopic Achilles tendon repair technique is utilized, direct stitching of the ruptured site is challenging due to the frayed tendon stumps. To explore whether undesirable coaptation of the tendon stumps influences the generation of the tendons.

METHODS

This study is a retrospective analysis of 46 patients who underwent a modified endoscopic Achilles tendon rupture repair from October 2018 to June 2020. Patients were divided into two groups according to the coaptation of tendon stumps on postoperative ultrasonography. Group 1 included 17 cases with undesirable coaptation (<50%), and Group 2 included 29 cases with appropriate coaptation (≥50%). Magnetic resonance imaging (MRI) was obtained postoperatively at 3, 6, and 12 months to evaluate the tendon morphological construction. Clinical evaluations were performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score, the Achilles Tendon Total Rupture Score (ATRS), muscle power, and the Achilles tendon resting angle at the final follow-up. Complications were also encountered. The Student's t-test and the Mann-Whitney U-test were used to assess differences among both groups.

RESULTS

The mean follow-up time was 37.5 ± 10.6 months in Group 1 and 39.0 ± 11.6 months in Group 2, respectively. The average age in Group 1 is slightly older than in Group 2 (37.3 ± 6.1 vs. 32.7 ± 6.3, p = 0.021). The tendon cross-section areas and thickness increased initially and decreased later on postoperative MRI evaluation. It also showed a significantly higher signal/noise quotient (SNQ) in Group 1 at postoperative 3 months. At postoperative 6 and 12 months, the SNQ between both groups was similar. The AOFAS score (95.9 ± 5.1 vs. 96.2 ± 4.9, p = 0.832), ATRS score (97.0 ± 3.6 vs. 97.7 ± 3.3, p = 0.527), and muscle power (21.38 vs. 24.74, p = 0.287) were not significantly different between both groups. However, the resting angle of Group 1 was significantly larger than that of Group 2 (4.6 ± 2.4 vs. 2.4 ± 2.3, p = 0.004). There was no difference in the complications (p = 0.628).

CONCLUSION

Although complete regeneration can be finally achieved, the early stage of tendon stump regeneration can be prolonged due to undesirable coaptation when endoscopic Achilles tendon repair technique is applied. The prolonged high signal duration on MRI indicates the less-than-ideal regeneration of the tendon, which might lead to elongation of the tendon.

Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses

PURPOSE

To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR.

METHODS

Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance.

RESULTS

There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3-5%) versus conservative treatment (3.9-13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5-10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation.

CONCLUSION

This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR.

LEVEL OF EVIDENCE

IV.

Outcomes Following Repair of Achilles Midsubstance Tears: Percutaneous Knotless Repair vs Open Repair

BACKGROUND

Optimum treatment for acute Achilles tendon rupture results in high mechanical strength, low risk of complications, and return to preinjury activity level. Percutaneous knotless repair is a minimally invasive technique with promising results in biomechanical studies, but few comparison clinical studies exist. Our study purpose was to compare functional outcomes and revision rates following acute Achilles tendon rupture treated between percutaneous knotless repair and open repair techniques.

METHODS

Patients 18 years or older with an acute Achilles tendon rupture, treated by a single surgeon with either open repair or percutaneous knotless repair, and more than 2 years after surgery were assessed for eligibility. Prospective clinical data were obtained from the data registry and standard electronic medical record. Additionally, the patients were contacted to obtain current follow-up questionnaires. Primary outcome measure was Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL). Secondary outcome measures were FAAM sports, 12-Item Short Form Health Survey (SF-12), Tegner activity scale, patient satisfaction with outcome, complications, and revisions. Postoperative follow-up closest to 5 years was used in this study.

RESULTS

In total, 61 patients were included in the study. Twenty-four of 29 patients (83%) in the open repair group and 28 of 32 patients (88%) in the percutaneous knotless repair group completed the questionnaires with average follow-up of 5.8 years and 4.2 years, respectively. We found no significant differences in patient-reported outcomes or patient satisfaction between groups (FAAM ADL: 99 vs 99 points, P = .99). Operative time was slightly longer in the percutaneous knotless repair group (46 vs 52 minutes, P = .02). Two patients in the open group required revision surgery compared to no patients in the percutaneous group.

CONCLUSION

In our study, we did not find significant differences in patient-reported outcomes or patient satisfaction by treating Achilles tendon midsubstance ruptures with percutaneous knotless vs open repair.

