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Cole K, Moosa A, Rhodes A, Elmesalmi M, Azaz R, Rowe H, Koç T. Audit of a Revised Pathway Aimed at Expediting Diagnosis and Treatment for Suspected Achilles Tendon Rupture. J Foot Ankle Surg 2024:S1067-2516(24)00091-7. [PMID: 38740278 DOI: 10.1053/j.jfas.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 05/16/2024]
Abstract
Treatment outcomes for Achilles tendon ruptures depend upon prompt diagnosis and management. A local study in 2018 highlighted inefficiencies in patient management, and a revised protocol was introduced allowing investigation and referral to be initiated by other healthcare professionals. This retrospective audit evaluates the impact of this on the timescale from presentation to treatment. It analyzes all suspected Achilles tendon ruptures within one District General Hospital from April 2021 to March 2022. Data regarding patient timelines was compared to the 2018 study. Over 12 months, 99 patients were referred to Virtual Fracture Clinic, 87.8% (n = 87) of which had a complete or partial tear on ultrasound scan (USS). In comparison to 2018, the average time from presentation to USS request reduced from 2.9 to 1.1 days (p < .01). 95% were scanned within one week of USS request and 31.3% within 48 hours (81% and 18%, previously). The average time from USS request to scan went from 6.8 to 3.2 days (p < .01). The time from presentation to treatment decision reduced from 10.9 to 6.2 days (p < .01) and the percentage of patients with a definitive treatment plan within one week increased from 34.5% to 74.2% (p < .01). Patients required 0.8 fewer appointments (p < .01) giving an estimated total saving of $10,110 ($128 per patient) during the analyzed period. The Achilles Tendon Rupture Pathway has significantly improved the proportion of patients undergoing USS within 48 hours and receiving a treatment decision within one week. This study demonstrates an efficient, cost-saving and replicable pathway for Achilles tendon ruptures.
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Affiliation(s)
- Kirsty Cole
- Queen Alexandra Hospital, Portsmouth, United Kingdom; Dorset County Hospital, United Kingdom.
| | | | - Amanda Rhodes
- Queen Alexandra Hospital, Portsmouth, United Kingdom
| | | | - Rawad Azaz
- Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Henry Rowe
- Queen Alexandra Hospital, Portsmouth, United Kingdom; Dorset County Hospital, United Kingdom
| | - Togay Koç
- Queen Alexandra Hospital, Portsmouth, United Kingdom; University Hospital Southampton, United Kingdom; University of Southampton, United Kingdom
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2
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Fenech M, Ajjikuttira A, Edwards H. Ultrasound assessment of acute Achilles tendon rupture and measurement of the tendon gap. Australas J Ultrasound Med 2024; 27:106-119. [PMID: 38784700 PMCID: PMC11109999 DOI: 10.1002/ajum.12384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Achilles tendon rupture is a common sports-related injury which can carry significant morbidity to patients. Ultrasound remains the workhorse of imaging as it can confirm and localise the extent of Achilles tendon injury. The sonographic anatomy, both normal and ruptured sonographic appearances, as well as sonographic technique must be appreciated to accurately image and report findings, critical to patient management. Particular attention should be applied to the measurement of the diastasis between acutely ruptured tendon ends as this information can assist with informing the decision of conservative vs. operative management. Further work is necessary to standardise the measurement technique including correlating the degree of plantarflexion of the foot with the sonographic tendon gap measures.
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Affiliation(s)
- Michelle Fenech
- School of Health, Medical and Applied Sciences, College of Clinical Sciences, Central Queensland UniversityBrisbane Campus, 160 Ann StreetBrisbane4000QueenslandAustralia
- Department of Medical ImagingRoyal Brisbane and Women's HospitalHerston, Brisbane4006QueenslandAustralia
| | - Aiyapa Ajjikuttira
- Department of Medical ImagingRoyal Brisbane and Women's HospitalHerston, Brisbane4006QueenslandAustralia
| | - Heath Edwards
- Department of Medical ImagingRoyal Brisbane and Women's HospitalHerston, Brisbane4006QueenslandAustralia
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Carmont MR, Gunnarsson B, Brorsson A, Nilsson-Helander K. 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. J ISAKOS 2024; 9:148-152. [PMID: 38154754 DOI: 10.1016/j.jisako.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 12/30/2023]
Abstract
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.
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Affiliation(s)
- Michael R Carmont
- Department of Trauma & Orthopaedic Surgery, Shrewsbury & Telford Hospital NHS Trust, Shropshire, TF1 6TF, United Kingdom; University of Keele, Staffordshire, ST5 5BG, United Kingdom; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden.
| | - Baldvin Gunnarsson
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
| | - Annelie Brorsson
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedic Surgery, Mölndal Hospital, University of Gothenburg, 431 60, Sweden; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, 413 90, Sweden
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Hammad ME, Fayed AM, Ayoub MA, Emran AM. Early satisfactory results of percutaneous repair in neglected achilles tendon rupture. BMC Musculoskelet Disord 2023; 24:446. [PMID: 37268932 DOI: 10.1186/s12891-023-06561-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/20/2023] [Indexed: 06/04/2023] Open
Abstract
PURPOSE This investigation aimed to study the outcome of percutaneous repair of Achilles tendon ruptures regarding patient-reported and objective outcomes. METHODS This is a retrospective review of a cohort of patients (n = 24) who underwent percutaneous repair of neglected Achilles rupture in the period between 2013 and 2019. Included patients were adults with closed injuries, presented 4-10 weeks after rupture, with intact deep sensation. All underwent clinical examination, X-rays to exclude bony injury and MRI for diagnosis confirmation. All underwent percutaneous repair by the same surgeon, using the same technique and rehabilitation protocol. The postoperative assessment was done subjectively using ATRS and AOFAS score and objectively using a percentage of heel rise comparison to the normal side and calf circumference difference. RESULTS The mean follow-up period was 14.85 months ± 3 months. Average AOFAS scores at 6,12 months were 91 and 96, respectively, showing statistically significant improvement from pre-op level (P < 0.001). Percentage of heel rise on the affected side and calf circumference showed statistically significant improvement over the 12 month follow up period (P < 0.001). Superficial infection was reported in two patients (8.3%), and two cases reported transient sural nerve neuritis. CONCLUSION Percutaneous repair of neglected Achilles rupture using the index technique proved a satisfactory patient-reported and objective measurement at a one-year follow-up. With only minor transient complications.
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Affiliation(s)
- Mostafa Elsebai Hammad
- Department of Orthopaedic surgery, Faculty of medicine, Tanta University, Hassan Radwan st. Tanta city, Gharbia governorate, Tanta city, Al-gharbia governorate, ZIP:31511, Egypt.
| | - Aly Maher Fayed
- Department of Orthopaedic surgery, Faculty of medicine, Tanta University, Hassan Radwan st. Tanta city, Gharbia governorate, Tanta city, Al-gharbia governorate, ZIP:31511, Egypt
| | - Mostafa Ahmed Ayoub
- Department of Orthopaedic surgery, Faculty of medicine, Tanta University, Hassan Radwan st. Tanta city, Gharbia governorate, Tanta city, Al-gharbia governorate, ZIP:31511, Egypt
| | - Ali Mahmoud Emran
- Department of Orthopaedic surgery, Faculty of medicine, Tanta University, Hassan Radwan st. Tanta city, Gharbia governorate, Tanta city, Al-gharbia governorate, ZIP:31511, Egypt
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Qureshi A, Gulati A, Adukia V, Shah A, Mangwani J. The influence of the site of rupture and gap distance in acute Achilles tendon rupture treated with functional rehabilitation. Injury 2023; 54:1216-1221. [PMID: 36828734 DOI: 10.1016/j.injury.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 02/26/2023]
Abstract
AIM To determine the influence of gap distance and its location on clinical and radiological outcomes in patients with acute rupture of Tendo-Achilles (TA) treated non-operatively with functional rehabilitation. METHODS Twenty-six patients with acute complete TA rupture underwent ultrasound (US) scanning within a week of their injury. The measurements taken included the distance of the rupture from the enthesis and the gap distance between the tendon edges in varying degrees of ankle and knee positions. All patients were managed non-operatively in functional weight-bearing orthoses. Nineteen patients were then followed up at a mean of 6.1 years (range 5.8-6.5) to assess their clinical and radiological outcomes. The outcomes included ultrasound assessment of tendon healing, Achilles Tendon Rupture Score (ATRS) and modified Leppilahti Score (mLS). RESULTS In the initial ultrasound, the mean distance of the rupture from the enthesis was 52 mm (range: 40-76). The mean gap distance with the foot plantigrade was 11.4 mm, which reduced to 4.8 mm with the foot in equinus. At final follow up, no re-ruptures had occurred. The mean ATRS and mLS were 86 and 71 respectively. There was a significant correlation between the distance of the rupture from the enthesis with the MLS total score (p = 0.02), mLS Fatigue domain score (p = 0.03), and the ATRS domains of strength (p = 0.04) and fatigue (p = 0.02). There was no significant correlation between the measured gap distance with respect to the mLS, ATRS or individual ATRS domain scores. Also, there was no significant difference in ATRS and mLS outcomes when comparing tendons with respect to healed tissue appearance and fibre orientation on ultrasound. CONCLUSION The initial gap distance had no relationship with any of the measured clinical outcomes at the final follow up. The distance of the gap from the enthesis, however, may carry a greater prognostic value following non-operative treatment of Achilles tendon injuries.
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Affiliation(s)
| | | | - Vidhi Adukia
- University Hospitals of Leicester NHS Trust, UK.
| | - Amit Shah
- University Hospitals of Leicester NHS Trust, UK
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Yang S, Shi W, Yan W, Ao Y, Guo Q, Yang Y. Comparison between primary repair and augmented repair with gastrocnemius turn-down flap for acute Achilles tendon rupture: a retrospective study with minimum 2-year follow-up. BMC Musculoskelet Disord 2023; 24:163. [PMID: 36871017 PMCID: PMC9985193 DOI: 10.1186/s12891-023-06260-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND To explore and compare the clinical outcomes in patients undergoing primary repair versus augmented repair with a gastrocnemius turn-down flap for acute Achilles tendon rupture. METHODS From 2012 to 2018, the clinical data of 113 patients with acute Achilles tendon rupture who were treated with primary repair or augmented repair with a gastrocnemius turn-down flap by the same surgeon were retrospectively reviewed. The patients' preoperative and postoperative scores on the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society Ankle⁃Hindfoot (AOFAS) score, the Victorian Institute of Sport Assessment⁃Achilles (VISA-A), the Achilles tendon total rupture score (ATRS), and the Tegner Activity Scale were examined and compared. The postoperative calf circumference was measured. A Biodex isokinetic dynamometer was used to evaluate the plantarflexion strength on both sides. The time to return to life and exercise as well as the strength deficits in both groups were recorded. Finally, the correlation analyses between patient characteristics and treatment details with clinical outcomes were conducted. RESULTS In total, 68 patients were included and completed the follow-up. The 42 and 26 patients who were treated with primary repair and augmented repair were assigned to group A and B, respectively. No serious postoperative complications were reported. No significant between-group differences in any outcomes were observed. It was found that female sex was correlated with poorer VISA-A score (P = 0.009), complete seal of paratenon was correlated with higher AOFAS score (P = 0.031), and short leg cast was correlated with higher ATRS score (P = 0.006). CONCLUSIONS Augmented repair with a gastrocnemius turn-down flap provided no advantage over primary repair for the treatment of acute Achilles tendon rupture. After surgical treatment, females tended to had poorer outcomes, while complete seal of paratenon and short leg cast contributed to better results. LEVEL OF EVIDENCE Cohort study; Level of evidence, 3.
