Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis

Background

This systematic review and meta-analysis investigated the treatment for Achilles tendon rupture (ATR) associated with the lowest risk of rerupture in older patients.

Methods

Five databases were searched through September 2022 for studies published in the past 10 years analyzing operative and nonoperative ATR treatment. Studies were categorized as "nonelderly" if they reported only on patients aged 18-60 years. Studies that included at least 1 patient older than age 70 were categorized as "elderly inclusive." Of 212 studies identified, 28 were eligible for inclusion. Of 2965 patients, 1165 were treated operatively: 429 (37%) from elderly-inclusive studies and 736 (63%) from nonelderly studies. Of the 1800 nonoperative patients 553 (31%) were from nonelderly studies and 1247 (69%) were from elderly-inclusive studies.

Results

For nonoperative treatment, the rate of rerupture was higher in nonelderly studies (83/1000 cases, 95% CI = 58, 113) than in elderly-inclusive studies (38/1000 cases, 95% CI = 22, 58; P<.001). For operative treatment no difference was found in the rate of rerupture between nonelderly studies (7/1000 cases, 95% CI = 0, 21) and elderly-inclusive studies (12/1000 cases, 95% CI = 0, 35; P<.78). Overall, operative treatment was associated with a rerupture rate of 1.5% (95% CI: 1.0%, 2.8%) (P<.001), which was lower than the 5% rate reported by other studies for nonoperative management (P<.001).

Conclusion

Older patients may benefit more than younger patients from nonoperative treatment of ATR. More studies are needed to determine the age at which rerupture rates decrease among nonoperatively treated patients.

Level of Evidence

3.

Females present larger deficit in heel-rise height at 3 months following an Achilles tendon rupture compared with males

PURPOSE

There is a lack of knowledge concerning differences between females and males in the early stages after an acute Achilles tendon rupture. This article aims to explore the different factors affecting early function after an Achilles tendon rupture with a validated test battery that includes functional tests, clinical measurements and patient-reported outcome at a 3-month follow-up analysis of a larger prospective study.

METHODS

This study was part of the DUSTAR-study (Diagnostic UltraSonography for the choice of Treatment of acute Achilles tendon Rupture) where the main aim was to evaluate if an acute ultrasonography could determine which patients, with an Achilles tendon rupture, should be treated surgically or nonsurgically. At the 3-month follow-up, the results between males and females were compared.

RESULTS

One hundred and twenty-seven patients were included at the 3-month follow-up; of these, 102 (80%) were males and 25 (20%) were females. Amongst the females, 11 (44%) were able to perform a single leg heel-rise compared to 48 (47%) of the males; however, the difference was not statistically significant. There was no difference between the sexes in the frequency of completing a single-leg heel-rise at 3 months after injury; however, there were statistically significant differences between the groups when comparing Limb Symmetry Index (LSI) of heel-rise height and heel-rise work. The females had a median heel-rise height LSI/median heel-rise work LSI of 45%/14% compared to males who reached a level of 57%/23% (p = 0.006/p = 0.010). At the 3-month follow-up, the median (range) Achilles tendon Total Rupture Score (ATRS) reported by females was 28.5 (8-51), which had a nonsignificant difference compared to males who reported a median (range) ATRS of 30 (1-86).

CONCLUSION

The risk of reduced heel-rise height and worse heel-rise work 3 months after an acute Achilles tendon rupture increases by being a female. Through this knowledge, we highlighted the importance of an individualised treatment for acute Achilles tendon ruptures with better outcome for both males and females.

LEVEL OF EVIDENCE

Level II.

Feasibility of an early progressive resistance exercise program for acute Achilles tendon rupture

BACKGROUND

Long-term strength deficits are common after Achilles tendon ruptures. Early use of progressive resistance exercises may help reduce strength deficits, but the feasibility of this approach is unknown. The aim was to investigate the feasibility of early progressive resistance exercises regarding patient acceptability and compliance with the intervention.

METHODS

We recruited patients with an acute Achilles tendon rupture treated non-surgically. During 9 weeks of immobilisation with a walking boot, participants attended weekly supervised physiotherapy sessions of progressive resistance exercises and performed home exercises, consisting of isometric ankle plantarflexion, seated heel-rise, and elastic band exercises. Acceptability was evaluated using a 7-point Likert scale (1 = very unacceptable and 7 = very acceptable) with feasibility threshold at 80% of the participants rating ≥ 4. Adherence to the exercises was defined as 80% of the participants performing at least 50% of the home exercises. During the intervention, tendon healing and adverse events were monitored.

RESULTS

Sixteen participants (mean age 46 (range 28-61), male/female = 13/3) completed the intervention. Pre-injury Achilles tendon total rupture score was 98 (SD 8). All participants rated the acceptability of the exercises ≥ 5 (moderate acceptable to very acceptable) at 9- and 13-week follow-up and 9/16 rated 7 points (very acceptable). Participants performed 74% (range 4-117) of the total prescribed home exercises and 15/16 performed > 50%. One participant was not compliant with the home exercises due to feeling uncomfortable performing these independently. There were no re-ruptures, but one case of deep venous thrombosis.

CONCLUSIONS

The early progressive resistance exercise program for treatment of non-surgically treated Achilles tendon rupture was feasible. Future studies should investigate the efficacy of the progressive intervention.

TRIAL REGISTRATION

The study was registered at Clinical Trials (NCT04121377) on 29 September 2019.

CLINICALTRIALS

NCT04121377 .

Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year

OBJECTIVE

The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results.

HYPOTHESES

There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols.

METHODS

This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review.

RESULTS

Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07).

CONCLUSIONS

This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes.

LEVEL OF EVIDENCE

III; retrospective comparative, non-randomized.

Hyperuricemia as an independent risk factor for achilles tendon rupture in male: a case-control study

OBJECTIVE

To study the correlation between achilles tendon rupture (ATR) and hyperuricemia, also verify the known risk factors for ATR.

METHODS

A retrospective review of 488 subjects was performed (182 with Achilles tendon rupture, 306 controls with ankle sprains). Demographic variables and risk factors for rupture were tabulated and compared. The baseline data and related indicators were compared, and the risk factors of ATR were analyzed by constructing a binary logistic regression model.

RESULTS

Univariate logistic analysis showed that BMI, smoking, and hyperuricemia were risk factors for the development of ATR (OR = 1.65, 95%CI 1.13-2.42, P = 0.01; OR = 1.47, 95%CI 1.00-2.24, P < 0.05; OR = 2.85, 95%CI 1.84-4.42, P < 0.01). Multifactorial analysis showed that BMI ≥ 25 kg/m2, smoking, and hyperuricemia were independent risk factors for the development of ATR (OR = 1.66, 95%CI 1.11-2.49, P = 0.01; OR = 2.15, 95%CI 1.28-3.60, P < 0.01; OR = 3.06, 95%CI 1.92-4.89, P < 0.01). Among the blood biochemical indicators, total cholesterol (TC) and uric acid (UA) were independent risk factors for the occurrence of ATR (OR = 1.54, 95% CI 1.12-2.12, P = 0.01; OR = 1.01, 95% CI 1.01-1.01, P < 0.01).

