Strength Measurement After Achilles Tendon Repair

Portable device for measuring isometric plantar-flexion force after open Achilles repair: Retrospective cohort of 30 recreational athletes with one-year minimum follow-up

BACKGROUND

Plantar flexion force in recreational athletes after repair of Achilles tendon tears has rarely been reported, due to the lack of a widely available and fast measurement method. Knowledge of this parameter would allow optimisation of muscular and sports recovery. The main objective of this study was to measure the isometric force of the triceps surae at least 1 year after unilateral Achilles-tendon repair, comparatively to the unaffected side, using a portable device. The secondary objectives were to compare Achilles tendon and calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test versus the normal side and to assess functional scores at last follow-up.

HYPOTHESES

(i) Plantar flexion force does not differ significantly between the operated and contralateral sides. (ii) Calf-muscle trophicity, dorsiflexion, and the single-leg heel-rise test do not differ significantly between the operated and contralateral sides.

PATIENTS AND METHODS

This single-centre retrospective study included patients aged 18 to 65 years with a history of open repair of an acute unilateral Achilles tear at least 1 year earlier. Plantar flexion force, calf-muscle trophicity, dorsiflexion, and the heel-to-floor distance were measured on both sides and compared. The ATRS, VISA-A score, and EFAS score were determined. All complications were recorded.

RESULTS

The study included 30 patients with a mean follow-up of 20.3 months (range, 12-28 months). The operated side had significantly lower values for isometric triceps surae force, calf circumference, and heel-to-floor distance compared to the contralateral side (p<0.0001). Tendon width was significantly greater on the operated side (p<0.0001). Dorsiflexion did not differ significantly between sides (p=0.106). Mean functional score values were 91.5±6 for the ATRS (maximum, 100), 85±12 for the VISA-A score (maximum, 100), and 19.5±4 for the EFAS score (maximum, 24).

DISCUSSION

Isometric triceps-surae force measured using a portable device at least 1 year after open surgical Achilles-tendon repair was significantly decreased compared to the contralateral side. Calf circumference and heel-to-floor distance were also significantly lower. These data indicate a need for improved monitoring of triceps surae recovery to optimise rehabilitation and sports resumption.

LEVEL OF EVIDENCE

IV, retrospective comparative cohort study.

Rerupture and wound complications following Achilles tendon repair: A systematic review

Despite the relatively high frequency of Achilles ruptures, there is no general consensus on the optimal treatment method. A general trend toward more patients being treated nonoperatively has emerged recently with the advent of functional rehabilitation. However, much of the recent data on this subject has been highly variable. This systematic review focused on Achilles tendon rupture (ATR) treatment outcomes, with a focus on rerupture and complication rates. This systematic review specifically focused on articles regarding ATR treatment that also included rerupture and complication rates. Treatments were divided into three categories: open minimally invasive, open standard, and nonoperative. Bivariate analyses were performed to compare complication and rerupture rates among pairs of treatment options, as well as between early weight bearing versus immobilization. There was significantly higher complications for minimally invasive compared to nonoperative treatment (risk ratio [RR] = 4.4154; p < 0.05), lower complication rates for minimally invasive compared to open treatment (RR = 0.3231; p < 0.05), and higher complications for open standard compared to nonoperative treatment (RR = 5.6350; p < 0.001). There were significantly lower rerupture rates in minimally invasive compared to nonoperative treatment (RR = 0.4085; p < 0.001), a significantly lower rerupture rate in nonoperative treatment compared to open treatment (RR = 0.2282; p < 0.001), and no significant difference in rerupture rates when comparing minimally invasive to open standard treatment. We found that operative treatment is associated with fewer reruptures and more complications than a nonoperative approach. Minimally invasive surgery appears to be associated with a lower rate of complications than open operative treatment.

Reliability and Reference Norms of Single Heel-Rise Test Among Children: A Cross-sectional Study

There is a lack of data regarding the single heel-rise test (SHRT) among children. Hence, we aimed to establish reliability and reference norms of SHRT among children aged 8 to 12 years. About 500 healthy children were randomly selected from the recognized school and community settings. After demographic measurements, SHRT was conducted to evaluate the strength of each plantar flexors. SHRT repetitions were assessed by the same rater on 2 occasions for intrarater (on the same day) and test-retest reliability (on different days) and by 2 raters for inter-rater reliability. Relative reliability was described in terms of the intraclass correlation coefficient (ICC) and Pearson correlation coefficient (r). Absolute reliability was indicated by the standard error of measurement (SEm), minimal detectable change (MDC), and Bland-Altman graph. The mean of the number of repetitions of SHRT was calculated to derive the reference norm of SHRT. The anthropometric parameters were correlated with SHRT for multiple regression analysis. Intrarater, test-retest, and inter-rater reliability of SHRT were, ICC = 0.81, ICC = 0.70, and ICC = 0.57, respectively. The Bland-Altman graph confirmed limits of agreement for intrarater, test-retest, and inter-rater reliability. The reference norm of SHRT is documented to be 20.6 ± 4.8. SEm and MDC are found to be 2 and 3, respectively. Multiple regression analysis predicted a correlation of age, weight, and calf muscle girth with SHRT. SHRT is moderate to good reliable in assessing the strength of plantar flexors. The reference norms of SHRT have been derived for healthy children aged 8 to 12 years.