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Affiliation(s)
- Shuai Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Weili Shi
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Wenqiang Yan
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Yingfang Ao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China
| | - Qinwei Guo
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China.
| | - Yuping Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, 49 North Garden Road, Beijing, Haidian District, 100191, China.
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Hansen MS, Bencke J, Kristensen MT, Kallemose T, Hölmich P, Barfod KW. Achilles tendon gait dynamics after rupture: A three-armed randomized controlled trial comparing an individualized treatment algorithm vs. operative or non-operative treatment. Foot Ankle Surg 2023; 29:143-150. [PMID: 36528540 DOI: 10.1016/j.fas.2022.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Individual treatment selection has been proposed as the key to optimized treatment. The purpose was to investigate if treatment selection using the individualized treatment algorithm Copenhagen Achilles Rupture Treatment Algorithm (CARTA) differs between patients treated as usual regarding gait dynamics and tendon elongation. METHODS The patients were randomized to one of three parallel groups: 1) intervention group: participants treated according to CARTA, 2) control group: participants treated non-operatively, 3) control group: participants treated operatively. The primary outcome was ankle peak power during push off during walking at 12 months. RESULTS 156 patients were assessed for eligibility. 21 were allocated to the intervention group, and 20 and 19 to the control groups. The results indicated no statistically significant differences between the intervention group and the control groups. CONCLUSIONS Individualized treatment selection based on CARTA did not demonstrate less affected gait dynamics or less tendon elongation than patients treated as usual.
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Affiliation(s)
- Maria Swennergren Hansen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark; Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Jesper Bencke
- Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Morten Tange Kristensen
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark.
| | - Thomas Kallemose
- Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Per Hölmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark.
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Deng H, Cheng X, Yang Y, Fang F, He J, Tian Y, Li T, Xiao Y, Feng Y, Wang P, Chong W, Hai Y, Zhang Y. Rerupture outcome of conservative versus open repair versus minimally invasive repair of acute Achilles tendon ruptures: A systematic review and meta-analysis. PLoS One 2023; 18:e0285046. [PMID: 37130120 PMCID: PMC10153690 DOI: 10.1371/journal.pone.0285046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/14/2023] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVE To compare the rerupture rate after conservative treatment, open repair, and minimally invasive surgery management of acute Achilles tendon ruptures. DESIGN Systematic review and network meta-analysis. DATA SOURCES We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to August 2022. METHODS Randomised controlled trials involving different treatments for Achilles tendon rupture were included. The primary outcome was rerupture. Bayesian network meta-analysis with random effects was used to assess pooled relative risks (RRs) and 95% confidence intervals. We evaluated the heterogeneity and publication bias. RESULTS Thirteen trials with 1465 patients were included. In direct comparison, there was no difference between open repair and minimally invasive surgery for rerupture rate (RR, 0.72, 95% CI 0.10-4.4; I2 = 0%; Table 2). Compared to the conservative treatment, the RR was 0.27 (95% CI 0.10-0.62, I2 = 0%) for open repair and 0.14 (95% CI 0.01-0.88, I2 = 0%) for minimally invasive surgery. The network meta-analysis had obtained the similar results as the direct comparison. CONCLUSION Both open repair and minimally invasive surgery were associated with a significant reduction in rerupture rate compared with conservative management, but no difference in rerupture rate was found comparing open repair and minimally invasive surgery.
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Affiliation(s)
- Haidong Deng
- Department of Orthopedic, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Xin Cheng
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Yang
- Department of Orthopedic, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Fang Fang
- Center for Evidence Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Jialing He
- Center for Evidence Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yixin Tian
- Center for Evidence Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Tiangui Li
- The First People's Hospital of Longquanyi District, Chengdu, Sichuan, China
| | - Yangchun Xiao
- Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yuning Feng
- Department of Orthopedic, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Peng Wang
- Center for Evidence Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Yang Hai
- Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Yu Zhang
- Department of Orthopedic, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
- Center for Evidence Based Medical, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
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Leino O, Keskinen H, Laaksonen I, Mäkelä K, Löyttyniemi E, Ekman E. Incidence and Treatment Trends of Achilles Tendon Ruptures in Finland: A Nationwide Study. Orthop J Sports Med 2022; 10:23259671221131536. [PMID: 36389616 DOI: 10.1177/23259671221131536] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/04/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Oskari Leino
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Heli Keskinen
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Inari Laaksonen
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Eliisa Löyttyniemi
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Elina Ekman
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
- Faculty of Medicine, University of Turku, Turku, Finland
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10
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Rendek Z, Bon Beckman L, Schepull T, Dånmark I, Aspenberg P, Schilcher J, Eliasson P. Early Tensile Loading in Nonsurgically Treated Achilles Tendon Ruptures Leads to a Larger Tendon Callus and a Lower Elastic Modulus: A Randomized Controlled Trial. Am J Sports Med 2022; 50:3286-3298. [PMID: 36005394 PMCID: PMC9527451 DOI: 10.1177/03635465221117780] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early tensile loading improves material properties of healing Achilles tendon ruptures in animal models and in surgically treated human ruptures. However, the effect of such rehabilitation in patients who are nonsurgically treated remains unknown. HYPOTHESIS In nonsurgically treated Achilles tendon ruptures, early tensile loading would lead to higher elastic modulus 19 weeks after the injury compared with controls. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS Between October 2015 and November 2018, a total of 40 nonsurgically treated patients with acute Achilles tendon rupture were randomized to an early tensile loading (loaded group) or control group. Tantalum bead markers were inserted percutaneously into the tendon stumps 2 weeks after the injury to allow high-precision measurements of callus deformation under mechanical testing. The loaded group used a training pedal twice daily to produce a gradual increase in tensile load during the following 5 weeks. Both groups were allowed full weightbearing in an ankle orthosis and unloaded range of motion exercises. Patients were followed clinically and via roentgen stereophotogrammetric analysis and computed tomography at 7, 19, and 52 weeks after the injury. RESULTS The mean ± standard deviation elastic modulus at 19 weeks was 95.6 ± 38.2 MPa in the loaded group and 108 ± 45.2 MPa in controls (P = .37). The elastic modulus increased in both groups, although it was lower in the loaded group at all time points. Tendon cross-sectional area increased from 7 weeks to 19 weeks, from 231 ± 99.5 to 388 ± 142 mm2 in the loaded group and from 188 ± 65.4 to 335 ± 87.2 mm2 in controls (P < .001 for the effect of time). Cross-sectional area for the loaded group versus controls at 52 weeks was 302 ± 62.4 mm2 versus 252 ± 49.2 mm2, respectively (P = .03). Gap elongation was 7.35 ± 13.9 mm in the loaded group versus 2.86 ± 5.52 mm in controls (P = .27). CONCLUSION Early tensile loading in nonsurgically treated Achilles tendon ruptures did not lead to higher elastic modulus in the healing tendon but altered the structural properties of the tendon via an increased tendon thickness. REGISTRATION NCT0280575 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Zlatica Rendek
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Leo Bon Beckman
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Thorsten Schepull
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Ida Dånmark
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden
| | - Per Aspenberg
- Author deceased,Orthopedic Department, Linköping University Hospital, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- Orthopedic Department, Linköping University Hospital, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Pernilla Eliasson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden,Pernilla Eliasson, MSc, PhD, Department of Biomedical and Clinical Sciences, Division of Cell Biology, Linköping University, Cell Biology Building Floor 10, Linköping, SE-58183, Sweden ()
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11
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Barfod KW, Hansen MS, Sandholdt H, Boesen A, Hölmich P, Troelsen A, Kristensen MT. The Copenhagen Achilles Length Measurement Performed at Time of Acute Achilles Tendon Rupture is Correlated to Tendon Elongation After 1 Year. J Foot Ankle Surg 2022; 61:1098-1102. [PMID: 35241344 DOI: 10.1053/j.jfas.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/25/2022] [Indexed: 02/03/2023]
Abstract
Elongation of the tendon has been proposed as the most important factor leading to poor outcome after acute Achilles tendon rupture (ATR). The aim of this paper was to investigate if Amlang's ultrasound classification (AmC) or the Copenhagen Achilles Length Measurement (CALM) when assessed in the acute phase after ATR could predict elongation 1 y after rupture. 107 males and 27 females, aged 18 to 70 y and treated nonsurgically were included. AmC and CALM were assessed at time of rupture and correlated to elongation measured with CALM and Achilles Tendon Resting Angle (ATRA) at 1 y. Receiver operating characteristic (ROC) analysis was performed to determine a cut off for acceptable elongation at time of rupture given that elongation at 1 y was not to exceed 10%. AmC showed no statistically significant correlation. CALM at baseline correlated to CALM at 1 y r = 0.214 (p = .02) and ATRA at 1 y r = 0.218 (p = .02). The ROC model had AUC = 0.67 for 7% elongation at baseline yielding a sensitivity of 0.77 and specificity of 0.50 for predicting elongation of 10% or more at 1 y. Elongation of the Achilles tendon at baseline measured with CALM was weakly correlated to elongation at 1 y. A cut off of 7% elongation at baseline caught 77% of patients who, when treated nonsurgically, ended up with an elongation above 10% at 1 y. A prospective trial investigating CALM as part of a selection algorithm for deciding between operative and nonoperative treatment is needed.
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Affiliation(s)
- Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark.
| | - Maria Swennergren Hansen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Håkon Sandholdt
- Clinical Research Center, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Anders Boesen
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Per Hölmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Morten Tange Kristensen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, and Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
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12
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Affiliation(s)
| | - Harish Kurup
- United Lincolnshire Hospitals NHS Trust, Boston, United Kingdom
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13
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Functional outcome of early weight bearing for acute Achilles tendon rupture treated conservatively in a weight-bearing orthosis. Foot Ankle Surg 2022; 28:595-602. [PMID: 34301483 DOI: 10.1016/j.fas.2021.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/07/2021] [Accepted: 06/28/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The optimal management for Achilles tendon (AT) ruptures is controversial and still continues to encourage debate. Conventionally, operative repair was favoured secondary to its lower rates of re-rupture, however in more recent years, we have seen promising results and a reduction in complications with conservative management. One reason for this improvement may be due to the introduction of a functional weight-bearing orthosis, however, results for complete AT ruptures is still unclear. This study aims to evaluate the functional outcomes of early weight bearing in a functional orthosis for conservatively managed, complete AT ruptures. METHODOLOGY This study was done at East Kent Hospital University Foundation Trust in between 2019-2020. In this prospective study, we have analysed data from 41 patients with US diagnosed compete AT ruptures, with a gap less than 5 cm. Every patient was treated in a functional weight-bearing orthosis (VACOped®) for 8 weeks with early weight-bearing following a specific treatment protocol, followed by rehabilitation with a trained physiotherapist. All patients received a final follow-up at 1 year post injury, where we recorded the following functional outcome measurements on each leg: calf girth, single leg heel raise height, single leg heel raise repetitions and the ATRS score. RESULT Our study population was predominantly male with an average age of 50 (range 22-79). The majority of the cohort were physically active, with more than 75% involved in a form of sporting activity pre-injury and 15% involved in higher level activity and competitive sport. The mean ATRS score was 82.1, with a re-rupture rate of only 2%. The average calf bulk difference was 1.6 cm, average heel raise height difference was 1.8 cm and a heel raise repetition difference of 6. There was a statistically significant correlation between ATRS score and calf muscle girth (p = 0.02). However, there was no significant correlation between ATRS score and heel raise height or single heel raise repetitions. CONCLUSION Early weight-bearing in a functional orthosis provides excellent functional outcomes for conservatively managed, complete AT ruptures, and is associated with very low re-rupture rates. However, a multidisciplinary approach with a guided rehabilitation programme is essential for optimising functional outcome.