LEVEL OF EVIDENCE

Level IlI, retrospective cohort study.

Return to sport after surgical repair of the Achilles tendon

Achilles tendon rupture is among the most common sports injuries. In patients with high functional demands, surgical repair is preferred to facilitate early return to sporting function. This article reviews the literature and provides evidence-based guidance for return to sport after operative management of Achilles tendon rupture. A search was performed using PubMed, Embase and Cochrane Library for all studies reporting on return to sport after operative management of Achilles tendon rupture. The review included 24 studies reporting on 947 patients, and found that 65-100% of patients were able to return to sport between 3 and 13.4 months post-injury, with incidence of rupture recurrence 0-5.74%. These findings will help patients and healthcare professionals plan a recovery timeline, discuss athletic functionality post-recovery, and understand complications of repair and risk of tendon re-rupture.

Thromboembolic Events During Weightbearing vs Nonweightbearing Accelerated Rehabilitation Protocols for Complete Achilles Tendon Ruptures

Background

Achilles tendon rupture can be treated nonoperatively with functional rehabilitation. However, prolonged immobilization has associated risk of venous thromboembolism (VTE). Early weightbearing may reduce VTE risk, and this was introduced to our rehabilitation protocol. We investigated the prevalence of symptomatic VTE events before and after the introduction of the early weightbearing protocol.

Methods

Adults with ultrasonography-confirmed complete tendo-Achilles ruptures between January 2017 and June 2020 were included. Preprotocol, patients were instructed to not weightbear for 4 weeks. In 2018, immediate weightbearing was introduced to the treatment protocol. All patients in both cohorts were given low-molecular-weight heparin for 4 weeks. Patients with symptomatic VTE events were investigated with duplex ultrasonographic scan or chest computed tomography. Two independent anonymized examiners collected data from electronic records. Rates of symptomatic VTEs were compared.

Results

A total of 296 patients were included. Sixty-nine patients were managed with the nonweightbearing protocol, and 227 patients were managed with the early-weightbearing protocol. Two patients in each group developed deep vein thrombosis and 1 developed pulmonary embolism in the early-weightbearing group. Rates of VTEs were lower in the early-weightbearing group (1.3% vs 2.9%) but did not reach statistical significance (P = .33).

Conclusion

In this cohort we found that symptomatic VTE after nonoperatively treated Achilles tendon rupture was uncommon. We did not demonstrate a reduction in symptomatic VTE between our early weightbearing and nonweightbearing rehabilitation protocols. We believe a larger study may help clarify whether early weightbearing is beneficial in VTE reduction.

Level of Evidence

Level III, retrospective cohort study.

Outcomes of Open Repair Treatment for Acute Versus Chronic Achilles Tendon Ruptures: Long-Term Retrospective Follow-Up of a Minimum 10 Years-A Pilot Study

The aim of the present study was to compare repaired Achilles tendon (AT) remodelling, whether its function was restored and what effects the surgery had on our patients' gait cycle in a long-term follow-up study. The study population comprised 30 human subjects treated acutely and chronically for AT ruptures, using the same surgical technique in all cases. The study group was divided into two subgroups regarding the age of their AT injury, i.e., how much time elapsed between the injury and when a correct diagnosis was made and when adequate treatment was applied. Following these criteria, persons presenting at less than 4 weeks postinjury were classified as acute rupture (AR) patients and those presenting at more than 4 weeks after injury were grouped as chronic rupture (CR) patients. Both patient groups were operated on using a surgical method favoured at least a decade ago, i.e., open repair through a posteromedial approach. The AT was augmented with a plantaris longus tendon autograft, followed by suturing using the pull-out suture technique. The results were measured using clinical, ultrasonographic (US) and pedobarographic methods. Our ultrasonographic and pedobarographic findings revealed differences between both patient groups, thus indicating that delayed surgery had negative impacts on treatment success, however, with good long-term functional score outcomes in both patient groups. Nevertheless, delayed treatment of AT ruptures did not leave individual gait phases unaffected, as it also affected the plantar surface and balance performance of the affected limb. As per the results, the Achilles tendon manifested decreased capacity following delayed treatment; however, its long-term functional outcomes were favourable, irrespective of whether it was for acute or chronic patients.