CONCLUSION

Our study confirmed that, as in previous results, higher BMI, smoking, and total cholesterol are risk factors for ATR, Hyperuricemia may contribute to the development of ATR, and adjunctive tests for TC and UA in the blood biochemistry may be helpful in predicting the risk of ATR.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Risk factors and clinical characteristics of surgical site infections in athletes undergoing Achilles tendon repair surgery

Achilles tendon ruptures are common in athletes, requiring surgical intervention. However, the risk of surgical site infections (SSIs) post-surgery poses significant challenges. This study aims to analyse the risk factors and microbial aetiology associated with SSIs in athletes undergoing Achilles tendon repair. A comprehensive retrospective analysis was conducted from May 2021 to July 2023. The study included 25 patients with SSIs (case group) and 50 patients without SSIs (control group) post Achilles tendon repair surgery. Inclusion criteria encompassed patients with medically confirmed Achilles tendon ruptures who underwent surgical repair. Exclusion criteria included prior tendon pathologies and significant chronic illnesses. Diagnostic criteria for SSIs involved symptoms like elevated body temperature and localized tenderness, along with laboratory confirmations such as positive microbiological cultures. The study utilized VITEK® 2 for bacterial identification and involved statistical analyses like univariate and multivariate logistic regression. The study identified Staphylococcus aureus as the primary pathogen in SSIs. Significant risk factors included lack of prophylactic antibiotic use, presence of diabetes, open wounds and prolonged surgery duration. Univariate analysis revealed stark contrasts in these factors between infected and non-infected groups, while multivariate analysis underscored their importance in SSI development. S. aureus emerged as the predominant pathogen in SSIs post Achilles tendon repair. Critical risk factors such as absence of prophylactic antibiotics, diabetes, open wounds and extended surgery duration play a vital role in SSIs. Addressing these factors is essential for better postoperative outcomes in Achilles tendon repair surgeries.

Tendon Elongation and Function After Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures: A Randomized Controlled Trial

BACKGROUND

Achilles tendon ruptures often result in long-term functional deficits despite accelerated (standard) rehabilitation.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate if delayed loading would influence functional, clinical, and structural outcomes of the muscles and tendon 1 year after a surgical repair. It was hypothesized that delaying the loading would reduce the heel-rise height deficit 1 year after Achilles tendon rupture.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In total, 48 patients with a surgically repaired Achilles tendon rupture were randomized to 2 groups: the standard group received the currently accepted rehabilitation, and the delayed group received the same rehabilitation except that initial loading was delayed by 6 weeks. The primary outcome was the heel-rise height difference between the injured and uninjured sides at 1 year. The secondary outcomes were (1) tendon length measured with magnetic resonance imaging, (2) muscle fascicle length and pennation angle of the gastrocnemius medialis muscle, (3) Doppler activity measured with ultrasonography, (4) Achilles tendon Total Rupture Score (ATRS), and (5) isometric muscle strength.

RESULTS

The mean heel-rise height deficits for the standard and delayed groups were -2.2 cm and -2.1 cm, respectively (P = .719). The soleus part of the tendon was already elongated 1 week after surgery in both groups without a between-group difference (side-to-side difference: standard, 16.3 mm; delayed, 17.5 mm; P = .997) and did not change over 52 weeks. The gastrocnemius tendon length was unchanged at 1 week but elongated over time without a between-group difference (side-to-side difference at 52 weeks: standard, 10.5 mm; delayed, 13.0 mm; P = .899). The delayed group had less Doppler activity at 12 weeks (P = .006) and a better ATRS (standard, 60 points; delayed, 72 points; P = .032) at 52 weeks.

CONCLUSION

Delayed loading was not superior to standard loading in reducing the heel-rise height difference at 1 year. The data indirectly suggested reduced inflammation in the initial months and a better patient-reported outcome at 1 year in the delayed group. The soleus part of the tendon was already markedly elongated (35%) 1 week after surgery, while the length of the gastrocnemius tendon was unchanged at 1 week but was 6% elongated at 1 year. Together, these data indirectly suggest that the delayed group fared better, although this finding needs to be confirmed in future investigations.

REGISTRATION

NCT04263493 (ClinicalTrials.gov identifier).

Modified Dresden Technique With a Distal Locking Suture for Achilles Tendon Repair: Technique Tip

[Formula: see text].

Comparison of percutaneous and open repair of Achilles tendon rupture: results and complications from a single institution

BACKGROUND

The Achilles tendon is the strongest tendon in the human body, but it is prone to injury, especially in modern times when recreational sports are growing in popularity. As a result, Achilles tendon rupture is becoming an increasingly common medical problem in modern society. The main objective of this study was to compare the outcomes of percutaneous repair and open repair for the treatment of Achilles tendon rupture.

METHODS

A retrospective study was conducted involving a total of 316 patients who had undergone surgical treatment for Achilles tendon rupture between 2013 and 2021. The data collected from the medical history of these patients included the type of surgical procedure, the mechanism of injury, the age and sex of the patients, the time spent in the hospital, and any possible complications of the surgical treatment (such as infections, reruptures, or sural nerve injuries).

RESULTS

The study revealed that there was no significant difference between percutaneous and open surgical approaches in terms of sural nerve injury. However, there was a statistically significant advantage of the percutaneous method in terms of the number of infections, which was significantly lower than that of the open method. Additionally, the median length of hospital stay was found to be four days longer with the open approach. However, the study noted that a statistically significant advantage of the percutaneous method for rerupture could not be established due to the small number of patients with rerupture and the insufficient ratio of patients with rerupture in relation to the size of the observed population.

CONCLUSIONS

Percutaneous repair is an effective treatment option for Achilles tendon rupture and has outcomes equal to or better than those of open repair. Therefore, this approach is recommended as the preferred method of treatment due to the presence of fewer complications, provided that the indications for this technique are appropriate.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Delayed Presentation of Achilles Tendon Ruptures Is Associated With Marked Alterations in the Gene Expression of COL1A1, MMPs, TIMPs, and IL-6

BACKGROUND

Both acute and chronic Achilles tendon ruptures are affected by alterations in the extracellular matrix during the healing process of the tendon. Yet, these alterations in gene expression patterns are not well characterized.

PURPOSE

To characterize temporal and spatial differences in gene expression patterns after an Achilles tendon rupture and to evaluate if cells from chronic Achilles tendon ruptures have the same ability to form new tendon tissue (tendon constructs) as healthy tendon cells.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 35 patients with surgically treated Achilles tendon ruptures were included in the study and divided into 3 groups: acute (<4 weeks), short-term chronic (1-6 months), and long-term chronic (>6 months). Biopsy specimens were collected during surgical repair and were used to analyze the gene expression within the different groups and to compare mRNA levels in the proximal and distal tendon ends. A complementary in vitro experiment was performed to evaluate if cells from chronic Achilles tendon ruptures can form tendon constructs.

RESULTS

The mRNA levels for COL1A1 and COL3A1 were significantly higher in the short-term chronic group compared with the acute group (P < .05). Both MMP-1 and MMP-13 had the highest mRNA levels in the acute group (P < .01) compared with the long-term chronic group, while MMP-2 had the highest mRNA level in the short-term chronic group. Significant differences between the proximal and distal tendon ends were only detected for the monocyte and macrophage marker CD163 (P < .05), which was more expressed proximally. Cells extracted from chronic Achilles tendon ruptures displayed a similar ability and effectiveness to form tendon constructs as healthy tendon cells.