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14
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The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors. Knee Surg Sports Traumatol Arthrosc 2022; 30:2457-2469. [PMID: 35018477 DOI: 10.1007/s00167-021-06824-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
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.
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15
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Williams CJ, Hodkinson S, Chandrasekaran K, Koc T, Gibb I, Dando C, Bowen C, Oakley J. A retrospective audit of the timescales involved in the diagnosis and management of suspected Achilles tendon ruptures at a single National Health Service trust: A quality service improvement and redesign project. ULTRASOUND (LEEDS, ENGLAND) 2022; 30:117-125. [PMID: 35509302 PMCID: PMC9058383 DOI: 10.1177/1742271x211023800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022]
Abstract
Introduction The Achilles tendon is the most frequently ruptured tendon. Prompt diagnosis of this injury ensures optimal management decisions are instituted early ensuring the best outcome and patient experience, at minimal cost to the United Kingdom National Health Service. Despite this, regional and national variations to diagnosis and management exist, with anecdotal evidence of inefficiencies in the local patient pathway. To explore this further, a retrospective departmental audit of timescales from presentation to ultrasound diagnosis and definitive treatment decision was undertaken. Methods All suspected Achilles tendon ruptures in 2018 were identified through electronic and written patient records, and information on timescales involved in the diagnosis and management of each compiled. Descriptive statistics were used to map each step of the pathway and timescales involved, with performance assessed against local departmental standards and the Swansea Morriston Achilles Rupture Treatment (SMART) protocol. Results In total, 119 patients were identified, of which 113 received an ultrasound examination. Local departmental standards were met in the majority of cases, with 78% (n = 88) diagnosed by ultrasound within one week of the request and 83% (n = 91) given a treatment decision within two weeks of presentation. However, this was suboptimal when compared with timeframes utilised for developing the SMART protocol, with only 7% (n = 8) scanned within 48 hours of presentation. Conclusions Key areas of the patient pathway were identified for quality service improvement and redesign, with multidisciplinary discussion resulting in the development of a revised patient pathway which expedites diagnosis and treatment for these injuries.
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Affiliation(s)
- C J Williams
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - S Hodkinson
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - T Koc
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - I Gibb
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - C Dando
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - C Bowen
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - J Oakley
- School of Health and Care Professions, Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
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Oliver WM, Mackenzie SA, Lenart L, McCann CJ, Mackenzie SP, Duckworth AD, Clement ND, White TO, Maempel JF. Age, personal and family history are independently associated with venous thromboembolism following acute Achilles tendon rupture. Injury 2022; 53:762-770. [PMID: 34689989 DOI: 10.1016/j.injury.2021.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/29/2021] [Accepted: 10/10/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The primary aim was to determine independent patient, injury and management-related factors associated with symptomatic venous thromboembolism (VTE) following acute Achilles tendon rupture (ATR). The secondary aim was to suggest a clinical VTE risk assessment tool for patients with acute ATR. METHODS From 2010-2018, 984 consecutive adults (median age 47yrs, 73% [n = 714/984] male) sustaining an acute ATR were retrospectively identified. Ninety-five percent (n = 939/984) were managed non-operatively in a below-knee cast (52%, n = 507/984) or walking boot (44%, n = 432/984), with 5% (n = 45/984) undergoing primary operative repair (<6wks post-injury). VTE was diagnosed using local medical records and national imaging archives, reviewed at a mean 5yrs (range 1-10) post-injury. Multivariate logistic regression was performed to determine independent factors associated with VTE. RESULTS The incidence of VTE within 90 days of ATR was 3.6% (n = 35/984; deep vein thrombosis 2.1% [n = 21/984], pulmonary embolism 1.9% [n = 19/984]), and the median time to VTE was 24 days (interquartile range 15-44). Age ≥50yrs (adjusted OR [aOR] 2.3, p = 0.027), personal history of VTE/thrombophilia (aOR 6.1, p = 0.009) and family history of VTE (aOR 20.9, p<0.001) were independently associated with VTE following ATR. These non-modifiable risk factors were incorporated into a VTE risk assessment tool. Only 23% of patients developing VTE (n = 8/35) had a relevant personal or family history, but incorporating age ≥50yrs into the VTE risk assessment tool (alongside personal and family history) identified 69% of patients with VTE (n = 24/35). Non weight-bearing for ≥2wks after ATR was also independently associated with VTE (aOR 3.2, p = 0.026). CONCLUSIONS Age ≥50 years, personal history of VTE/thrombophilia and a positive family history were independently associated with VTE following ATR. Incorporating age into our suggested VTE risk assessment tool enhanced its sensitivity in identifying at-risk patients. Early weight-bearing in an appropriate orthosis may be beneficial to all patients in VTE risk reduction.
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Affiliation(s)
- William M Oliver
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, United Kingdom.
| | - Samuel A Mackenzie
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, United Kingdom.
| | - Lucia Lenart
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, United Kingdom.
| | - Conor J McCann
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, United Kingdom.
| | - Samuel P Mackenzie
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, United Kingdom.
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, United Kingdom; Centre for Population Health Sciences, Usher Institute, University of Edinburgh, 49 Little France Crescent, EH16 4SB, United Kingdom.
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, United Kingdom.
| | - Timothy O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Midlothian, EH16 4SA, United Kingdom.
| | - Julian F Maempel
- Department of Trauma, Orthopaedics and Sports Medicine, Mater Dei Hospital, Msida, MSD 2090, Malta; University of Malta Medical School, University of Malta, Msida, MSD 2090, Malta.
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17
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Coopmans L, Amaya Aliaga J, Metsemakers WJ, Sermon A, Misselyn D, Nijs S, Hoekstra H. Accelerated Rehabilitation in Non-operative Management of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis. J Foot Ankle Surg 2022; 61:157-162. [PMID: 34400090 DOI: 10.1053/j.jfas.2021.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/10/2021] [Indexed: 02/03/2023]
Abstract
The optimal treatment and rehabilitation strategy for Achilles tendon ruptures is still under debate. There is a paradigm shift toward early mobilization and weightbearing. We examined the treatment effect of accelerated functional rehabilitation in nonoperative management of acute Achilles tendon ruptures. A systematic search of PubMed, EMBASE, and Web of Science databases for articles comparing accelerated versus delayed rehabilitation in the nonoperative management of acute Achilles tendon rupture was performed. Outcomes of interest were Achilles tendon rupture score (ATRS) (standardized patient-reported instrument related to symptoms and physical activity after treatment of an acute Achilles tendon rupture), rerupture rate, strength, range of motion, return to work, and sports. A total of 2001 articles were identified using our search strategy. We included 6 randomized controlled trials of interest. Although the concept of accelerated rehabilitation has gained popularity in recent years, no statistically significant differences could be revealed in any of the outcomes of interest. We performed a meta-analysis on the following outcomes: ATRS (mean difference -0.93 95% confidence interval [CI] -6.01 to 4.14), Rerupture rate (odds ratio [OR] 0.97, 95% CI: 0.46-2.03), Return to sports (OR 1.31, 95% CI 0.76-2.25), Return to work (mean difference 5.24, 95% CI to -12.04 to 22.51). The treatment effect of accelerated rehabilitation in nonoperatively treated patients seems to be small. However, we recommend accelerated rehabilitation for all conservatively treated patients, because it is a safe option and no detrimental effects have been described in the literature. Furthermore, many patients prefer this type of rehabilitation to avoid the practical disadvantages of prolonged immobilization.
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Affiliation(s)
- Laurens Coopmans
- Faculty of Medicine, KU Leuven - University of Leuven, Leuven, Belgium
| | - Jorge Amaya Aliaga
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Orthopaedics and Traumatology, VU Brussel - Free University of Brussels, Brussels, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - An Sermon
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - Dominique Misselyn
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium.
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18
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Sikorski Ł, Czamara A. Ground Reaction Forces during Vertical Hops Are Correlated with the Number of Supervised Physiotherapy Visits after Achilles Tendon Surgery. J Clin Med 2021; 10:jcm10225299. [PMID: 34830581 PMCID: PMC8620226 DOI: 10.3390/jcm10225299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 12/26/2022] Open
Abstract
The objective of this study was to assess the effectiveness of, and the correlation between, an average of 42 supervised physiotherapy (SVPh) visits for the vertical ground reaction forces component (vGRF) using ankle hops during two- and one-legged vertical hops (TLH and OLH, respectively), six months after the surgical suturing of the Achilles tendon using the open method (SSATOM) via Keesler’s technique. Hypothesis: Six months of supervised physiotherapy with a higher number of visits (SPHNVs) was positively correlated with higher vGRF values during TLH and OLH. Group I comprised male patients (n = 23) after SSATOM (SVPh x = 42 visits), and Group II comprised males (n = 23) without Achilles tendon injuries. In the study groups, vGRF was measured during TLH and OLH in the landing phase using two force plates. The vGRF was normalized to the body mass. The limb symmetry index (LSI) of vGRF values was calculated. The ranges of motion of the foot and circumferences of the ankle joint and shin were measured. Then, 10 m unassisted walking, the Thompson test, and pain were assessed. A parametric test for dependent and independent samples, ANOVA and Tukey’s test for between-group comparisons, and linear Pearson’s correlation coefficient calculations were performed. Group I revealed significantly lower vGRF values during TLH and OLH for the operated limb and LSI values compared with the right and left legs in Group II (p ≤ 0.001). A larger number of visits correlates with higher vGRF values for the operated limb during TLH (r = 0.503; p = 0.014) and OLH (r = 0.505; p = 0.014). An average of 42 SVPh visits in 6 months was insufficient to obtain similar values of relative vGRF and their LSI during TLH and OLH, but the hypothesis was confirmed that SPHNVs correlate with higher relative vGRF values during TLH and OLH in the landing phase.
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Affiliation(s)
- Łukasz Sikorski
- Department of Physiotherapy, College of Physiotherapy in Wrocław, 50-038 Wrocław, Poland;
- Correspondence: ; Tel.: +48-601-911-013
| | - Andrzej Czamara
- Department of Physiotherapy, College of Physiotherapy in Wrocław, 50-038 Wrocław, Poland;
- Center of Rehabilitation and Medical Education, 50-038 Wrocław, Poland
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Carmont MR, Brorsson A, Barfod KW, Ginder L, Littlehales J, Karlsson J, Nilsson-Helander K. The reliability, reproducibility and utilization of the radiographic Achilles Tendon Loading Angle in the management of Achilles Tendon rupture. Foot Ankle Surg 2021; 27:760-766. [PMID: 33059973 DOI: 10.1016/j.fas.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/16/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND During management of Achilles tendon rupture, determination of tendon-end approximation, either clinically or by ultrasound is difficult, following brace application of during loading. The Radiographic Achilles Tendon Loading Angle (RadATLA) is proposed as a method of measuring ankle position whilst loading in a brace during the management of Achilles tendon rupture. This study aims to determine the reliability and reproducibility of the RadATLA. METHODS A loaded true lateral ankle radiograph including the fifth metatarsal head was taken when wearing a brace at the 6-week time point in 18 patients (19 ankles). following Achilles tendon repair or reconstruction. The RadATLA was compared with the Tibio-talar angle, other radiographic and clinical measures used to quantify foot and ankle position during the first 6 weeks of early rehabilitation in a resting position and during loading. RESULTS The intra-rater reliability of both angles was found to be good (>0.8). The RadATLA was found to have an excellent intra-rater reliability with Intra-class correlation of (ICC) 0.992-0.996 (95%CI 0.889-0.999), standard error of the measurement (SEM) 1.03-3.65 and Minimal Detectable Change (MDC) 2.86-10.12. The inter-rater reliability was good with ICC of 0.798-0.969 (95%CI-0.03 to 0.964), SEM 2.9-7.6, and MDC 8.1-20.9. The RadATLA loaded at 6 weeks in all patients was at mean (SD) (range) 41.9˚ (16.5), (18.5-75.9). There was a significant difference between the patients in the Repair group compared with patients in the Reconstruction group both in RadATLA loaded at 6 weeks: 35.6˚ (11.2), (18.5-56.5) versus 55.5˚ (19), (20-75.9), (p = 0.01). The amount loaded in all patients was at mean (SD) (range) 29.2Kg (17.7), (2-56) and the percentage Body Weight was 30.7% (19), (2.1-63.2). There were no differences between the groups neither in amount loaded nor in percentage Body weight (p = 0.614-0.651). CONCLUSIONS The RadATLA is a reliable and reproducible angle and can be used to determine the position of the ankle, when loaded in a brace during rehabilitation following Achilles tendon rupture.