Factors That Affect Return to Sports After an Achilles Tendon Rupture: A Qualitative Content Analysis

Background

Achilles tendon rupture is common among physically active individuals, yet a high percentage fail to return to their former activity after the injury. Quantifiable factors such as type of treatment, hours of rehabilitation, and age have not been associated with return-to-play rates. A factor that influences recovery is the participant's experience before and throughout the rehabilitation process, which can be explored using a qualitative content analysis.

Purpose

To explore and describe what influences the participant to return to physical activity after an Achilles tendon rupture.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Twenty participants (14 men; mean age, 46 years) were interviewed as part of this study. All participants had ruptured their Achilles tendon 4 to 6 years before the interviews. From the interviews, codes were extracted that evolved into 19 subcategories, 6 categories, and 1 theme.

Results

The overarching theme that emerged was "Help me and then I can fix this." The 6 categories were (1) one's own drive to succeed, (2) having a supportive social network, (3) trusting the support from the health and social systems, (4) receiving and adapting information from others drives persistence in returning to activity, (5) impact of the injury on psychological factors; and (6) influence of physiological aspects.

Conclusion

To be able to recover properly from an Achilles tendon rupture and return to activity, the study participants described the importance of obtaining the support needed to be able to gain optimal rehabilitation. In the participants' opinion, for a greater chance of successful treatment and rehabilitation, it was vital to be provided with good support.

Percutaneous Achilles Tendon Repair Using Ultrasound Guidance: An Intraoperative Ultrasound Technique

Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach.

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

BACKGROUND AND OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

Prospective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019).

INCLUSION CRITERIA

≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography. Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected.

RESULTS

VAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries).

CONCLUSIONS

Percutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

BACKGROUND AND OBJECTIVE

The purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures.

MATERIAL AND METHODS

Prospective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019).

INCLUSION CRITERIA

≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography. Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected.

RESULTS

VAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries).

CONCLUSIONS

Percutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

Incidence and Treatment Trends of Achilles Tendon Ruptures in Finland: A Nationwide Study

Background:

Global reports indicate rising Achilles tendon rupture (ATR) incidence. In recent decades, the optimal treatment for this injury has been widely studied. Alongside the cumulating comparative evidence regarding the optimal method of treatment, nonoperative treatment has increased in popularity compared with operative treatment.

Purpose:

To determine the current incidence of ATRs and their treatment in Finland and how these have changed from 1997 to 2019.

Study Design:

Descriptive epidemiology study.

Methods:

Two national registers (the National Hospital Discharge Register and the Finnish Register of Primary Health Care Visits) were used to identify all ATR cases and operations to treat them; the incidence was calculated based on the annual adult population size.

Results:

During the study period, ATR incidence increased from 17.3 to 32.3 per 100,000 person-years. The increase in incidence seemed to plateau starting in the second half of the study period. The rise in ATR incidence occurred in both sexes and all age groups but most markedly among the elderly. The incidence of operative treatment decreased from 13.6 to 4.9 per 100,000 person-years. This decline was observed from 2008 onward and in all age groups.

Conclusion:

The incidence of ATRs increased and the use of operative treatment decreased. The decreasing trend of operative treatment is in line with other international reports and resonates with the current literature about the optimal treatment of ATRs.

[Reconstruction of Soft Tissue Defects of the Achilles Tendon Region: a Literature Review]

BACKGROUND

Soft tissue defects in the achilles tendon region occur after trauma, but also as a complication after open recon- struction of the tendon with subsequent infection.

OBJECTIVES

Recommendations for the treatment of soft tissue injuries involving the Achilles tendon are presented.

MATERIALS AND METHODS

A search of the German, French and English literature on reconstruction of soft tissue defects of the Achilles tendon region was performed, which were differentiated into singular and combined tendocutaneous defects. Combined defects were further subdivided into three reconstructive principles: a simple soft tissue reconstruction without tendon repair or a combined reconstruction of the soft tissue as well as the tendon using either a vascularized tendon transplant or an avascular tendon graft.

RESULTS

Local and distally-based pedicled flaps include a relatively high risk or perioperative morbidity, whereas free flaps are described with significantly lower complications rates. Therefore, the authors prefer free flaps for reconstruction. Potential donor sites are the Medial Sural Artery (MSAP-) flap for smaller defects or free fasciocutaneous or muscle flaps in patients with large defects. The standard for tendocutaneousreconstructions is the free anterolateral thigh flap including vascularized fascia. Non-vascularized tendon grafts are frequently applied from the flexor hallucis longus- or peroneus brevis tendon.