CONCLUSION

A high collagenase gene activity after an Achilles tendon rupture indicated possible rapid matrix degradation in the acute phase. Chronic ruptures appeared to initiate the healing process even before treatment, indicated by the higher expression of collagen in the short-term chronic group. Cells from chronic Achilles tendon ruptures also displayed an ability to form new tendon tissue in vitro.

CLINICAL RELEVANCE

The study shows a rapid increase in collagenase gene expression, which could lead to matrix degradation that continues for months after an Achilles tendon rupture.

Feasibility of Blood Flow Restriction Exercise in Adults with a Non-surgically Treated Achilles Tendon Rupture; a Case Series

Blood flow restriction exercise (BFRE) appears to provide a unique opportunity to preserve lower limb muscle and function in patients with an Achilles tendon rupture. The purpose of this study was to investigate the feasibility of BFRE in patients with an Achilles tendon rupture. Additionally, to evaluate muscle volume and patient-reported ankle function, symptoms, complications, and physical activity following 12 weeks of BFRE. Feasibility was measured by adherence to training sessions, drop-out rate, intervention acceptability, ankle pain exacerbation (NRS), and adverse events. At baseline and 12-weeks follow-up, patients completed the Achilles Tendon Total Rupture Score questionnaire and had their thigh and calf circumference measured. At follow-up, patients' ability to perform a single-leg heel rise was tested. Sixteen of 18 patients completed the intervention and for those, adherence to training sessions was 88% ±16%. The mean NRS following BFRE sessions was 1.1 (95%CI: 1; 1.2). Three adverse events occurred during the 12 weeks. Two re-ruptures after completion of the BFRE program and one deep venous thrombosis following cast removal. BFRE was found to be feasible in a subset of patients with an Achilles tendon rupture. However, with three adverse events in a population of 18 patients, the effectiveness and safety of BFRE warrants further investigation.

Current treatment concepts for Achilles tendon rupture

Achilles tendon rupture is a common and primary cause of lower limb tendon injury suffered during sports-related activities. The causes of Achilles tendon rupture include the calf muscle and tendon overuse, poor tendon quality, and various medical conditions. Historically, acute Achilles tendon rupture was treated conservatively. However, historical techniques are now associated with an increased risk of rerupture. To address this problem, open repair has been proposed. Open repair is associated with a reduced risk of rerupture; however, it is also closely associated with wound complications, like wound infection, whose treatment is time-consuming and costly. Therefore, minimally invasive Achilles tendon repair has been proposed as a promising option with acceptable functional outcomes. Nevertheless, despite its benefits, minimally invasive Achilles tendon repair is associated with increased risks of sural nerve injury and rerupture. In this review, we evaluate the currently used treatment strategies for acute Achilles tendon rupture and their historical evolution to provide evidence-based recommendations for physicians.

The use of platelet-rich plasma in pathologies of the foot and ankle: A comprehensive review of the recent literature

Platelet-rich plasma (PRP) is an autologous serum containing higher concentrations of platelets and growth factors above normal blood. The process of obtaining PRP involves the extraction of blood from the patient which is then centrifuged to obtain a concentrated suspension of platelets. PRP continues to evolve as a potential treatment modality with many applications in orthopaedic surgery. The therapeutic components of PRP possess numerous theoretical regenerative properties. The present manuscript outlines how PRP is prepared, noting the tremendous variability between preparation protocols. Given the growing body of evidence examining the use of PRP in pathologies of the foot and ankle, we assess its efficacy as it relates to our field. Specifically, we evaluate the literature in the past five years regarding the role of PRP in treating plantar fasciitis, Achilles tendinopathy, insertional Achilles tendinitis, Achilles tendon ruptures, osteochondral lesions of the talus, hallux rigidus, and ankle osteoarthritis.

Risk factors for Achilles tendon rupture: an updated systematic review

OBJECTIVE

Identifying risk factors for Achilles Tendon Rupture (ATR) is one of the first necessary steps for its prevention. This systematic review aimed to update the systematic review published in 2014 in ATR etiology.

METHODOLOGY

A systematic review was carried out using PubMed, EBSCO, and ScienceDirect databases. All types of research studies (Randomized Control Trials - RCTs, Cohort studies, Case-control studies and Cross-sectional studies) that considered ATR, were eligible. The inclusion criteria for eligibility of the studies were to be written in the English language, and to include populations of men and/or women, both athletes, and non-athletes, healthy individuals, and patients. Two independent reviewers used the assessment instrument Newcastle-Ottawa Scale independently, to evaluate the quality of each selected study. Further, two reviewers worked independently to extract the study characteristics, and the GRADE methodology was used to assess the level of certainty of each risk factor.

RESULTS

From 9526 studies initially identified, 19 studies were eligible for further analysis to identify risk factors for ATR. Seventeen studies were considered good quality, and two studies fair quality. Low to very low certainty of evidence was found for the following medications: steroids, quinolones, and oral bisphosphonate, as well as for other factors such as chronic tendon inflammation and Achilles' tendinopathy, spring season, diabetes, previous musculoskeletal injury, regular participation in athletic activity, hyperparathyroidism, renal failure, and genetic factors.

CONCLUSIONS

The risk factors found prove that ATR is a multifactorial injury. Appropriate methodologies and well-designed studies are needed to determine the factors and their significance in ATR risk. Finally, the role of biomechanical and psychological aspects in the ATR etiology may be of interest in future studies, as we could not extract relative data in our review.

Shear Wave Tensiometry Can Detect Loading Differences Between Operated and Unaffected Achilles Tendon

BACKGROUND

The clinically relevant healing process of a ruptured and repaired Achilles tendon (AT) can last more than a year. The purpose of this cross-sectional study was to test if shear wave tensiometry is able to detect AT loading changes between a surgically managed AT rupture versus the unaffected contralateral tendon. Our secondary aims were to evaluate differences in mechanical properties when measured with myotonometry and morphological properties of the tendons measured with ultrasonographic imaging.

METHODS

Twenty-one patients with surgically treated AT ruptures were investigated 12-37 months after surgery. Tendon load was measured using a shear wave tensiometer composed of an array of 4 accelerometers fixed on the tendon. Shear wave speed along the Achilles tendon was evaluated at different levels of ankle torque for both the operated and the unaffected side. Mechanical properties of the tendons were evaluated using MyotonPRO and morphological properties using ultrasonographic imaging. Friedman test was used to assess differences in AT wave speed, stiffness, thickness, and cross-sectional area between the operated and the unaffected tendon.

RESULTS

We found a significant shear wave speed difference between sides at every ankle joint torque (P < .05) with a large effect size for the lowest ankle torque and small to medium effect sizes for higher ankle torque. Stiffness, thickness, and cross-sectional area of the operated tendon remained significantly higher compared to the unaffected side.

CONCLUSION

In this cohort, we found that shear wave tensiometry can detect differences between operated and unaffected AT during a standardized loading procedure. The shear wave speed along the operated tendon, as well as the mechanical and morphologic properties, remains higher for 1-3 years after a rupture.

LEVEL OF EVIDENCE

Level III, case-control study.