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Affiliation(s)
- Michael R Carmont
- The Department of Trauma & Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom; The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Sweden.
| | - Annelie Brorsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Sweden
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopaedic Research Center-Copenhagen (SORC-C), Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Laurence Ginder
- The Department of Radiology & Imaging, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom
| | - Julie Littlehales
- The Department of Trauma & Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Shropshire, United Kingdom
| | - Jón Karlsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Sweden
| | - Katarina Nilsson-Helander
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Sweden
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20
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Julies E, Williams T, Hall S. The Surgical Care Practitioner role in Achilles tendon re-rupture: A case study. J Perioper Pract 2021; 31:454-462. [PMID: 34478332 DOI: 10.1177/17504589211002377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The value of a Surgical Care Practitioner to an orthopaedic team is demonstrated in this case study of a patient who presented with a re-ruptured Achilles tendon. It highlights the role the practitioner plays in the patient journey and illustrates it's value throughout the clinical course from consultation through to discharge. The Surgical Care Practitioner, as a member of the extended surgical team can help to explain the diagnosis and associated treatment options, facilitate informed consent and provide expert procedural assistance to the surgeon. A Surgical Care Practitioner is ideally placed to answer patient queries and aid in rehabilitation.
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Affiliation(s)
- Elda Julies
- Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Tim Williams
- Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Susan Hall
- Anglia Ruskin University, Chelmsford, UK
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21
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Cramer A, Jacobsen NC, Hansen MS, Sandholdt H, Hölmich P, Barfod KW. Diabetes and treatment with orally administrated corticosteroids negatively affect treatment outcome at follow-up after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2021; 29:1584-1592. [PMID: 33211215 DOI: 10.1007/s00167-020-06371-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/05/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Studies investigating the influence of comorbidities on patient-reported outcomes after acute Achilles tendon ruptures (ATR) are lacking. In this study, the aim was to investigate the effect of comorbidity and medical treatment on the patient-reported outcome measure Achilles tendon total rupture score (ATRS). METHODS The study was performed as a registry study from the Danish Achilles tendon Database (DADB). In the DADB, ATRS was registered at baseline (prior to rupture), at 3-6 month, 1-year and 2-year follow-ups. The outcomes were ATRS at follow-up and the change in ATRS from baseline to follow-up. Variables of interest were diabetes, hypertension, rheumatic disease and treatment with orally administrated corticosteroids. Linear mixed-effects models including all follow-up time points in the same model were used adjusting for sex, age group, treatment (operative or non-operative) and the investigated comorbidities. RESULTS Data were collected from 2012 to 2019. Two thousand and four patients with ATR were included. Patients with the investigated comorbidities and treatment with orally administrated corticosteroid scored 10.6-19.1 points lower in mean ATRS at baseline (prior to rupture) compared to patients without the respective disease or treatment. At follow-up, patients with diabetes (mean difference, [95% CI]) (- 6.2, [- 11.7; - 0.8]; P = 0.03) and patients in treatment with orally administrated corticosteroids (- 10.9, [- 16.2; - 5.7]; P < 0.01) had a statistically significantly worse ATRS than patients without the respective disease. However, change in ATRS from baseline to follow-up was not affected. Hypertension and rheumatic disease did not affect ATRS at follow-up but had a positive effect on change in ATRS (4.3, [0.5; 8.1]; P = 0.03) and (12.0, [5.0; 19.9]; P < 0.01), respectively. No other statistically significant differences were found. CONCLUSION This study showed that patients with diabetes, hypertension, rheumatic disease and patients in treatment with orally administrated corticosteroids had a lower ATRS at baseline (prior to the rupture) when compared to patients without the respective disease or treatment. Diabetes and treatment with orally administrated corticosteroids did negatively affect ATRS at follow-up, but none of the investigated comorbidities or treatment with orally administrated corticosteroids did negatively affect change in ATRS from baseline to follow-up. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Allan Cramer
- Department of Orthopedic Surgery, Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Copenhagen University Hospital, Kettegård Allé 30, Amager-Hvidovre, 2650, Hvidovre, Denmark.
| | - Nanna Cecilie Jacobsen
- Department of Orthopedic Surgery, Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Copenhagen University Hospital, Kettegård Allé 30, Amager-Hvidovre, 2650, Hvidovre, Denmark
| | - Maria Swennergren Hansen
- Department of Orthopedic Surgery, Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Copenhagen University Hospital, Kettegård Allé 30, Amager-Hvidovre, 2650, Hvidovre, Denmark.,Department of Physiotherapy, Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
| | - Håkon Sandholdt
- Clinical Research Center, Copenhagen University Hospital, Hvidovre, Denmark
| | - Per Hölmich
- Department of Orthopedic Surgery, Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Copenhagen University Hospital, Kettegård Allé 30, Amager-Hvidovre, 2650, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Department of Orthopedic Surgery, Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Copenhagen University Hospital, Kettegård Allé 30, Amager-Hvidovre, 2650, Hvidovre, Denmark
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22
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Winson DMG, MacNair R, Hutchinson AM, Owen NJ, Evans R, Williams P. Delayed Achilles tendon rupture presentation: Non-operative management may be the SMART choice. Foot (Edinb) 2021; 46:101724. [PMID: 33039246 DOI: 10.1016/j.foot.2020.101724] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/04/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This biomechanical study aims to assess the function of patients who were treated non-operatively for delayed diagnosis Achilles tendon rupture. Patients were treated using the Swansea Morriston Achilles Rupture Treatment protocol (SMART), which is a physiotherapy led non-operative treatment program. METHODS 19 patients (16M:3F) were enrolled and prospectively assessed using Achilles Repair Scores (ARS)/Achilles Tendon Rupture Scores (ATRS) (PROMS), Ankle ROM and isokinetic peak torque for plantarflexion of the ankle. MRI scans of both the injured and uninjured TA were performed to compare both AP diameter and length. RESULTS Both ATRS and ARS improved between short- and long-term follow-up. The mean difference in plantar torque between the injured and uninjured leg was 21.9%. There was no significant difference in ankle plantarflexion or dorsiflexion. There was no significant difference in length of the injured and uninjured TA on MRI. Three patients failed the SMART protocol requiring surgical fixation. DISCUSSION The SMART protocol can be an effective method of treatment even in younger and active patients especially if delay to treatment is less than 12 weeks. It may still be preferable for patients with a large gap size or high functional demand to elect for surgical intervention, but clinicians should consider the SMART protocol as an alternative to surgery and discuss it with some patients as a viable alternative.
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Affiliation(s)
- Daniel M G Winson
- Trauma and Orthopaedic Department, Morriston Hospital, Swansea SA6 6NL, UK.
| | - Rory MacNair
- Radiology Department, Morriston Hospital, Swansea SA6 6NL, UK
| | | | - Nick J Owen
- Applied Biomechanics Department, Swansea University, Singleton Park, Swansea SA2 8PP, UK
| | - Rhodri Evans
- Radiology Department, Morriston Hospital, Swansea SA6 6NL, UK
| | - Paul Williams
- Trauma and Orthopaedic Department, Morriston Hospital, Swansea SA6 6NL, UK
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23
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Biggs A, Scott G, Solan MC, Williamson M. Achilles tendon rupture: what you need to know. Br J Hosp Med (Lond) 2021; 82:1-7. [PMID: 33646025 DOI: 10.12968/hmed.2020.0593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Heel pain and a history of a 'pop' or feeling 'something go' are the buzz phrases classically associated with Achilles tendon rupture. However, the diagnosis is often missed in clinical practice because of the assumption that this is a sporting injury suffered only by the young or middle-aged. In a sedentary older patient, the injury may be dismissed as an ankle sprain. If swelling is present but no injury is recalled then deep vein thrombosis is suspected, but Achilles rupture is not. The diagnosis of Achilles tendon rupture is clinical, based on history and examination. Radiological imaging (ultrasound scan) is useful to plan orthopaedic management and exclude concomitant deep vein thrombosis. In most cases, non-operative management with the ankle held plantar flexed in a boot is the current best practice.
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Affiliation(s)
- A Biggs
- Department of Trauma and Orthopaedics, Royal Surrey Hospital, Guildford, Surrey, UK
| | - G Scott
- Department of Trauma and Orthopaedics, Royal Surrey Hospital, Guildford, Surrey, UK
| | - M C Solan
- Department of Trauma and Orthopaedics, Royal Surrey Hospital, Guildford, Surrey, UK
| | - M Williamson
- Department of Trauma and Orthopaedics, Royal Surrey Hospital, Guildford, Surrey, UK
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Tarantino D, Palermi S, Sirico F, Corrado B. Achilles Tendon Rupture: Mechanisms of Injury, Principles of Rehabilitation and Return to Play. J Funct Morphol Kinesiol 2020; 5:jfmk5040095. [PMID: 33467310 PMCID: PMC7804867 DOI: 10.3390/jfmk5040095] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
The Achilles tendon is the thickest, strongest and largest tendon in the human body, but despite its size and tensile strength, it frequently gets injured. Achilles tendon ruptures (ATRs) mainly occur during sports activities, and their incidence has increased over the last few decades. Achilles tendon tears necessitate a prolonged recovery time, sometimes leaving long-term functional limitations. Treatment options include conservative treatment and surgical repair. There is no consensus on which is the best treatment for ATRs, and their management is still controversial. Limited scientific evidence is available for optimized rehabilitation regimen and on the course of recovery after ATRs. Furthermore, there are no universally accepted outcomes regarding the return to play (RTP) process. Therefore, the aim of this narrative review is to give an insight into the mechanism of injuries of an ATR, related principles of rehabilitation, and RTP.