CONCLUSIONS

Reconstructions over the Achilles tendon require thin and stable reconstructions that additionally allow slippage of soft tissues. Moreover, the use of normal shoes should be possible. The postoperative strength and range of motion of the ankle joint show comparable functional results after vascularized and non-vascularized tendon reconstruction.

Early analysis shows that endoscopic flexor hallucis longus transfer has a promising cost-effectiveness profile in the treatment of acute Achilles tendon ruptures

PURPOSE

Current options for treating an Achilles tendon rupture (ATR) include conservative and surgical approaches. Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost-effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost-effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective.

METHODS

A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost-effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one-way sensitivity analysis was conducted by sequentially varying each model parameter within a given range.

RESULTS

For the reference case, incremental cost-effectiveness ratios exceeded the willingness-to-pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100,000, open surgery was cost-effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments.

CONCLUSION

Surgical treatments have a moderate likelihood of being cost-effective at a willingness-to-pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health-related quality of life may be better suited for improved cost-effectiveness.

LEVEL OF EVIDENCE

Level III.

Outcomes of Percutaneous Achilles Repair Compared With Endoscopic Flexor Hallucis Longus Tendon Transfer to Treat Achilles Tendon Ruptures

BACKGROUND

Both percutaneous and endoscopically assisted methods are reported to produce good results in the surgical management of acute Achilles tendon ruptures. The aim of this retrospective study was to compare between a percutaneous method and a recently described isolated endoscopically assisted flexor hallucis longus (FHL) transfer method as surgical means of management in patients with acute Achilles tendon ruptures.

METHODS

One hundred seventeen patients were included in the current study and divided into 2 groups: 59 patients who underwent percutaneous Achilles repair (PAR Group) and 58 patients who underwent isolated endoscopic FHL transfer (FHL Group) were compared. Patients were clinically evaluated using American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score (ATRS), and Achilles tendon resting angle (ATRA) measures. In addition, ankle plantarflexion power, FHL dynamometry, Tegner activity levels, and return to previous levels of activity were also documented for all patients.

RESULTS

Nine months after surgery, patients in the FHL transfer group were more likely to be able to return to normal activities (91% vs 73%, P < .01). Thirty months after surgical treatment, we found no difference in ATRS, AOFAS, ATRA, ankle plantarflexion strength, or Tegner activity scores between study groups. Overall complications were reported in 6 patients in the FHL group (10.3%) and in 8 patients in the PAR group (13.6%). No major neurovascular or skin complications were encountered.

CONCLUSION

The current study demonstrated satisfactory and comparable results and complications when comparing isolated endoscopic FHL tendon transfer or percutaneous Achilles tendon repairs in the surgical management of acute Achilles tendon ruptures.

LEVEL OF EVIDENCE

Level III, retrospective controlled trial.

Locating the danger zone to avoid injury to the sural nerve during Achilles calcaneal tendon repair. A systematic review of cadaveric studies with clinical implications

INTRODUCTION

Although iatrogenic injuries to the sural nerve (SN) are commonly encountered in calcaneal (Achilles) tendon (CaT) repair surgeries, the relationship between both structures have anatomical variations. A quantitative evidence synthesis has not been yet conducted. Our systematic review aims to better define the safe zone where the SN crosses the lateral border of CaT.

METHODS

Electronic databases were searched to locate relevant anatomical studies recording details regarding the distance at which SN crosses the CaT. The Checklist for Anatomical Reviews and Meta-Analyses (CARMA) was followed. The primary outcome was the mean distance from CaT insertion to SN crossing site, to locate a safe zone. The secondary outcome was the mean horizontal distance from the SN to the CaT lateral border.

RESULTS

Seven studies met the inclusion criteria with a total of 204 cadaveric limbs. The danger zone was located 2 cm distal and proximal to the mean distance of the crossing point. The mean distance from CaT insertion to the SN crossing site was 9.91 ± 0.67 cm. The mean horizontal distance between SN and the CaT lateral border decreased from a mean of 19.8 ± 2.06 mm at the calcaneal tuberosity level to 3.6 ± 0.4 mm at 10 cm proximal to the tuberosity.