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.

A Critical Biomechanical Evaluation of Foot and Ankle Soft Tissue Repair

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated.

Midterm outcome and strength assessment after proximal rectus femoris refixation in athletes

PURPOSE

Proximal rectus femoris avulsions (PRFA) are relatively rare injuries that occur predominantly among young soccer players. The aim of this study was to evaluate midterm postoperative results including strength potential via standardized strength measurements after proximal rectus femoris tendon refixation. It was hypothesized that the majority of competitive athletes return to competition (RTC) after refixation of the rectus femoris tendon without significant strength or functional deficits compared to the contralateral side.

METHODS

Patients with an acute (< 6 weeks) PRFA who underwent surgical refixation between 2012 and 2019 with a minimum follow-up of 12 months were evaluated. The outcome measures compiled were the median Tegner Activity Scale (TAS) and mean RTC time frames, Harris Hip Score (HHS), Hip and Groin Outcome Score (HAGOS) subscales, International Hip Outcome Tool-33 (iHOT-33), and Visual Analog Scale (VAS) for pain. In addition, a standardized isometric strength assessment of knee flexion, knee extension, and hip flexion was performed to evaluate the functional result of the injured limb in comparison to the uninjured side.

RESULTS

Out of 20 patients, 16 (80%) patients were available for final assessment at a mean follow-up of 44.8 ± SD 28.9 months. All patients were male with 87.5% sustaining injuries while playing soccer. The average time interval between trauma and surgery was 18.4 ± 8.5 days. RTC was possible for 14 out of 15 previously competitive athletes (93.3%) at a mean 10.5 ± 3.4 months after trauma. Patients achieved a high level of activity postoperatively with a median (interquartile range) TAS of 9 (7-9) and reported good to excellent outcome scores (HHS: 100 (96-100); HAGOS: symptoms 94.6 (89.3-100), pain 97.5 (92.5-100), function in daily living 100 (95-100), function in sport and recreation 98.4 (87.5-100), participation in physical activities 100 (87.5-100), quality of life 83.1 ± 15.6; iHot-33: 95.1 (81.6-99.8)). No postoperative complications were reported. Range of motion, isometric knee flexion and extension, as well as hip flexion strength levels were not statistically different between the affected and contralateral legs. The majority of patients were "very satisfied" (56.3%) or "satisfied" (37.5%) with the postoperative result and reported little pain (VAS 0 (0-0.5)).

CONCLUSION

Surgical treatment of acute PRFA yields excellent postoperative results in a young and highly active cohort. Hip flexion and knee extension strength was restored fully without major surgical complications.

LEVEL OF EVIDENCE

Retrospective cohort study; III.

Achilles tendon elongation after acute rupture: is it a problem? A systematic review

PURPOSE

Rupture of the Achilles tendon (AT) is a common injury. Strength deficits may persist over the long term, possibly owing to elongation of the tendon or inferior mechanical properties. This study aimed to provide a systematic review of the literature on the prevalence and consequences of tendon elongation in patients after acute AT rupture treatment. It was hypothesized that an elongated tendon would be associated with a worse clinical outcome.

METHODS

The databases for MEDLINE, CENTRAL and Web of Science were searched. Clinical studies related to AT rupture reporting tendon elongation and clinical or functional outcomes, with a minimum follow-up of 6 months, were eligible for inclusion. Only studies testing for statistical correlations (SCs) between AT elongation and other outcomes were eligible, with the exception of biomechanical studies in which statistically significant AT elongation was found to be a generalized finding in the study group. For these studies to be eligible, the study group had to be compared with a healthy control group, or the injured limb compared with the uninjured limb, regarding biomechanical parameters.

RESULTS

Twenty-eight papers were selected for inclusion. Mean AT elongation measured with imaging techniques ranged from 0.15 to 3.1 cm (n = 17). Ten studies investigated SCs with Patient Reported Outcome Measures (PROMs), in which two found SCs with tendon elongation. Five studies reported strength and power evaluations and their correlation with AT elongation, with two having found SCs between decreased strength and tendon elongation. In ten studies reporting data on biomechanical tests, nine found influence of tendon elongation. In this group, four out of five studies found SCs with biomechanical parameters.

CONCLUSION

Fair evidence of the influence of tendon elongation in biomechanical parameters was found. In a general population, evidence of a detrimental effect of tendon elongation on PROMs or functional strength at follow-up was not found in this review.

LEVEL OF EVIDENCE

Level IV.