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25
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Resistance Exercises in Early Functional Rehabilitation for Achilles Tendon Ruptures Are Poorly Described: A Scoping Review. J Orthop Sports Phys Ther 2020; 50:681-690. [PMID: 33094667 PMCID: PMC8168134 DOI: 10.2519/jospt.2020.9463] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To (1) describe which resistance exercises are used in the first 8 weeks of treatment for acute Achilles tendon rupture and (2) assess the completeness of reporting of the exercise descriptions. DESIGN Scoping review. LITERATURE SEARCH We searched the MEDLINE, Embase, CINAHL, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases. STUDY SELECTION CRITERIA Randomized controlled trials, cohort studies, and case series (10 or more participants) that reported using resistance exercise in the immobilization period in the first 8 weeks of treatment for acute Achilles tendon rupture were included. DATA SYNTHESIS Completeness of exercise description was assessed with the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier exercise descriptor framework. RESULTS Thirty-eight studies were included. Fifty-one resistance exercises were extracted and categorized as isometric exercises (n = 20), heel raises (n = 6), strengthening with external resistance (n = 13), or unspecified (n = 12). A median of 8 (interquartile range, 6-10) of a possible 19 CERT items was reported. The amount of items described of the 13 Toigo and and Boutellier exercise descriptors ranged from 0 to 11. CONCLUSION A variety of resistance exercises targeted at the ankle plantar flexors were used as part of early functional rehabilitation after Achilles tendon rupture. However, most studies provided inadequate description of resistance exercise interventions. J Orthop Sports Phys Ther 2020;50(12):681-691. Epub 23 Oct 2020. doi:10.2519/jospt.2020.9463.
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26
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Cramer A, Jacobsen NC, Hansen MS, Sandholdt H, Hölmich P, Barfod KW. Outcome after acute Achilles tendon rupture is not negatively affected by female sex and age over 65 years. Knee Surg Sports Traumatol Arthrosc 2020; 28:3994-4002. [PMID: 32350575 DOI: 10.1007/s00167-020-06003-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Studies suggest that women have worse treatment outcome than men after acute Achilles tendon rupture (ATR). The aim of this study was to investigate if sex and age affect treatment outcome after ATR. METHODS The study was performed as a registry study in the Danish Achilles tendon Database. The primary outcome was change in the Achilles tendon Total Rupture Score (ATRS) from baseline to 4 months, 1 year and 2 years follow-up. Variables of interest were sex and age group (< 40 years, 40-65 years and > 65 years). RESULTS Data were collected from April 2012 to March 2018. Five-hundred and sixteen patients (416 men, 100 women) were included in the study population. At baseline, women scored 4.3 points lower in ATRS compared to men. No statistically significant difference between the sexes regarding change in ATRS were found. Women scored statistically significantly less in absolute ATRS at 1 year follow-up (mean difference 9.4; 95% CI 3.8, 14.9; P = 0.03). Patients older than 65 years scored statistically significantly more in ATRS change compared to patients between 40-65 years (mean difference 12.8; 95% CI 6.1-19.5; P < 0.001). CONCLUSION This study did not show a statistically significant or clinically relevant difference between the sexes in ATRS change from baseline to follow-up. The mean difference in ATRS change between patients older than 65 years and patients between 40-65 years was clinically relevant with better outcome for patients older than 65 years. When comparing ATRS between groups with an unequal sex distribution, the findings of a baseline difference and a difference in absolute ATRS at 1 year follow-up between the sexes, advocate for reporting of sex-specific data or for use of change in ATRS from baseline to follow-up instead of absolute ATRS. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Allan Cramer
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.
| | - Nanna Cecilie Jacobsen
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Maria Swennergren Hansen
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark.,Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Copenhagen, Denmark
| | - Håkon Sandholdt
- Clinical Research Centre, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Per Hölmich
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center-Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Kettegård Allé 30, 2650, Hvidovre, Denmark
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27
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Harrington TL, Breedlove GJ, Sharpe JJ. Systematic Review of Nonoperative Functional Protocols for Acute Achilles Ruptures Utilizing a Formal Rehabilitation Protocol Showing Lowest Rerupture Rates. Foot Ankle Spec 2020; 13:508-515. [PMID: 32975140 DOI: 10.1177/1938640020916954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To lay out a comprehensive protocol for practitioners and physical therapists that has the lowest rerupture rates for nonoperative treatment of acute Achilles ruptures. METHOD Relevant articles were searched in PubMed, CINAHL Plus, and Cochrane Library using keyword combinations: nonoperative AND/OR Achilles rupture AND functional AND/OR protocol or functional AND/OR rehabilitation. To be included in the full analysis, the studies had to have detailed functional protocols with physical therapy program details and outcome scores of rupture rates and/or Achilles Tendon Rupture Score (ATRS). We ultimately found 7 articles that fit our inclusion criteria for analysis. All of them had rerupture rates, and 4 had ATRS scores and functional protocols with mention of formal physical therapy programs. RESULTS Lowest rerupture rates were found in strict functional rehabilitation protocols that were full weightbearing in boot immediately at full equinus or 30° plantar flexed. They started active range of motion at 5 to 8 weeks and started formal physical therapy at 10 weeks.Levels of Evidence: Level III: Evidence obtained from well-designed non-experimental descriptive studies.
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Affiliation(s)
- Tara L Harrington
- Folsom Orthopedics and Sports Medicine, Folsom, California (TLH).,Orthopedic Associates of Lake County, Madison, Ohio (GJB).,Orthopedic Associates of Lake County, Concord, Ohio (JJS)
| | - Gerald J Breedlove
- Folsom Orthopedics and Sports Medicine, Folsom, California (TLH).,Orthopedic Associates of Lake County, Madison, Ohio (GJB).,Orthopedic Associates of Lake County, Concord, Ohio (JJS)
| | - Jonathan J Sharpe
- Folsom Orthopedics and Sports Medicine, Folsom, California (TLH).,Orthopedic Associates of Lake County, Madison, Ohio (GJB).,Orthopedic Associates of Lake County, Concord, Ohio (JJS)
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28
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Yassin M, Myatt R, Thomas W, Gupta V, Hoque T, Mahadevan D. Does size of tendon gap affect patient-reported outcome following Achilles tendon rupture treated with functional rehabilitation? Bone Joint J 2020; 102-B:1535-1541. [PMID: 33135439 DOI: 10.1302/0301-620x.102b11.bjj-2020-0908.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation. METHODS Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included. RESULTS In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson's correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%). CONCLUSION Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535-1541.
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Affiliation(s)
- Mohamed Yassin
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Richard Myatt
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - William Thomas
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Vatsal Gupta
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Tagrit Hoque
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Devendra Mahadevan
- Department of Trauma & Orthopaedics, Royal Berkshire Hospital, Reading, UK
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29
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Venturini S, Garbett M, Houchen-Wolloff L, Mangwani J. Unusual Presentation of a Swelling in the Achilles Tendon After an Acute Rupture: A Case Report. J Orthop Case Rep 2020; 10:88-91. [PMID: 32953665 PMCID: PMC7476688 DOI: 10.13107/jocr.2020.v10.i02.1712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Achilles tendon rupture is common and most cases heal with appropriate treatment. However, complications in the treatment of this condition can be debilitating, especially for young, active individuals. Case Report We present the case of a 37-year-old man who presented with ongoing pain on weight-bearing and swelling in the left Achilles tendon area8 months after acute rupture treated with functional bracing and early rehabilitation. Magnetic resonance imaging showed intrasubstance thickening of the tendon with a large swelling. Successful decompression of the swelling was achieved using an arthroscopic technique and the patient returned to normal activities. Conclusion Physiotherapy and return to normal activities were limited in our patient due to high levels of discomfort and pain. Prolonged immobility following tendon rupture has been shown to cause increased scar tissue proliferation. This may have hindered functional rehabilitation progress and negatively impacted on the reparative process.
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Affiliation(s)
- Sara Venturini
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Marie Garbett
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Linzy Houchen-Wolloff
- Department of Physiotherapy, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Jitendra Mangwani
- Department of Orthopaedic surgery Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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30
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Maempel JF, Clement ND, Duckworth AD, Keenan OJF, White TO, Biant LC. A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures. Am J Sports Med 2020; 48:2755-2764. [PMID: 32816521 DOI: 10.1177/0363546520944905] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There has been a shift toward functional nonoperative rehabilitation in the treatment of Achilles tendon rupture (ATR) despite a shortage of studies directly comparing nonoperative functional rehabilitation with traditional nonoperative immobilization. PURPOSE To compare patient-reported outcome measures and functional outcomes for nonoperatively treated ATR with traditional cast immobilization or functional rehabilitation in a walking boot. STUDY DESIGN Randomized controlled clinical trial; Level of evidence, 2. METHODS In a single-center nonblinded study, 140 patients were randomized to compare treatment for acute ATR in (1) an immobilizing cast in reducing degrees of equinus over a 10-week period with 8 weeks of nonweightbearing mobilization or (2) a walking boot for 8 weeks with reducing equinus and immediate full weightbearing. Exclusion criteria were delayed presentation >2 weeks after injury, tendon reruptures, and latex allergy. Analysis was undertaken on an intention-to-treat basis. RESULTS A total of 69 patients (median age, 41 years [interquartile range, 33-50.5 years]) were randomized to walking boot treatment and 71 patients (41 [32-49]) to cast treatment. At 6 months, patients treated in a walking boot reported better Short Musculoskeletal Function Assessment (SMFA) dysfunction index (6.62 [2.21-12.50] vs 10.66 [4.96-13.42]; P = .050), SMFA bother index (7.29 [2.08-14.58] vs 10.42 [5.73-19.27]; P = .04), Achilles Tendon Total Rupture Score (71.5 [53.50-84.25] vs 54.0 [37-76]; P = .01), and Foot and Ankle Questionnaire core score (91 [81.89-97.55] vs 85 [78.25-92.09]; P = .04). At 1 year, there was no difference in SMFA dysfunction index (2.21 [0.74-5.88] vs 2.94 [1.47-6.62]; P = .25), SMFA bother index (2.08 [0-9.38] vs 5.21 [0.52-11.98]; P = .25), Achilles Tendon Total Rupture Score (92 [72.50-96] vs 87.5 [66.0-94.75]; P = .21), or Foot and Ankle Questionnaire core score (97.75 [89.46-99.00] vs 95.50 [90.88-97.50]; P = .18). Rerupture occurred in 5 and 11 patients (P = .075) and venous thromboembolism in 2 and 3 patients (P = .67) in the boot and cast groups, respectively. Fifteen patients in the boot group but none in the cast group had skin problems (P < .001). Patients treated in a boot returned to driving at a median 12 weeks (vs 13 weeks for cast; P = .045), but there was no difference in time to return to work (P = .48). CONCLUSION Functional rehabilitation with early weightbearing is a safe alternative to traditional immobilizing treatment for ATR, giving better early functional outcomes, albeit with a higher incidence of transient minor skin complications. REGISTRATION NCT02598843 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Julian F Maempel
- Royal Prince Alfred Hospital, Sydney, Australia.,University of Malta Medical School, Msida, Malta
| | | | - Andrew D Duckworth
- Royal Infirmary of Edinburgh, Edinburgh, UK.,University of Edinburgh, Edinburgh, UK
| | | | - Tim O White
- Royal Infirmary of Edinburgh, Edinburgh, UK.,University of Edinburgh, Edinburgh, UK
| | - Leela C Biant
- University of Manchester Medical School, Manchester, UK.,Manchester Orthopaedic Centre, Manchester University NHS Foundation Trust, Manchester, UK
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Binkley HM, Douglass D, Phillips K, Wise SL. Rehabilitation and Return to Sport After Nonsurgical Treatment of Achilles Tendon Rupture. Strength Cond J 2020. [DOI: 10.1519/ssc.0000000000000536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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32
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Hansen MS, Vestermark MT, Hölmich P, Kristensen MT, Barfod KW. Individualized treatment for acute Achilles tendon rupture based on the Copenhagen Achilles Rupture Treatment Algorithm (CARTA): a study protocol for a multicenter randomized controlled trial. Trials 2020; 21:399. [PMID: 32398120 PMCID: PMC7218535 DOI: 10.1186/s13063-020-04332-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/19/2020] [Indexed: 11/16/2022] Open
Abstract
Background An individualized treatment algorithm (Copenhagen Achilles Rupture Treatment Algorithm (CARTA)) based on the ultrasonographic appearance of an acute Achilles tendon rupture has been developed aiming to select the correct patients for operative and non-operative treatment. The objective of this study is to investigate if this individualized treatment algorithm gives a better functional outcome than treating all patients either operatively or non-operatively per default. Methods/design This study is conducted as a multicenter, three-armed randomized controlled trial. Participants are included from four hospitals in Denmark and randomized 1:1:1 to one of three parallel groups: 1) Intervention group—participants are treated according to an individualized treatment algorithm; 2) Control group A—participants are treated non-operatively; 3) Control group B—participants are treated operatively. The individualized treatment algorithm for the intervention group is based on an ultrasonographic examination; tendon overlap and elongation below 7% is to be treated non-operatively, while no tendon overlap and/or elongation above 7% will be treated operatively. Over a period of 3 years, 300 participants will be included. The primary outcome is the heel-rise work test at 12 months post-injury. Secondary outcomes are tendon elongation, the Achilles tendon Total Rupture Score (ATRS), the rate of re-ruptures, and other complications. The primary analysis will be conducted as an intention-to-treat analysis. Discussion This trial will indicate if treatment of acute Achilles tendon rupture can be individualized based on elongation and tendon overlap. It is hypothesized that different patients will benefit from different treatments instead of offering all the same treatment. Trial registration ClinicalTrials.gov, NCT03525964. Registered 16 May 2018.