DISCUSSION

This review demonstrated that 10 cm is the average distance from the CaT insertion onto the calcaneal tuberosity to the point of crossing of the SN. A safe zone would be 2 cm away proximally and distally from the crossing point. We recommend placing the proximal lateral sutures away from this region. This finding should help surgeons avoid SN injuries during open or percutaneous approaches for calcaneal tendon rupture.

Practice of Multidisciplinary Collaborative Chain Management Model in Constructing Nursing Path for Acute Trauma Treatment

Prompt and effective treatment is the key to improve the prognosis of patients with acute trauma, and nursing plays an important role. However, conventional nursing has many limitations. Some studies have pointed out that the multidisciplinary collaborative chain management model can optimize the emergency procedures, ensure the continuity of the emergency treatment process, and optimize the treatment details. This study analyzed the practice of constructing an acute trauma care pathway based on a multidisciplinary collaborative chain management model. The results showed that the application of the multidisciplinary collaborative chain management model in the construction of acute trauma treatment nursing paths can enhance the emergency efficiency and nursing treatment, prevent the occurrence of adverse events, and improve the prognosis of patients.

The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors

PURPOSE

The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture.

METHODS

A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years.

RESULTS

Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050).

CONCLUSION

The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture.

LEVEL OF EVIDENCE

III.

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.

Delayed Wound Healing After Achilles Tendon Suture: An Arthroscopic Solution

This technical note describes an arthroscopic technique for treating delayed wound healing after Achilles tendon suture. Ankle arthroscopy is used to clean up the inflammatory tissues and foreign bodies that lead to delayed wound healing, with the advantages of simple postoperative care and low infection risk. This method may provide a less traumatic and low-risk option for the treatment of delayed wound healing after Achilles tendon surgery. The purpose of this technical note is to describe surgical procedures and related recommendations.

Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures in Professional Soccer Players

BACKGROUND

Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR.

METHODS

Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated.

RESULTS

All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength.

CONCLUSION

The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort.

LEVEL OF EVIDENCE

Level II, prospective cohort case series study.

Muscle-tendon morphomechanical properties of non-surgically treated Achilles tendon 1-year post-rupture

BACKGROUND

Achilles tendon rupture appears to alter stiffness and length of the tendon. These alterations may affect the function of tendon in force transmission and in energy storage and recovery. We studied the mechanical properties of the Achilles' tendon post-rupture and their association with function.

METHODS

Twenty-four (20 males, 4 females) participants (mean age: 43 y, 176 cm, 81 kg) were recruited. Ultrasonography and dynamometry were used to assess the muscle-tendon unit morphological and mechanical properties of non-surgically treated patients 1-year post rupture.

FINDINGS

Injured tendons were longer with difference of 1.8 cm (95%CI: 0.5-1.9 cm; P < 0.001), and thicker by 0.2 mm (0.2-0.3 mm; P < 0.01). Medial gastrocnemius cross-sectional area was 1.0 cm² smaller (0.8-1.1 cm²; P < 0.001), fascicles were 0.6 cm shorter (0.5-0.7 cm; P < 0.001) and pennation angle was 2.5° higher (1.3-3.6°; P < 0.001) when compared to the uninjured limb. We found no differences between injured and uninjured tendon stiffness 1-year post-rupture (mean difference: 29.8 N/mm, -7.7-67.3 N/mm; P = 0.170). The injured tendon showed 1.8 mm (1.2-2.4 mm; P < 0.01) lower elongation during maximal voluntary isometric contractions. Patient-reported functional outcome was related to the tendon resting length (β = 0.68, r(10) = 4.079, P = 0.002). Inter-limb differences in the medial gastrocnemius fascicle length were related to inter-limb differences in maximum contractions (β = 1.17, r(14) = 2.808, P = 0.014).

INTERPRETATION

Longer Achilles tendon resting length was associated with poorer self-evaluated functional outcome. Although the stiffness of non-surgically treated and uninjured tendons was similar 1-year post rupture, plantar flexion strength deficit was still present, possibly due to shorter medial gastrocnemius fascicle length.