Dynamic Tensile Stress Promotes Regeneration of Achilles Tendon in a Panda Rope Bridge Technique Mice Model

Regeneration of ruptured Achilles tendon remains a clinical challenge owing to its limited regenerative capacity. Dynamic tensile stress plays a positive role in the regeneration of tendon, although the specific underlying mechanisms remain unclear. In this study, the Achilles tendon defect-regeneration model was created in male C57BL/6 mice aged 8 weeks. The animals were randomly assigned to four groups-repair, non-repair, repair with fixation, and non-repair with fixation. The repair group and repair with fixation group adopted the panda rope bridge technique (PRBT) repair method. Our results demonstrated the presence of more densely aligned and mature collagen fibers, as well as more tendon-related makers, in the repair group at both 2- and 4-week post-surgery. Furthermore, the biomechanical strength of the regenerated tendon in the repair group was highly improved. Most importantly, the expressions of integrin αv and its downstream and the phosphorylation levels of FAK and ERK were remarkably higher in the repair group than in the other groups. Furthermore, blocking FAK or ERK with selective inhibitors PF573228 and U0126 resulted in obvious adverse effects on the histological structure of the regenerated Achilles tendon. In summary, this study demonstrated that dynamic tensile stress based on the PRBT could effectively promote the regeneration of the Achilles tendon, suggesting that dynamic tensile stress enhances the cell proliferation and tenogenic differentiation via the activation of the integrin/FAK/ERK signaling pathway.

Differential elongation of the gastrocnemius after Achilles tendon rupture: a novel technique of selective shortening to treat push-off weakness with case series and literature review

PURPOSE

Differential elongation of the gastrocnemius after Achilles tendon rupture (ATR) may compromise the ability of athletes to return to competition. Recognition of this differential elongation of the gastrocnemius relative to the soleus is vital to treat patients with weakness in push-off. This paper describes a novel technique performed for selective shortening of the gastrocnemius to treat push-off weakness.

METHODS

Three patients with differential proximal retraction of the gastrocnemius greater than 20 mm after treatment for ATR with inability to run and jump underwent surgical correction with this novel technique and were followed-up for 2 years. A novel selective shortening of the gastrocnemius with autologous hamstring graft was performed in these patients. The Achilles Tendon Total Rupture Score (ATRS) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were recorded preoperatively and at the final follow-up.

RESULTS

All three patients were able to return to running and jumping at final follow-up. The ATRS improved significantly in the strength, fatigue, running and jumping domains but there appeared to be a less notable improvement in activities of daily living domain. The AOFAS score showed improvement with the greatest margin in the domain of activity limitation.

CONCLUSION

This procedure is the first described selective shortening method of the gastrocnemius tendons after differential elongation following ATR. It is a safe and reliable technique providing improved ATRS and AOFAS scores in three patients who were all able to return to running and jumping sports at 2-year follow-up.

LEVEL OF EVIDENCE

IV.

Early Tendon Morphology as a Biomarker of Long-term Patient Outcomes After Surgical Repair of Achilles Tendon Rupture: A Prospective Cohort Study

Background

Patient outcome after acute Achilles tendon rupture (ATR) varies and is difficult to predict. Whether early variations in healing, visualized with ultrasonography, can predict long-term patient outcome is unclear.

Purpose

To (1) examine the associations of Achilles tendon cross-sectional area (CSA) and elongation (TE) during healing of ATR repair with patient outcomes at 12 months postoperatively and (2) investigate the predictive or diagnostic capacity of the morphological biomarkers.

Study Design

Cohort study; Level of evidence, 2.

Methods

This study was based on previously collected data from 86 patients who underwent acute standardized ATR repair between 2013 and 2018 and who were included in a prior randomized trial investigating early functional mobilization (EFM). In the EFM group, loading was allowed immediately after surgery, while in the comparison group, loading was allowed first at 2 weeks postoperatively. Achilles tendon CSA and length were measured with ultrasound at 6 weeks, 6 months, and 12 months postoperatively. CSA ratio and absolute difference in the length of the healthy and injured tendons were calculated. Patient-reported outcome was registered with the validated Achilles tendon Total Rupture Score and functional outcome with the heel-rise endurance test at 12 months postoperatively. The limb symmetry index (LSI) was calculated for maximum heel-rise height (HRHmax) and total concentric work. Multiple linear regression adjusted for age was used, and the area under the receiver operating characteristic curve (AUC) was calculated to evaluate predictive capacity.

Results

A larger CSA ratio at 6 weeks was associated with higher LSI HRHmax at 12 months (R2, 0.35; P < .001) and exhibited good predictive capacity (AUC, 0.82). More TE at 12 months was associated with lower LSI total concentric work at 12 months (R2, 0.21; P = .001) and exhibited acceptable predictive capacity (AUC, 0.71).

Conclusion

Greater Achilles tendon CSA seen on ultrasound 6 weeks after surgical repair had good clinical prediction for long-term functional outcome. TE at 12 months was predictive of inferior functional outcome.

Registration

NCT02318472 (ClinicalTrials.gov identifier).

A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients

INTRODUCTION

Achilles tendon sleeve avulsion (ATSA) is a rare injury that often results from pre-existing insertional Achilles tendinopathy and occurs when a tendon avulses from the insertion as a continuous sleeve. To date, outcomes of operative treatment for ATSA in older patients have not been reported. Therefore, this study aims to compare the characteristics and outcomes of Achilles tendon (AT) reattachment with or without tendon lengthening for ATSA between older and younger patients.

MATERIALS AND METHODS

This study enrolled 25 consecutive patients who underwent operative treatment following a diagnosis of ATSA between January 2006 and June 2020. The inclusion criterion was a minimum follow-up duration of one year. The enrolled patients were divided into two groups according to their age at operation: ≥ 65 years (group 1, 13 patients) and < 65 years (group 2, 12 patients). AT reattachment was performed in all patients using two 5.0-mm suture anchors after an inflamed distal stump resection in the 30° plantar-flexed ankle position.

RESULTS

The degree of active dorsiflexion and plantar flexion, mean visual analog scale score, and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were not significantly different between the two groups (P > 0.05 each). The rate of satisfactory clinical outcomes (defined as fair or greater) was 84.6% and 91.7% in groups 1 and 2, respectively.

CONCLUSION

We observed that comparable clinical outcomes could be achieved after AT reattachment with or without lengthening for ATSA between older and younger patients.

Achilles tendon thickening does not affect elasticity and functional outcome after surgical repair of Achilles rupture: A retrospective study

PURPOSE

Previous studies have confirmed that Achilles tendon occurs Achilles thickening after repair surgery of the rupture. Although this mechanism has been elucidated in the laboratory, there are few reports on its impact on clinical function. We designed a retrospective study to investigate the Achilles thickening after Achilles tendon rupture repair and its correlation between the elasticity and postoperative function.

METHODS

In this retrospective analysis, patients who underwent surgical treatment for acute Achilles tendon rupture from April 2016 to April 2020 were included. All the patients were regularly followed up at 3 months, 1 year, and 2 years after surgery. American Orthopaedic Foot Ankle Surgeon (AOFAS) scale and Leppilahti score were used to evaluate functional outcomes. Achilles elasticity was measured by ultrasound shear wave of elasticity. Achilles thickening was calculated as maximal transverse and longitudinal diameter in cross-sectional plane of magnetic resonance scan. Sample t-tests was used for different follow-up periods. Correlation between Achilles thickening and other factors were analyzed using Pearson's method. p < 0.05 indicates a statistically significant difference.