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Affiliation(s)
- Maria Swennergren Hansen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital, Kettegård Alle 30, 2650, Amager-Hvidovre, Denmark. .,Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Kettegård Alle 30, 2650, Amager-Hvidovre, Denmark.
| | - Marianne Toft Vestermark
- Department of Orthopedic Surgery, Viborg Regional Hospital, Heiberbs Allé 4, 8800, Viborg, Denmark
| | - Per Hölmich
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Kettegård Alle 30, 2650, Amager-Hvidovre, Denmark
| | - Morten Tange Kristensen
- Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital, Kettegård Alle 30, 2650, Amager-Hvidovre, Denmark.,Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
| | - Kristoffer Weisskirchner Barfod
- Sports Orthopedic Research Center - Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Kettegård Alle 30, 2650, Amager-Hvidovre, Denmark
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33
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Maffulli N, D'Addona A, Maffulli GD, Gougoulias N, Oliva F. Delayed (14-30 Days) Percutaneous Repair of Achilles Tendon Ruptures Offers Equally Good Results As Compared With Acute Repair. Am J Sports Med 2020; 48:1181-1188. [PMID: 32176527 DOI: 10.1177/0363546520908592] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Minimally invasive repair of acute Achilles tendon ruptures has been performed for several years, resulting in reduced morbidity as compared with open repair. HYPOTHESIS A minimally invasive technique can be used to manage Achilles tendon ruptures in patients presenting between 14 and 30 days from injury. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS We prospectively recruited 21 consecutive patients who presented between 14 and 30 days after the index injury, and we compared them with 21 patients who were matched according to sex, age (±2 years), and level of activity, who presented within 14 days of the index injury. All patients underwent the same minimally invasive procedure under local anesthesia: a core suture repair consisting of a modified Bunnell suture in the proximal stump and a modified Kessler suture in the distal stump. RESULTS At 12 months after minimally invasive repair, patients with delayed treatment had a median Achilles tendon rupture score of 91 (SD, 2.4; range, 87-96) as compared with 91 (SD, 2.2; range, 86-96) in patients treated acutely, who presented at a median 2.4 days (range 1-6 days) from the injury. There were no significant differences between groups in terms of mean (SD) Achilles tendon resting angle: delayed repair group, -3.9° (2.0); acute repair group, -3.7° (1.9) (P = .69). No patient in either group developed a wound infection. One patient in the acute group experienced an iatrogenic sural nerve injury. CONCLUSION Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patient treated <14 after injury.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Italy.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, London, UK.,School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Newcastle-under-Lyme, UK
| | - Alessio D'Addona
- Department of Public Health, Section of Orthopaedics and Trauma Surgery, School of Medicine and Surgery "Federico II," Naples, Italy
| | | | - Nikolaos Gougoulias
- Frimley Health NHS Foundation Trust, Frimley Park Hospital, Frimley, UK.,Foot Surgery Private Practice, Thessaloniki and Athens, Greece
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi, Italy
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Park SH, Lee HS, Young KW, Seo SG. Treatment of Acute Achilles Tendon Rupture. Clin Orthop Surg 2020; 12:1-8. [PMID: 32117532 PMCID: PMC7031433 DOI: 10.4055/cios.2020.12.1.1] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/31/2019] [Indexed: 12/15/2022] Open
Abstract
There is no clear consensus on the optimal treatment of acute Achilles tendon rupture. Recently, studies have demonstrated the critical role of functional rehabilitation in the treatment of ruptured Achilles tendons. Hence, conservative treatment is preferred by a growing number of surgeons seeking to treat the condition without the risk of complications from surgery. However, operative treatment is still considered as a more reliable treatment option for acute Achilles tendon rupture. In this review article, we provide an overview of recent treatment strategies for acute rupture of the Achilles tendon.
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Affiliation(s)
- Seung-Hwan Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho Seong Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki Won Young
- Department of Orthopedic Surgery, Eulji Hospital, Seoul, Korea
| | - Sang Gyo Seo
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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35
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Carmont MR, Zellers JA, Brorsson A, Silbernagel KG, Karlsson J, Nilsson-Helander K. No difference in strength and clinical outcome between early and late repair after Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2020; 28:1587-1594. [PMID: 30594954 PMCID: PMC7176605 DOI: 10.1007/s00167-018-5340-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 12/13/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE This retrospective study aimed to determine the patient-reported and functional outcome of patients with delayed presentation, who had received no treatment until 14 days following injury of Achilles tendon rupture repaired with minimally invasive surgery and were compared with a group of sex- and age-matched patients presenting acutely. Based on the outcomes following delayed presentation reported in the literature, it was hypothesized that outcomes would be inferior for self-reported outcome, tendon elongation, heel-rise performance, ability to return to play, and complication rates than for acutely managed patients. METHODS Repair was performed through an incision large enough to permit mobilisation of the tendon ends, core suture repair consisting of a modified Bunnell suture proximally and a Kessler suture distally and circumferential running suture augmentation. RESULTS Nine patients presented 21.8 (14.9) days (range 14-42 days) after rupture. The rate of delayed presentation was estimated to be 1 in 10. At 12 months following repair, patients with delayed treatment had median (range) ATRS score of 90 (69-99) compared with 94 (75-100) in patients treated acutely presenting 0.66 (1.7) (0-5) days. There were no significant differences between groups: ATRA [mean (SD) delayed: - 6.9° (5.5), acute: - 6° (4.7)], heel-rise height index [delayed: 79% (20), acute: 74% (14)], or heel-rise repetition index [delayed: 77% (20), acute: 71% (20)]. In the delayed presentation group, two patients had wound infection and one iatrogenic sural nerve injury. CONCLUSIONS Patients presenting more than 2 weeks after Achilles tendon rupture may be successfully treated with minimally invasive repair. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael R. Carmont
- Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK ,Department of Orthopaedic Surgery, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jennifer A. Zellers
- Program of Physical Therapy, Washington University School of Medicine, St Louis, MO USA
| | - Annelie Brorsson
- Department of Orthopaedic Surgery, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | | | - Jón Karlsson
- Department of Orthopaedic Surgery, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Robertson A, Godavitarne C, Bellringer S, Guryel E, Auld F, Cassidy L, Gibbs J. Standardised virtual fracture clinic management of Achilles tendon ruptures is safe and reproducible. Foot Ankle Surg 2019; 25:782-784. [PMID: 30686540 DOI: 10.1016/j.fas.2018.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/27/2018] [Accepted: 10/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Traditional fracture clinics are some of the busiest clinics in a hospital, often with significant patient waiting times and delays. The use of virtual fracture clinic (VFC) for the management of certain injuries to reduce the workload on the traditional fracture clinic, in addition to reducing costs is growing in popularity. The tendoachilles is the most frequently ruptured tendon in the body but despite this, management remains a keenly debated topic. METHODS All adult patients referred to the VFC with an actual or suspected Achilles tendon rupture were identified between January 2015 to October 2017. RESULTS This study found that patient with and acute achilles tendon ruptures managed according to a standardised VFC protocol had a re-rupture rate of 3.82%. CONCLUSIONS One of the advantages of a VFC model that is standardised, initiated in the ED, is that it has no variation in outcome seen in our patient group.
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Affiliation(s)
- Alastair Robertson
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom.
| | - Charles Godavitarne
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Simon Bellringer
- Western Sussex Hospitals NHS Foundation Trust, Spitalfield Lane, Chichester, West Sussex, PO19 6SE, United Kingdom
| | - Enis Guryel
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Felicity Auld
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | | | - James Gibbs
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
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37
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Zellers JA, Christensen M, Kjær IL, Rathleff MS, Silbernagel KG. Defining Components of Early Functional Rehabilitation for Acute Achilles Tendon Rupture: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119884071. [PMID: 31803789 PMCID: PMC6878623 DOI: 10.1177/2325967119884071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer A Zellers
- Program in Physical Therapy, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marianne Christensen
- Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark.,Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Inge Lunding Kjær
- Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
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Medeiros DM. Conservative treatment of Achilles tendon partial tear in a futsal player: A case report. Physiother Theory Pract 2019; 37:1158-1165. [PMID: 31661369 DOI: 10.1080/09593985.2019.1683924] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background and purpose: Achilles tendon is the most commonly injured part in the lower limb, especially in athletes. Treatment options for Achilles tendinopathy and total rupture are well described; however, there is a lack of information regarding treatment protocols for partial tears. Thus, the purpose of this case report was to describe the examination, intervention and outcomes of patient who suffered an acute Achilles tendon partial tear. Case description: A case is described here, in which the diagnosis of Achilles tendon partial tear was based on both magnetic resonance imaging and physical evaluation. Both the patient and the physical therapy team opted for non-surgical treatment. A 12-week course of conservative treatment including exercise, tendon loading, electrical stimulation, and photobiomodulation is described. Outcomes: Ankle dorsiflexion range of motion and hop tests. Discussion: This case report demonstrated that non-surgical treatment for Achilles tendon partial tear was effective for this patient and enabled the athlete to return to pre-injury levels of activity 6 months following the injury.
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Affiliation(s)
- Diulian Muniz Medeiros
- Graduate Program of Rehabilitation Sciences, Physical Therapy Department, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
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39
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Aujla RS, Patel S, Jones A, Bhatia M. Non-operative functional treatment for acute Achilles tendon ruptures: The Leicester Achilles Management Protocol (LAMP). Injury 2019; 50:995-999. [PMID: 30898390 DOI: 10.1016/j.injury.2019.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/06/2019] [Accepted: 03/09/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study is to present outcomes and objective measures of assessment for acute Achilles tendon (AT) ruptures treated with an eight-week functional dynamic treatment protocol in a VACOped® boot with immediate full weight bearing mobilisation, the Leicester Achilles Management Protocol (LAMP). METHODS A prospective study of all patients treated with the LAMP with minimum 12-month follow-up was performed. Patients completed the Achilles Tendon Rupture Score (ATRS) and in the latter part of the study, objective measures of the calf muscle girth and heel raise height were obtained. RESULTS 442 patients were treated with the LAMP. There were nine (2%) re-ruptures in the 442 non-operative treated group of patients throughout the study period. ATRS at twelve months or more were available in 234 patients and objective measures in 77 patients. The mean age was 50 years. The mean ATRS was 75.5 at an average of 23 months post injury. Men had a statistically significant higher ATRS score when compared to women (p < 0.05). There was statistically significant difference in the calf muscle girth and the heel raise height when compared to the uninjured side at 12-months post-injury (p < 0.05). These differences did not correlate with the ATRS (p > 0.05). CONCLUSIONS The LAMP is a simple yet effective regime for the non-operative treatment of acute AT ruptures, which can be universally adopted without the need for many resources. Compared to other studies, the overall time in the boot is less with low complication rates and similar patient reported outcomes.