OUP accepted manuscript

Hypertrophic scar formation and non-healing wounds following Achilles tendon repair arise from poor vascularity to the incisional site or from excess mechanical stress/strain to the incision during the healing process. The embrace® scar therapy dressing is a tension offloading device for incisional scars. This study explored the effects of tension offloading during Achilles scar formation. A healthy 30-year-old male without any medical co-morbidities developed an acute rupture of his left Achilles tendon. The patient underwent open repair 1 week after injury. At post-operative day (POD) 14, the patient started daily tension offloading treatment on the inferior portion of the incision through POD 120. By POD 120, the untreated portion of the Achilles incision appeared hypertrophic and hyperpigmented, while the treated portion of the scar appeared flat with minimal pigmentation changes. The 12-week treatment of tension offloading on an Achilles tendon repair incision significantly improved cosmesis compared to untreated incision.

The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture

PURPOSE

Operative repair of Achilles tendon rupture may lead to complications, which influence outcome adversely. The aim of this study was to determine the incidence, impact and response to treatment of post-operative adhesions.

METHODS

From February 2009 to 2021, 248 patients operated on with percutaneous or minimally invasive surgical repair have been prospectively evaluated using the Achilles tendon Total Rupture Score (ATRS) and Heel-Rise Height Index (HRHI), following acute Achilles tendon rupture.

RESULTS

Fourteen (5.6%) patients were identified as having adhesions. Four patients reported superficial adhesions and ten patients reported a deeper tightness of the tendon. At a mean (SD) of 10.5 (2.3) months following repair, the overall ATRS was at a median (IQR) 65 (44.5-78) points and (HRHI) was mean (SD) 81.5 (13.5)%. Of those deemed to have deep adhesions the antero-posterior diameter of the tendon was at mean (SD) 15.6 (4.6) mm. Open release of superficial adhesions resulted in improved ATRS in all patients. Endoscopic debridement anterior to the Achilles tendon led to alleviation of symptoms of tightness and discomfort from deep adhesions and improved outcome in terms of the ATRS score. At a mean (SD) of 15.9 (3.3)-month follow-up from initial rupture and repair, the patients reported at median (IQR) ATRS scores of 85 (64.8-92.8) points, Tegner level 5 (3-9) and mean (SD) HRHI 86.2 (9.5)%. Patients significantly improved both ATRS and HRHI following release at median (IQR) of 16.5 (- 1.8-29.3) points (p = 0.041) and mean (SD) 5.6 (8.3)% (p = 0.043).

CONCLUSIONS

The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. The occurrence of superficial adhesions was associated with a lower outcome scores as well as symptoms of anterior tendon tightness and stiffness were associated with a lower score in most patients. Surgical release of adhesions led to a significant improvement in outcome.

Check-rein technique for Achilles tendon elongation following conservative management for acute Achilles tendon ruptures: a two-year prospective clinical study

Background

Following conservative management for acute Achilles tendon (AT) ruptures, the tendon may heal in continuity, and some patients may present with an elongated Achilles tendon–gastrosoleus complex. This study investigated the efficacy and feasibility of a novel minimally invasive technique, which we named “check-rein procedure”, in patients with intact and elongated AT following conservative management for AT ruptures.

Methods

All patients who underwent the check-rein procedure for elongation of the gastrosoleus–AT complex by one experienced surgeon were prospectively enrolled. The AT resting angle (ATRA) and AT rupture score (ATRS) were assessed at baseline and repeated at 2-year follow-up, as were calf circumference and isometric plantarflexion strength of both ankles.

Results

Forty-three patients (43 procedures) were analysed. The mean time elapsed from injury to surgery was 28.7 ± 7.9 weeks. The mean age at surgery was 38.5 ± 5.7 years. At the last follow-up, ATRS, ATRA, isometric strength difference, and calf circumference of the affected side were increased (P < 0.0001). The rate of the return to sport was 98% (42 of 43). No wound complications or rupture were experienced by any patient.

Conclusion

The check-rein technique for AT elongation after conservative management of AT tears is effective and feasible to restore tendon length and calf function. The surgical outcome was influenced by the preoperative performance status, and longer time elapsed from injury to surgery worsens the outcomes.

Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates

BACKGROUND

An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling.

PURPOSE

To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 1.

METHODS

Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I2 < 25%) and by random-effects models if heterogeneity was moderate to high (I2≥ 25%).

RESULTS

Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications.

CONCLUSION

This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.