RESULTS

AOFAS scale and Leppilahti score at 1 year were significantly higher than at 3 months postoperatively (both p < 0.001). These functional scales were also improved at 2-year follow-up significantly (both p < 0.001). The dorsiflexion difference showed gradually recovery in each follow-up period (t = -17.907, p < 0.001). The elasticity of the Achilles appeared to continuously decreases during the postoperative follow-up period in all position sets (p < 0.001). In thickening evaluation, the cross-sectional area of the thickest plane of Achilles was significantly higher at 1 year postoperatively (310.5 ± 25.2) mm2 than that at 3 months postoperatively ((278.0 ± 26.2) mm2, t = -8.219, p < 0.001) and became thinner in 2-year magnetic resonance scan ((256.1 ± 15.1) mm2, t = 16.769, p < 0.001). The correlations between Achilles thickening, elasticity, and functional outcome did not show statistical significance (p > 0.05) in every follow-up period.

CONCLUSION

Achilles tendon thickens after surgery in the 1st year, but begins to gradually return to thinning about 2 years after surgery. There was no significant correlation between the increase and decrease of thickening and the patients' clinical function scores, Achilles elasticity, and bilateral ankle dorsiflexion difference.

Use of point-of-care ultrasound in a low-resource setting to diagnose Achilles tendon rupture and avulsion fracture of the calcaneal bone

BACKGROUND

Point-of-care ultrasound (POCUS) is becoming more prevalent in recent years for evaluating patients presenting with musculoskeletal injuries in the emergency department (ED). This imaging modality has been utilized to diagnose soft tissue and bony injuries accurately, obtain appropriate consultation, and perform timely interventional procedures in the ED.

CASE PRESENTATION

We present the case of a 55-year-old man who presented to the ED with significant left ankle pain following a ground-level fall. His physical examination showed swelling and tenderness around the ankle. POCUS examination aided the rapid and accurate detection of acute Achilles tendon rupture.

CONCLUSION

This case demonstrates that POCUS is a valuable diagnostic tool in evaluating patients with a suspected Achilles tendon rupture, especially in a resource-limited setting.

An Atelocollagen Injection Enhances the Healing of Nonoperatively Treated Achilles Tendon Tears: An Experimental Study in Rats

Background

There is growing interest in nonoperative treatment for the management of Achilles tendon ruptures (ATRs). However, nonoperative treatment is limited by the risk of tendon reruptures and low satisfaction rates. Recently, atelocollagen injections have been reported to have beneficial effects on tendon healing.

Purpose

To evaluate the beneficial effects of injected atelocollagen on Achilles tendon healing and investigate the mechanism of atelocollagen on tendon healing.

Study Design

Controlled laboratory study.

Methods

Percutaneous tenotomy of the right Achilles tendon in 66 rats was performed. The animals were equally divided into the noninjection group (NG) and the collagen injection group (CG). At 1, 3, and 6 weeks, the Achilles functional index, cross-sectional area, load to failure, stiffness, stress, and the modified Bonar score were assessed. Transmission electron microscopy, western blotting, and immunohistochemistry were also performed.

Results

The Achilles functional index (-6.8 vs -43.0, respectively; P = .040), load to failure (42.1 vs 27.0 N, respectively; P = .049), and stiffness (18.8 vs 10.3 N/mm, respectively; P = .049) were higher in the CG than those in the NG at 3 weeks. There were no significant differences in histological scores between the 2 groups. Transmission electron microscopy analysis showed that the mean diameter of collagen fibrils in the CG was greater than that in the NG at 3 weeks (117.2 vs 72.6 nm, respectively; P < .001) and 6 weeks (202.1 vs 144.0 nm, respectively; P < .001). Western blot analysis showed that the expression of collagen type I in the CG was higher than that in the NG at 1 week (P = .005) and 6 weeks (P = .001).

Conclusion

An atelocollagen injection had beneficial effects on the healing of nonoperatively treated Achilles tendon injuries. The Achilles tendon of CG rats exhibited better functional, biomechanical, and morphological outcomes compared with NG rats. The molecular data indicated that the mechanism of atelocollagen injections may be associated with an increased amount of collagen type I.

Clinical Relevance

An atelocollagen injection might be a good adjuvant option for the nonoperative treatment of ATRs.

[Clinical study on a novel minimally invasive Achilles tendon suture instrument for treating fresh closed Achilles tendon rupture]

Objective

To assess the effectiveness of a novel minimally invasive Achilles tendon suture instrument in the treatment of fresh closed Achilles tendon rupture.

Methods

A retrospective study was conducted on 150 patients who underwent surgical intervention for fresh closed Achilles tendon rupture. Eighty patients were treated with the novel minimally invasive Achilles tendon suture instrument (minimally invasive group) and 70 patients with traditional open surgery (traditional group). The two groups were comparable in terms of gender, age, injured side, cause of injury, the interval between injury and operation, and the distance from the fracture end to the calcaneal tuberosity ( P>0.05). The operation time, intraoperative blood loss, incision length, hospital stays, hospitalization expenses, and complications were recorded and compared. At 1 year after operation, the ankle joint function was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score.

Results

The minimally invasive group demonstrated significantly shorter operation time, smaller incision length, and lower intraoperative blood loss when compared with the traditional group ( P<0.05). However, there was no significant difference in terms of hospital stays and hospitalization expenses between the two groups ( P>0.05). All patients were followed up 12-24 months after operation (mean, 15.5 months). In the traditional group, 6 cases of incision necrosis and 7 cases of Achilles tendon adhesion occurred, while in the minimally invasive group, all incisions healed at first intention and no Achilles tendon adhesion occurred. The differences in the incidences of the two complications between the two groups were significant ( P<0.05). At 1 year after operation, the AOFAS ankle-hindfoot score in the minimally invasive group was superior to that of the traditional group ( P<0.05).

Conclusion

In comparison with traditional open surgery, the use of self-designed novel minimally invasive Achilles tendon suture instrument proves to be an ideal technique for treating fresh closed Achilles tendon ruptures. This approach offers the benefits of smaller incisions, fewer complications, and better postoperative functional recovery, without increasing hospital costs.

Risk Factors for Contralateral Tendon Rupture in Patients With Acute Achilles Tendon Rupture

The present study was performed to determine the incidence and risk factors of contralateral Achilles tendon rupture after an initial tendon rupture, and to identify the associated patient characteristics. Medical records of 181 adult patients with acute Achilles tendon rupture were reviewed. We investigated the risk factors for contralateral Achilles tendon rupture and calculated the incidence density (per 100 person-years), survival rate, hazard ratios, and 95% confidence intervals. The risk factors were extracted, including blood type, age, body mass index (BMI), occupation, underlying comorbidities, history of alcohol intake or smoking, injury mechanism, and fluoroquinolone antibiotic or steroid use. Military personnel and manual laborers, including farmers and firefighters were considered to have an occupation involving physical activity. Ten patients (5.5%) were identified as having nonsimultaneous, contralateral Achilles tendon rupture a mean of 3.3 years (range 1.0-8.3 years) after the initial tendon rupture. The incidence density of contralateral tendon rupture was 0.89 per 100 person-years. The 8-year survival rate of contralateral tendon rupture was 92.2%. Unadjusted and adjusted hazard ratios (with 95% confidence intervals, p value) of blood type O were 3.71 (1.07-12.82, p = .038) and 2.90 (0.81-10.32, p = .101), respectively, and those of occupations involving physical activity were 5.87 (1.64-20.98, p = .006) and 4.69 (1.27-17.28, p = .02), respectively. Based on the present data, blood type O and occupations involving physical activity are significantly associated with an increased risk of contralateral tendon rupture in adult patients who have sustained Achilles tendon rupture.