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Affiliation(s)
- Randeep S Aujla
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
| | - Shakil Patel
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Annette Jones
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maneesh Bhatia
- Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom
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40
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Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Bosma E, van Raaij TM, Munzebrock AV, Zijlstra WP, Zwerver J, Reininga IHF. The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study. BMC Musculoskelet Disord 2019; 20:69. [PMID: 30744626 PMCID: PMC6371453 DOI: 10.1186/s12891-019-2437-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 01/28/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Achilles tendon rupture (ATR) is a common sports injury, with a rising incidence and significant impairments. Due to the lack of treatment guidelines, there is no consensus about diagnostic methods, primary treatment (non-surgical or surgical) and rehabilitation. It is hypothesized that this lack of consensus and guidelines leads to sub-optimal recovery and higher societal costs. The primary aim of this study is to give a broad insight into the recovery after ATR. Secondarily this study aims to explore factors contributing to recovery and gain insight into the cost-effectiveness of ATR management. METHODS This multicenter prospective cohort study will include all adult (≥ 18 years) patients with an ATR treated at the three main hospitals in the Northern Netherlands: University Medical Center Groningen, Martini Hospital Groningen and Medical Center Leeuwarden. All subjects will be invited for three visits at 3, 6 and 12 months post-injury. The following data will be collected: patient-reported outcome measures (PROMs), physical tests, imaging and economic questionnaires. At 3 months post-injury personal, injury, and treatment data will be collected through a baseline questionnaire and assessment of the medical file. The PROMs concern the Dutch version of the Achilles Tendon Total Rupture Score, EQ-5D-5 L, Oslo Sport Trauma Research Center Overuse Injury Questionnaire, Injury Psychological Readiness Return to Sport Scale, Tampa Scale of Kinesiophobia, Expectations, Motivation and Satisfaction questionnaire and a ranking of reasons for not returning to sport. The administered physical tests are the heel-rise test, standing dorsiflexion range of motion, resting tendon length and single leg hop for distance. Ultrasound Tissue Characterization will be used for imaging. Finally, economic data will be collected using the Productivity Cost Questionnaire and Medical Consumption Questionnaire. DISCUSSION This prospective cohort study will contribute to optimal decision making in the primary treatment and rehabilitation of ATRs by providing insight into (1) ATR recovery (2) novel imaging for monitoring recovery (3) (barriers to) return to sport and (4) cost-effectiveness of management. The analysis of these data strives to give a broad insight into the recovery after ATR as well as provide data on novel imaging and costs, contributing to individualized ATR management. TRIAL REGISTRATION Trialregister.nl. NTR6484 . 20/06/2017. 20/07/2017.
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Affiliation(s)
- Olivier C. Dams
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ron L. Diercks
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaus W. Wendt
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eelke Bosma
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Tom M. van Raaij
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Arvid V. Munzebrock
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Wierd P. Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Johannes Zwerver
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Dams OC, van den Akker-Scheek I, Diercks RL, Wendt KW, Zwerver J, Reininga IHF. Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines. Knee Surg Sports Traumatol Arthrosc 2019; 27:2754-2764. [PMID: 29971520 PMCID: PMC6706364 DOI: 10.1007/s00167-018-5049-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 06/29/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE This study aimed to describe and analyse usual care of Achilles tendon ruptures (ATRs) by orthopaedic surgeons and trauma surgeons in the Netherlands. METHODS A nationwide online survey of ATR management was sent to all consultant orthopaedic and trauma surgeons in the Netherlands, requesting participation of those involved in ATR management. Data on individual characteristics and the entire ATR management (from diagnosis to rehabilitation) were gathered. Consensus was defined as ≥ 70% agreement on an answer. RESULTS A total of 91 responses (70 orthopaedic surgeons and 21 trauma surgeons) were analysed. There was consensus on the importance of the physical examination in terms of diagnosis (> 90%) and a lack of consensus on diagnostic imaging (ultrasound/MRI). There was consensus that non-surgical treatment is preferred for sedentary and systemically diseased patients and surgery for patients who are younger and athletic and present with larger tendon gap sizes. There was consensus on most of the non-surgical methods used: initial immobilisation in plaster cast with the foot in equinus position (90%) and its gradual regression (82%) every 2 weeks (85%). Only length of immobilisation lacked consensus. Surgery was generally preferred, but there was a lack of consensus on the entire followed protocol. Orthopaedic and trauma surgeons differed significantly on their surgical (p = 0.001) and suturing techniques (p = 0.002) and methods of postoperative immobilisation (p < 0.001). Orthopaedic surgeons employed open repair and Bunnell sutures more often, whereas trauma surgeons used minimally invasive approaches and bone anchors. Rehabilitation methods and advised time until weight-bearing and return to sport varied. Orthopaedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment (p = 0.001) and surgery (p = 0.002) than trauma surgeons. CONCLUSION This is the first study to describe the entire ATR management. The results show a lack of consensus and wide variation in management of ATRs in the Netherlands. This study shows that especially the methods of the perioperative and rehabilitation phases were inconclusive and differed between orthopaedic and trauma surgeons. Further research into optimal ATR management regimens is recommended. In addition, to achieve uniformity in management more multidisciplinary collaboration between Dutch and international surgeons treating ATRs is needed. LEVEL OF EVIDENCE Cross-sectional survey, Level V.
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Affiliation(s)
- Olivier C. Dams
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands ,0000 0000 9558 4598grid.4494.dDepartment of Orthopaedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Ron L. Diercks
- 0000 0000 9558 4598grid.4494.dDepartment of Orthopaedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Klaus W. Wendt
- 0000 0000 9558 4598grid.4494.dDepartment of Trauma Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johannes Zwerver
- 0000 0000 9558 4598grid.4494.dDepartment of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Inge H. F. Reininga
- 0000 0000 9558 4598grid.4494.dDepartment of Trauma Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Alcelik I, Saeed ZM, Haughton BA, Shahid R, Alcelik JC, Brogden C, Budgen A. Achillon versus open surgery in acute Achilles tendon repair. Foot Ankle Surg 2018; 24:427-434. [PMID: 29409202 DOI: 10.1016/j.fas.2017.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/06/2017] [Accepted: 04/24/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Open Achilles tendon repairs (OATR) are associated with high complication rates. Minimally invasive surgery (MIS) techniques like the Achillon Achilles tendon repair (AATR) were developed to reduce this. We performed a systematic review and meta-analysis to compare OATR with AATR. METHODS We performed an extensive literature search including all studies that compared the two techniques. Outcomes assessed included overall complication rate, re-rupture rate, sural nerve injury, wound length, The American Orthopaedic Foot and Ankle Scores (AOFAS) scores and return to sports. RESULTS Eight studies were suitable for inclusion totalling 210 patients in the AATR group vs 233 patients in the OATR group. Total complication rates were significantly reduced in the Achillon patients with odd ratio of 0.14 (CI 95%, 0.08-0.27, P<0.00001) in favour. There were no significant differences in re-rupture rate, sural nerve injury, return to sports and AOFAS scores following repair between the two groups. CONCLUSIONS AATR has fewer overall complications compared with OATR. It should be considered as an alternative to open surgical repair.
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Affiliation(s)
- Ilhan Alcelik
- Department of Orthopaedics, York Hospital, Wigginton Road, York YO31 8HE, United Kingdom.
| | - Zubair M Saeed
- Department of Orthopaedics, York Hospital, Wigginton Road, York YO31 8HE, United Kingdom.
| | - Ben A Haughton
- Department of Orthopaedics, York Hospital, Wigginton Road, York YO31 8HE, United Kingdom.
| | - Rizwan Shahid
- Department of Orthopaedics, York Hospital, Wigginton Road, York YO31 8HE, United Kingdom.
| | - John C Alcelik
- Year 12, All Saints RC School, Mill Mount Lane, York YO24 1BJ, United Kingdom.
| | - Craig Brogden
- Department of Orthopaedics, York Hospital, Wigginton Road, York YO31 8HE, United Kingdom.
| | - Adam Budgen
- Department of Orthopaedics, York Hospital, Wigginton Road, York YO31 8HE, United Kingdom.
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Treatment of acute Achilles tendon rupture with a standardised protocol. Arch Orthop Trauma Surg 2018; 138:1089-1096. [PMID: 29725765 DOI: 10.1007/s00402-018-2940-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Indexed: 02/09/2023]
Abstract
INTRODUCTION A treatment protocol favouring non-operative treatment and based on early weight-bearing and early range-of-motion exercises was implemented in standard clinical care of a level I trauma clinic. MATERIALS AND METHODS All patients treated due to acute Achilles tendon rupture between 2008 and 2014 were included in the study (n = 411). The patient records were retrospectively evaluated. RESULTS The mean age of patients was 47 (range 17-88) years. In total, 213 (52%) acute Achilles tendon ruptures were treated operatively and 198 (48%) non-operatively. The annual proportion of operatively treated patients declined from 70 to 21% during the study period. The traumatic re-rupture rate was similar between the operative (4%) and the non-operative (6%) treatment groups (p = 0.385), even though the patients in the non-operative group were significantly older and had more co-morbidities than the operatively treated patients. Of the operatively treated patients, 10% (n = 21) had wound healing problems. In 6/198 patients, the non-operative treatment had to be converted to surgical treatment in the early phase. Unsatisfactory functional outcome after the treatment was reported in 7/213 patients in the operative and 10/198 in the non-operative group (p = 0.234). CONCLUSIONS Our study showed that it is possible to implement a standardised treatment protocol to guide the decision-making and treatment and of an acute Achilles tendon rupture as a part of the daily care in a large standard trauma hospital. The clinical outcome and the rate of complications were fully comparable to the good clinical results achieved in RCT-study settings despite the heterogeneity of the treated patients and non-specialisation of the medical staff, showing that the protocol could find the most reasonable treatment for each patient and reduced dramatically the rate of operative treatment. LEVEL OF EVIDENCE Level III, comparative series.
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Ellison P, Molloy A, Mason LW. Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus? J Foot Ankle Surg 2018; 56:960-963. [PMID: 28842105 DOI: 10.1053/j.jfas.2017.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Indexed: 02/03/2023]
Abstract
Conservative "functional" management of acute Achilles tendon ruptures has become increasingly popular. Critical to this is the use of the walking orthosis, which positions the ankle in equinus to allow for early weightbearing. Our aim was to test whether 2 common orthoses achieved a satisfactory equinus position. A total of 11 sequentially treated Achilles tendon ruptures were assigned to either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus-corrected brace (EEB). The lateral radiographs of the cast immobilized tendons showed a mean tibiotalar angle (TTA) of 56° (range 54° to 57°) and a mean tibio-first metatarsal angle (1MTA) of 74° (range 62° to 85°). The FAWW resulted in a mean TTA of 28° (range 15° to 35°) and 1MTA of 37° (range 30° to 45°). The EEB resulted in a TTA of 48° (range 43° to 45°) and 1MTA of 54° (range 47° to 57°). Ankle equinus was significantly greater with the EEB than with the FAWW (p < .05) and similar to that with an equinus cast. The use of wedges produced an equinus appearance through the midfoot but not at the ankle. We express caution in the use of the FAWW because it is unlikely to achieve sufficient ankle equinus to shorten the Achilles tendon.