Patient perception of Achilles tendon rupture treatment

The optimal treatment of Achilles tendon ruptures (ATRs) is a subject of some debate amongst orthopedic surgeons. Many patients' understanding of Achilles injuries is limited and may be more informed by popular culture than anything objective. We sought to assess patient perceptions of ATRs using a proprietary questionnaire and correlate that with demographic information and the health literacy of the patient. Patients presenting with an Achilles tendon injury were asked to fill out a demographic form, the Literacy in Musculoskeletal Problems (LiMP) survey, to assess musculoskeletal health literacy, and a 22-question survey on ATRs designed to assess patient knowledge and perception of ATRs. Seventy percent of patients responded that surgery with or without other modalities is the most appropriate treatment for ATRs, while only 20% of patients responded that nonoperative treatment is most appropriate. Perceptions of treatment were not associated with demographic data or LiMP scores and appear to be biased to some degree towards surgery. In a setting in which the optimal treatment has not been fully worked out by surgeons, it is difficult to tell what influence patient perceptions may have on treatment, although it is possible these patient perceptions may cause surgeons to be more surgically aggressive.

Microcurrent and adipose-derived stem cells modulate genes expression involved in the structural recovery of transected tendon of rats

Tendon injuries are common and have a high incidence of re-rupture that can cause loss of functionality. Therapies with adipose-derived stem cells (ASC) and the microcurrent (low-intensity electrical stimulation) application present promising effects on the tissue repair. We analyzed the expression of genes and the participation of some molecules potentially involved in the structural recovery of the Achilles tendon of rats, in response to the application of both therapies, isolated and combined. The tendons were distributed in five groups: normal (N), transected (T), transected and ASC (C) or microcurrent (M) or with ASC, and microcurrent (MC). Microcurrent therapy was beneficial for tendon repair, as it was observed a statistically significant increase in the organization of the collagen fibers, with involvement of the TNC, CTGF, FN, FMDO, and COL3A1 genes as well as PCNA, IL-10, and TNF-α. ASC therapy significantly increased the TNC and FMDO genes expression with no changes in the molecular organization of collagen. With the association of therapies, a significant greater collagen fibers organization was observed with involvement of the FMOD gene. The therapies did not affect the expression of COL1A1, SMAD2, SMAD3, MKX, and EGR1 genes, nor did they influence the amount of collagen I and III, caspase-3, tenomodulin (Tnmd), and hydroxyproline. In conclusion, the application of the microcurrent isolated or associated with ASC increased the organization of the collagen fibers, which can result in a greater biomechanical resistance in relation to the tendons treated only with ASC. Future studies will be needed to demonstrate the biological effects of these therapies on the functional recovery of injured tendons.

Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review

Background:

Early functional rehabilitation is frequently discussed in treating Achilles tendon rupture. A consistent definition of what constitutes early functional rehabilitation has not been established across the literature, despite studies supporting its efficacy. A standardized definition would be helpful to pool data across studies, allow for between-study comparisons, and ultimately work toward developing clinical guidelines.

Purpose:

To define early functional rehabilitation (including when it is initiated and what it entails) when used to treat Achilles tendon rupture and to identify outcome measures for evaluating the effect of treatment.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Ovid MEDLINE, EMBASE, PEDro, CINAHL, and Cochrane databases were searched for relevant studies. Eligibility criteria for selecting studies consisted of randomized controlled trials, cohort studies, and case series (≥10 participants) including weightbearing or exercise-based interventions within 8 weeks after Achilles tendon rupture.

Results:

A total of 174 studies published between 1979 and 2018 were included. Studies were rated a median (interquartile range [IQR]) of 17 (15-20) on the Downs & Black checklist and included 9098 participants. Early functional rehabilitation incorporated weightbearing (95%), range of motion (73%), and isometric/strengthening exercises (50%). Weightbearing was initiated within the first week, whereas exercise (eg, ankle range of motion, strengthening, whole-body conditioning) was initiated in the second week. Initiation of exercises varied based on whether treatment was nonsurgical (mean, 3.0 weeks; IQR, 2.0-4.0 weeks) or simple (mean, 2.0 weeks; IQR, 0.0-2.3 weeks) or augmented surgical repair (mean, 0.5 weeks; IQR, 0.0-2.8 weeks) (P = .017). Functional outcomes including ankle range of motion (n = 84) and strength (n = 76) were reported in 130 studies. Other outcome domains included patient-reported outcomes (n = 89), survey-based functional outcomes (n = 50), and tendon properties (n = 53).

Conclusion:

Early functional rehabilitation includes weightbearing and a variety of exercise-based interventions initiated within the first 2 weeks after acute Achilles tendon rupture/repair. Because early functional rehabilitation has lacked a standardized definition, interventions and outcome measures are highly variable, and pooling data across studies should be done with attention paid to what was included in the intervention and how treatment was assessed.