Achilles Rupture in the Setting Posterior Tibial Osteochondroma: A Case Report and Guidelines for Management of Osteochondromas Adjacent to Tendons

Introduction

The presentation of the included patient is unique, and the thought process regarding management algorithms used to manage this patient is important to discuss so that other surgeons may benefit. This is the first report of its kind, to our knowledge.

Case Report

A 30-year-old healthy Caucasian male presented with acute Achilles tendon rupture after feeling a pop while playing basketball, in the setting of a known posterior tibial osteochondroma and a recent increase in physical activity.

Conclusion

The resultant injury is likely due to mechanical irritation at the tendon site, which caused wear over time and eventual acute rupture. We expanded our percutaneous repair to include an evaluation of the posterior compartment to adequately visualize and excise the large bony lesion. Therefore, we conclude that it is reasonable to counsel patients with known osteochondromas in this location due to the risk of possible Achilles injury, particularly if at all symptomatic.

Rates of Operative Management for Achilles Tendon Rupture Over the Last Decade and the Influence of Gender and Age

BACKGROUND

With emerging evidence supporting functional rehabilitation for Achilles tendon ruptures (ATRs), this study sought to evaluate the treatment trends for patients sustaining an acute ATR and whether gender and age may influence the rates of operative repair.

METHODS

A retrospective database review identified ATRs from 2010 through 2019. Patients were then stratified into three cohorts based on age (18-30, 30-45, and 46 and older), separated by gender, and then assessed whether patients were treated operatively or not. Cochran-Armitage Trend test was performed to analyze the trends of operative management. Chi-square analyses were performed to assess whether the proportion of patients who received operative management in each age cohort differed from 2010 to 2019. Logistic regression analyses were performed to assess whether gender influenced treatment.

RESULTS

Over the previous decade, the total rates of operative treatment for ATR significantly decreased (18.3%-12.3%, P < .0001). Each individual age cohort experienced a proportional decrease in operative management when comparing 2010 with 2019 (all P < .0001). Within all age cohorts, males were significantly more likely to receive operative treatment for an ATR over the previous decade (odds ratios: 2.63-3.22). Conclusion. Overall rates of operative management for ATR decreased across all cohorts likely due to previous studies providing evidence of similar results between operative and nonoperative managements. Over the previous decade, males were demonstrated to be far more likely than females to undergo operative management. Why females are less likely to receive an operation for ATR is likely multi-factorial and requires further exploration.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.

Case study: The influence of Achilles tendon rupture on knee joint stress during counter-movement jump - Combining musculoskeletal modeling and finite element analysis

BACKGROUND

Presently, the current research concerning Achilles tendon rupture repair (ATR) is predominantly centered on the ankle joint, with a paucity of evidence regarding its impact on the knee joint. ATR has the potential to significantly impede athletic performance and increase tibiofemoral contact forces in athletes. The purpose of this study was to prognosticate the distribution of stress within the knee joint during a countermovement jump through the use of a simulation method that amalgamated a musculoskeletal model of a patient who underwent Achilles tendon rupture repair with a finite element model of the knee joint.

METHODS

A male elite badminton player who had suffered an acute Achilles tendon rupture in his right leg one year prior was selected as our study subject. In order to analyze his biomechanical data, we employed both the OpenSim musculoskeletal model and finite element model to compute various parameters such as joint angles, joint moments, joint contact forces, and the distribution of knee joint stress.

RESULTS

During the jumping phase, a significantly lower knee extension angle (p < 0.001), ankle dorsiflexion angle (p = 0.002), peak vertical ground reaction force (p < 0.001), and peak tibiofemoral contact force (p = 0.009) were observed on the injured side than on the uninjured side. During the landing phase, the ankle range of motion (ROM) was significantly lower on the injured side than on the uninjured side (p = 0.009), and higher peak vertical ground reaction forces were observed (p = 0.012). Additionally, it is logical that an injured person will put higher load on the uninjured limb, but the finite element analysis indicated that the stresses on the injured side of medial meniscus and medial cartilage were significantly greater than the uninjured side.

CONCLUSIONS

An Achilles tendon rupture can limit ankle range of motion and lead to greater joint stress on the affected area during countermovement jumps, especially during the landing phase. This increased joint stress may also transfer more stress to the soft tissues of the medial knee, thereby increasing the risk of knee injury. It is worth noting that this study only involves the average knee flexion angle and load after ATR in one athlete. Caution should be exercised when applying the conclusions, and in the future, more participants should be recruited to establish personalized knee finite element models to validate the results.

Return to Play Following Achilles Tendon Rupture in NFL Players Based on Position

BACKGROUND

The purpose of this study was to determine the return-to-play (RTP) rate and postinjury performance after Achilles tendon (AT) ruptures in National Football League (NFL) skill position players.

METHODS

The study included NFL skill positions with an AT rupture between the 2009-2010 and 2015-2016 seasons. Performance data were collected and compared against a matched control group. RTP was defined as playing in at least 1 game after repair.

RESULTS

RTP rate was 57% for the study cohort. The tight ends (TEs) had the highest RTP rate at 71% while the wide receivers (WRs) had the lowest RTP rate at 38%. Compared with the control group, WRs with successful RTP had significantly less receptions per game (P = .01). For defensive players with RTP there were significant decreases in postrepair performance in tackles, passes defended, and fumbles forced/recovered compared with the control group.

CONCLUSION

A total of 57% of players achieved RTP with WRs and running backs (RBs) having the lowest RTP rates and TEs and linebackers (LBs) having the highest RTP rates. RBs, defensive backs (DBs), and LBs with successful RTP had decreased performance in all categories. This updated information may be helpful for athletes, physicians, scouts, and coaches in evaluating players with a history of AT rupture.

LEVELS OF EVIDENCE

Analytic, level 3, retrospective cohort study, Epidemiologic study.

Network proteomic analysis identifies inter-alpha-trypsin inhibitor heavy chain 4 during early human Achilles tendon healing as a prognostic biomarker of good long-term outcomes

The suboptimal or protracted regeneration of injured connective tissues often results in significant dysfunction, pain, and functional disability. Despite the prevalence of the condition, few studies have been conducted which focused on biomarkers or key molecules involved in processes governing healing outcomes. To gain insight into injured connective tissue repair, and using the Achilles tendon as a model system, we utilized quantitative proteomic and weighted co-expression network analysis of tissues acquired from Achilles tendon rupture (ATR) patients with different outcomes at 1-year postoperatively. Two modules were detected to be associated with prognosis. The initial analysis identified inter-alpha-trypsin inhibitor heavy chain 4 (ITIH4) as a biomarker or hub protein positively associated with better healing outcomes. Additional analysis identified the beneficial role of ITIH4 in inflammation, cell viability, apoptosis, proliferation, wound healing, and for the synthesis of type I collagen in cultured fibroblasts. Functionally, the effects of ITIH4 were found to be mediated by peroxisome proliferator-activated receptor gamma (PPARγ) signaling pathways. Taken together, these findings suggest that ITIH4 plays an important role in processes of connective tissue repair and advocate for the potential of ITIH4 as a therapeutic target for injured connective tissue repair.