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Affiliation(s)
- Philip Ellison
- Lower Limb Extended Scope Practitioner, Trauma and Orthopaedic Department, University Hospital Aintree, Liverpool, UK.
| | - Andrew Molloy
- Consultant Foot and Ankle Surgeon, Trauma and Orthopaedic Department, University Hospital Aintree, Liverpool, UK
| | - Lyndon William Mason
- Consultant Foot and Ankle Surgeon, Trauma and Orthopaedic Department, University Hospital Aintree, Liverpool, UK
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Reito A, Logren HL, Ahonen K, Nurmi H, Paloneva J. Risk Factors for Failed Nonoperative Treatment and Rerupture in Acute Achilles Tendon Rupture. Foot Ankle Int 2018; 39:694-703. [PMID: 29380628 DOI: 10.1177/1071100717754042] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative treatment is feasible in most patients with acute Achilles tendon rupture. Risk factors associated with failed nonoperative treatment are poorly understood. We investigated risk factors associated with rerupture after nonoperative treatment and otherwise failed nonoperative treatment of Achilles tendon rupture. METHODS All patients diagnosed with acute Achilles tendon rupture between January 2009 and June 2016 and who underwent 8 weeks of nonoperative treatment with functional rehabilitation were included in the study. Patients with rerupture or otherwise failed nonoperative treatment were identified retrospectively. Time to rerupture and association of age, sex, time from injury, diabetes, and visits to the physiotherapist for cases of reruptures and otherwise failed nonoperative treatment were investigated. A total of 210 patients were included in the study. RESULTS Fifteen patients sustained a rerupture. Rerupture incidence was 7.1%. Incidence of late reruptures, those occurring after return to daily activities at 12 weeks, was 1.9%. Six patients had otherwise failed nonoperative treatment. Median time to rerupture was 23 days (6 to 61) after the end of the treatment. The incidence of all-cause failure was 10.0%. Male gender was associated with reruptures ( P = .013) and failed nonoperative treatment for any reason ( P = .029). CONCLUSION It is important to highlight the increased risk of rerupture in male patients during the first month after the end of the nonoperative treatment. Age alone, even in male patients, was a poor indication for operative treatment since it did not predict early failure. Further studies will hopefully clarify the influence of activity level on the risk of rerupture. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | - Hanna-Liina Logren
- 1 Central Finland Hospital, Jyväskylä, Finland.,2 University of Eastern Finland, Kuopio, Finland
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Closing the gap on Achilles tendon rupture: A cadaveric study quantifying the tendon apposition achieved with commonly used immobilisation practices. Foot Ankle Surg 2018; 24:124-127. [PMID: 29409228 DOI: 10.1016/j.fas.2016.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 12/06/2016] [Accepted: 12/24/2016] [Indexed: 02/04/2023]
Abstract
The relative benefits of surgical and conservative treatment of Achilles tendon rupture are widely debated. With modern conservative management protocols, the re-rupture risk appears to fall to one similar to surgical repair with negligible loss of function. Conservative management typically employs a period of time in an equinus cast with sequential ankle dorsiflexion in a functional orthosis. The optimal duration of immobilisation and rate of dorsiflexion is unknown. We aimed to quantify the change in Achilles tendon approximation achieved in common immobilisation techniques to assist the design of rehabilitation protocols. Twelve fresh-frozen cadaveric specimens had 2.5cm of Achilles tendon excised. The gap between the tendon ends were measured via windowed full equinus casts and compared with functional boots with successively removed heel wedges. The greatest tendon apposition was achieved with the equinus cast. Each wedge removed decreased the reapproximation by approximately 5mm. This paper supports the early use of maximal equinus casting in early management of acute Achilles tendon ruptures.
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Lim CS, Lees D, Gwynne-Jones DP. Functional Outcome of Acute Achilles Tendon Rupture With and Without Operative Treatment Using Identical Functional Bracing Protocol. Foot Ankle Int 2017; 38:1331-1336. [PMID: 28891323 DOI: 10.1177/1071100717728687] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to compare the functional results of operative and nonoperative treatment of acute Achilles tendon rupture using an identical rehabilitation program of functional bracing. METHODS Over a 10-year period, 200 patients (99 operative, 101 nonoperative) aged between 18 and 65 years were treated at our institution's physiotherapy department after acute Achilles tendon rupture. There were 132 patients (62 operative, 70 nonoperative) available for a minimum 2-year follow-up (average 6.5 years; range, 2-13 years). Functional outcome was assessed using the Achilles tendon total rupture score (ATRS). RESULTS With the numbers available, no significant difference could be detected in ATRS between operative (mean 84.8, median 90) and nonoperative groups (mean 85.3, median 91; P = 0.55). No significant difference could be detected in ATRS between male and female patients however treated ( P = 0.30) or between patients younger and older than 40 years at time of injury ( P = 0.68). There was no correlation between ATRS score and age at injury in all patients (ρ = -0.0168, P = 0.85). In male patients, there was a weak trend with older patients at follow-up having better scores (ρ = 0.21, P = 0.069). However, among female patients, there was a significant negative correlation between ATRS scores and increasing age (ρ = -0.29, P = 0.03). Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS. CONCLUSIONS This study showed no significant difference detectable in ATRS between operative and nonoperative patients in the treatment of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Che Siu Lim
- 1 Whangarei Hospital, Orthopaedic Outpatients, Whangarei, New Zealand
| | - David Lees
- 2 Waikato District Health Board, Hamilton, New Zealand
| | - David P Gwynne-Jones
- 3 Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,4 Department of Orthopaedic Surgery, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand
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Dams OC, Reininga IHF, Gielen JL, van den Akker-Scheek I, Zwerver J. Imaging modalities in the diagnosis and monitoring of Achilles tendon ruptures: A systematic review. Injury 2017; 48:2383-2399. [PMID: 28943056 DOI: 10.1016/j.injury.2017.09.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/10/2017] [Accepted: 09/11/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the role of imaging in the diagnosis and monitoring of the Achilles tendon rupture (ATR). STUDY DESIGN Systematic review. DATA SOURCES PubMed and EMBASE in November 2016. ELIGIBILITY CRITERIA Clinical studies providing information on the methods and role of imaging in the diagnosis and monitoring of the ATR were included. RESULTS Fifty-six studies were included, most concerning the use of ultrasound (n=37) or MRI (n=18). Seven studies provided data on the diagnostic accuracy of imaging. Most ultrasound studies used a 7.5MHz probe (19/32 studies) and scanned the patient bilaterally in prone position, with recent studies tending to use higher frequency probes (r=0.42). Sensitivity [for detecting a rupture] ranged from 79.6 to 100%; the spread in specificity was large but two studies showed perfect (100%) data. Negative and positive likelihood ratios ranged from 0 to 0.23 and 1.0 to 10 respectively. MRI examination was generally performed with 1.5Tesla (T) MRI (6/12 studies) with a strong trend for higher T strength in more recent studies (r=0.71). One study reported a sensitivity of 90.9% and one a specificity of 100%. Although imaging can visualize structure and healing, these results were generally not related to the clinical picture. Overall, ultrasound was recommended over MRI for diagnosis and monitoring. Results of other imaging modalities remain inconclusive. CONCLUSION The adjunct role of imaging, especially of ultrasound and MRI, in the diagnosis and monitoring of ATRs was established. It is therefore recommended to rely primarily on the clinical examination and evaluation and to use imaging for ruling out other injuries and providing additional clinical information. More high-quality research is warranted into the diagnostic accuracy of imaging as well as less conventional imaging modalities' diagnostic and monitoring capabilities.
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Affiliation(s)
- Olivier C Dams
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Inge H F Reininga
- University of Groningen, University Medical Center Groningen, Department of Trauma Surgery, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jan L Gielen
- Antwerp University Hospital, S.P.O.R.T.S., Wilrijkstraat 10, Edegem-Antwerp, 2650, Belgium
| | - Inge van den Akker-Scheek
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johannes Zwerver
- University of Groningen, University Medical Center Groningen, Department of Sport and Exercise Medicine, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Carmont MR, Kuiper JH, Grävare Silbernagel K, Karlsson J, Nilsson-Helander K. Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures. J Exp Orthop 2017; 4:26. [PMID: 28733950 PMCID: PMC5520830 DOI: 10.1186/s40634-017-0101-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/14/2017] [Indexed: 12/28/2022] Open
Abstract
Background Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading. Methods Nineteen bovine Achilles tendons were repaired using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weight-bearing, before being loaded to failure. Results Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. Conclusion The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.
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Affiliation(s)
- Michael R Carmont
- Department of Orthopaedic Surgery, Princess Royal Hospital, Shrewsbury & Telford Hospital, Telford, UK. .,Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Jan Herman Kuiper
- Department of Biomechanical Engineering, The Robert Jones & Agnes Hunt District General Hospital, University of Keele, Keele, UK
| | | | - Jón Karlsson
- Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Nilsson-Helander
- Department of Orthopaedic Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedic Surgery, Kungsbacka Hospital, Kungsbacka, Sweden
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Clinical failure after Dresden repair of mid-substance Achilles tendon rupture: human cadaveric testing. Knee Surg Sports Traumatol Arthrosc 2017; 25:1849-1856. [PMID: 27256278 DOI: 10.1007/s00167-016-4182-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to describe the angle of clinical failure during cyclical mobilization exercises in the Achilles tendon of human cadaveric specimens that were repaired using the Dresden technique and FiberWire® No. 2. The secondary aim was to identify the secure limit of mobilization, the type of failure, and the type of apposition. METHODS The lower limbs of eight males (mean age: 60.3 ± 6.3 years) were repaired with the Dresden technique following complete, percutaneous mid-substance Achilles tendon rupture. A basal tension of 10 N at 30° of plantarflexion was placed on each specimen. The angle of the ankle during clinical failure (tendon ends separation >5 mm) was then tested via cyclical exercises (i.e. 100 cycles between 30° and 15° of plantarflexion; 100 cycles between 15° of plantarflexion and 0°; 100 cycles between 0° and 15° of dorsiflexion; and 100 cycles between 15° of dorsiflexion and full dorsiflexion). Clinical failure was determined using the Laplacian edge detection filter, and the angle of clinical failure was obtained using a rotatory potentiometer aligned in relation to the intermalleolar axis of each foot specimen. The type of failure (knot, tendon, or suture) and apposition (termino-terminal or non-termino-terminal) were determined. Descriptive statistics were used to obtain the mean; standard deviation; 95 % confidence interval; 1st, 25th, 50th, 75th, and 100th percentiles; and the standard error of the mean for angle data. Proportions were used to describe the type of failure and apposition. RESULTS The main results were a mean angle of clinical failure equal to 12.5° of plantarflexion, a limit of mobilization equal to 14.0° of plantarflexion, tendon failure type, and non-termino-terminal apposition in all specimens. CONCLUSIONS While the mean angle of clinical failure in human cadaveric models was 12.5° of plantarflexion, after 14.0° of plantarflexion, the percutaneous Dresden technique was found insecure for cyclical mobilization exercises, with a 5 % range of error. These findings are clinically relevant as they provide mechanical limits for diminishing the risk of Achilles lengthening during immediate rehabilitation.
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