Trial registration

http://clinicaltrials.gov, identifiers NCT02318472, NCT01317160.

Midterm Outcomes of Operatively and Nonoperatively Managed Achilles Tendon Ruptures in Young Adults

Background

There continues to be controversy regarding treatment options for Achilles tendon ruptures (ATR). The aim of our study is to compare outcomes between operatively and nonoperatively managed Achilles ruptures in young adults (age 18-30 years), which has not been previously evaluated.

Methods

At a single institution, all patients aged 18-30 years at time of injury who underwent treatment for an acute ATR from 2014 to 2021 were evaluated. Medical records were reviewed to collect demographics, dates of injury and treatment, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), rate of deep venous thrombosis (DVT) after treatment, and rate of rerupture. Patients then completed Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) questionnaires. Mann-Whitney nonparametric testing was used to evaluate for any statistical differences in PROMIS scores.

Results

Sixty-six operative patients qualified and 28 (42%) participated. Thirty-seven nonoperative patients qualified and 14 (38%) participated. All patients had a CCI of 0. One patient in the operative cohort and 2 in the nonoperative reported active smoking. In the operative and nonoperative cohorts, respectively, the average age was 24.4 and 27.8 years; average BMI 26.5 (SD = 4.8) and 27.3 (SD = 4.3, P = .52); DVT rates 4 (6.1%) and 2 (5.4%); and rerupture rates 2 (3.0%) and 1 (2.7%), respectively. PROMIS scores did not differ in the operative and nonoperative groups: PROMIS PF mean of 60.4 (SD = 9.8) and 62.9 (SD = 9.1), respectively (P = .33); as well as PROMIS PI mean of 44.6 (SD = 5.9) and 43.9 (SD = 6.5), respectively (P = .59).

Conclusion

This study should be interpreted with the understanding that we had a considerable loss to follow-up rate. In the study cohort, we found that young adults with ATR may be considered for either operative or nonoperative management. Rates of DVT, rates of rerupture, and PROMIS scores were not dissimilar between the 2 cohorts.

Level of Evidence

Level III, retrospective cohort study.

Republication of "Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?"

Background

Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications.

Methods

A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted.

Results

There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected (P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature (P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature (P < .0001; CI 0.067-1.94).

Conclusion

In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature.

Level of Evidence

Level IV.

Effectiveness of platelet-rich plasma in the treatment of Achilles tendon disease

BACKGROUND

The effectiveness of Platelet-Rich Plasma (PRP) in the treatment of patients with Achilles tendon rupture (ATR) and Achilles tendinopathy (AT) has been controversial.

AIM

To assess PRP injections’ effectiveness in treating ATR and AT.

METHODS

A comprehensive review of relevant literature was conducted utilizing multiple databases such as Cochrane Library, PubMed, Web of Science, Chinese Science and Technology Journal, EMBASE, and China Biomedical CD-ROM. The present investigation integrated randomized controlled trials that assessed the effectiveness of platelet-rich plasma injections in managing individuals with Achilles tendon rupture and tendinopathy. The eligibility criteria for the trials encompassed publications that were published within the timeframe of January 1, 1966 to December 2022. The statistical analysis was performed utilizing the Review Manager 5.4.1, the visual analogue scale (VAS), Victorian Institute Ankle Function Scale (VISA-A), and Achilles Tendon Thickness were used to assess outcomes.

RESULTS

This meta-analysis included 13 randomized controlled trials, 8 of which were randomized controlled trials of PRP for AT and 5 of which were randomized controlled trials of PRP for ATR. PRP for AT at 6 wk [weighted mean difference (WMD) = 1.92, 95%CI: -0.54 to 4.38, I² = 34%], at 3 mo [WMD = 0.20, 95%CI: -2.65 to 3.05, I² = 60%], and 6 mo [WMD = 2.75, 95%CI: -2.76 to 8.26, I² = 87%) after which there was no significant difference in VISA-A scores between the PRP and control groups. There was no significant difference in VAS scores between the PRP group and the control group after 6 wk [WMD = 6.75, 95%CI: -6.12 to 19.62, I² = 69%] and 6 mo [WMD = 10.46, 95%CI: -2.44 to 23.37, I² = 69%] of treatment, and at mid-treatment at 3 mo [WMD = 11.30, 95%CI: 7.33 to 15.27, I² = 0%] after mid-treatment, the PRP group demonstrated better outcomes than the control group. Post-treatment patient satisfaction [WMD = 1.07, 95%CI: 0.84 to 1.35, I² = 0%], Achilles tendon thickness [WMD = 0.34, 95%CI: -0.04 to 0.71, I² = 61%] and return to sport [WMD = 1.11, 95%CI: 0.87 to 1.42, I² = 0%] were not significantly different between the PRP and control groups. The study did not find any statistically significant distinction between the groups that received PRP treatment and those that did not, regarding the Victorian Institute of Sport Assessment - Achilles scores at 3 mo [WMD = -1.49, 95%CI: -5.24 to 2.25, I² = 0%], 6 mo [WMD = -0.24, 95%CI: -3.80 to 3.32, I² = 0%], and 12 mo [WMD = -2.02, 95%CI: -5.34 to 1.29, I² = 87%] for ATR patients. Additionally, no significant difference was observed between the PRP and the control groups in improving Heel lift height respectively at 6 mo [WMD = -3.96, 95%CI: -8.61 to 0.69, I² = 0%] and 12 mo [WMD = -1.66, 95%CI: -11.15 to 7.83, I² = 0%] for ATR patients. There was no significant difference in calf circumference between the PRP group and the control group after 6 mo [WMD = 1.01, 95%CI: -0.78 to 2.80, I² = 54%] and 12 mo [WMD = -0.55, 95%CI: -2.2 to 1.09, I² = 0%] of treatment. There was no significant difference in ankle mobility between the PRP and control groups at 6 mo of treatment [WMD = -0.38, 95%CI: -2.34 to 1.58, I² = 82%] and after 12 mo of treatment [WMD = -0.98, 95%CI: -1.41 to -0.56, I² = 10%] there was a significant improvement in ankle mobility between the PRP and control groups. There was no significant difference in the rate of return to exercise after treatment [WMD = 1.20, 95%CI: 0.77 to 1.87, I² = 0%] and the rate of adverse events [WMD = 0.85, 95%CI: 0.50 to 1.45, I² = 0%] between the PRP group and the control group.

CONCLUSION

The use of PRP for AT improved the patient’s immediate VAS scores but not VISA-A scores, changes in Achilles tendon thickness, patient satisfaction, or return to sport. Treatment of ATR with PRP injections alone improved long-term ankle mobility but had no significant effect on VISA-A scores, single heel lift height, calf circumference or return to sport. Additional research employing more extensive sampling sizes, more strict experimental methods, and standard methodologies may be necessary to yield more dependable and precise findings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IlI, retrospective cohort study.

The Association of Body Mass Index and Waist Circumference with the Risk of Achilles Tendon Problems: A Nationwide Population-Based Longitudinal Cohort Study

Background

The purpose of this study was to evaluate the association of body mass index (BMI) and waist circumference (WC) with the risk of Achilles tendinopathy (AT) or Achilles tendon rupture (ATR), using data from a nationwide population-based cohort. We hypothesized that higher BMI and WC would be independently associated with the increased risk of AT or ATR. In addition, a higher WC may potentiate the association between BMI and the risk of Achilles tendon problems.

Methods

We used the National Health Insurance database that covers the entire South Korean population to follow up subjects who participated in the National Health Screening Program (NHSP) from January 2009 to December 2010. The NHSP data include subjects' BMI, WC, blood test results, blood pressure, and information about lifestyle. Among the subjects, those who were newly diagnosed as having AT or ATR before December 31, 2017, were selected. To examine the association of the variables with the risk of AT or ATR and determine whether the effect of higher BMI varied according to WC, multivariate Cox proportional hazards regression was used.

Results

Among a total of 16,830,532 subjects, 125,814 and 31,424 developed AT and ATR, respectively. A higher BMI showed a greater association with the increased risk of ATR than AT (adjusted hazard ratio [HR], 3.49 vs. 1.96). A higher WC was associated with the increased risk of AT (adjusted HR, 1.22), but not ATR. In a separate analysis, the association between BMI and the risk of AT was higher when subjects had higher WC as compared to those with lower WC, being most significant in individuals with both higher BMI and higher WC.

Conclusions

Higher BMI was more associated with the increased risk of ATR than AT. Moreover, a high central fat distribution played an independent and potentiating role in the development of AT. This implies the greater importance of a high central fat distribution contributing to the development of AT in obese people.

Patients with Achilles Tendon Rupture Are Prone to Develop Ventricular Arrhythmia

BACKGROUND AND OBJECTIVES

This study aimed to examine the ventricular repolarization (VR) disturbances of patients operated on for acute spontaneous Achilles tendon ruptures (ATRs), by comparing them with a healthy individual control group.

MATERIALS AND METHODS

Between June 2014 and July 2020, a total of 29 patients (28 males, 1 female; mean age: 40 ± 9.78 years; range, 21-66 years) who presented to the emergency department within the first three weeks of injury, and were diagnosed with acute spontaneous ATRs and treated with an open Krackow suture technique, were retrospectively analyzed. Fifty-two healthy individuals (47 males, 5 females; mean age: 39 ± 11.45 years; range, 21-66 years) were recruited as a control group from the cardiology outpatient clinic. Clinical data (demographic features and laboratory parameters (serum glucose, creatinine, hemoglobin, white blood cell count, and lipid profile)) and electrocardiograms (ECGs) were collected from medical records. ECGs were evaluated for heart rate and VR parameters of QRS width, QTc interval, cQTd interval, Tp-e interval, and Tp-e/QT ratio. The clinical data and these ECG parameters were compared between groups.

RESULTS

There was no statistically significant difference between groups, regarding clinical data (all p < 0.05). Among ECG parameters, heart rate, QRS width, QTc interval, and cQTd interval were similar between groups (all p < 0.05). There were two important statistically significant findings of this research: The mean Tp-e interval was longer (ATR group: 72.4 ± 24.7, control group: 58.8 ± 14.5, p: 0.01), and the Tp-e/QT ratio was higher (ATR group: 0.2 ± 0.1, control group: 0.16 ± 0.4, p: 0.027) in the ATR group.

CONCLUSIONS

According to the ventricular repolarization disturbances found in this study, patients with ATR may be at a higher risk of ventricular arrhythmia than healthy people. As a result, ATR patients should be assessed for ventricular arrhythmia risk by an expert cardiologist.

Re-ruptures and early outcomes after surgical repair of acute Achilles tendon ruptures: prospective, comparative multicenter study

PURPOSE

The primary objective of this study was to compare the re-rupture rate, clinical results, and functional outcomes six months after the surgical repair of an acute Achilles tendon rupture between three different techniques (open repair, percutaneous repair with the Tenolig®, and minimally invasive repair).

METHODS

A prospective, comparative, multicenter, non-randomized study was performed and included 111 patients who had an acute ruptured Achilles tendon: 74 underwent an open repair, 22 underwent a percutaneous repair using the Tenolig® and 15 had a minimally invasive repair. At six months follow-up we analyzed the number of re-ruptures, phlebitis, infections, complex regional pain syndrome, clinical outcomes (muscle atrophy, ankle dorsal flexion), functional scores (ATRS, VISA-A, EFAS, SF-12), and return to running.

RESULTS

There were more re-ruptures (p=0.0001) after repair with the Tenolig® (27%) than with open repairs (1.3%) and minimally invasive repairs (0%). The rate of other complications was not different. No clinical differences were found between the three groups. Only some functional scores EFAS Total (p=0.006), and VISA-A (p=0.015) were worse in the Tenolig® group. All the other results were similar between the three groups.

CONCLUSION

Despite heterogeneous studies in literature, the results of this comparative and prospective study between three surgical techniques of Achilles tendon repair confirmed that Tenolig® repair increased the rate of early re-rupture compared to open or minimally invasive techniques.

Return to sport after surgical repair of the Achilles tendon

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

Level III, retrospective cohort study.

Video analysis of Achilles tendon ruptures in professional male football (soccer) reveals underlying injury patterns and provides strategies for injury prevention

PURPOSE

In professional football (soccer), Achilles tendon ruptures are severe injuries. Video analysis promotes a better understanding of the underlying situational and biomechanical patterns, and provides a roadmap for future research to improve the management and prevention of Achilles tendon ruptures. The purpose of this study was to identify injury patterns contributing to acute Achilles tendon ruptures in professional male football players.

METHODS

Professional male football players with an acute Achilles tendon rupture were identified using an online database. For every in-competition injury, the corresponding football match was detected. Video footage of the injury was accessed using Wyscout.com or publicly available video databases. Situational patterns and injury biomechanics of the injury frame were independently analysed by two reviewers using a standardised checklist and a motion analysis software. Finally, consensus was reached to describe the main injury patterns of Achilles tendon ruptures in professional male football players.

RESULTS

The search identified video footage of 80 Achilles tendon ruptures in 78 players. Most injuries (94%) occurred through indirect or non-contact mechanisms. The kinematic analysis revealed characteristic joint positions at the time of injury consisting of hip extension, knee extension, ankle dorsiflexion, foot abduction, and foot pronation in most cases. The underlying direction of movement was from flexion to extension (knee) and from plantarflexion to dorsiflexion (ankle). Player actions identified as main injury patterns were stepping back (26%), landing (20%), running/sprinting (18%), jumping (13%), and starting (10%).

CONCLUSION

Most Achilles tendon ruptures in professional male football players are closed-chain indirect or non-contact injuries. Sudden loading to the plantarflexor musculotendinous unit remains to be the main component for most cases. By achieving a better understanding of underlying injury mechanisms, this study provides new strategies for the prevention of Achilles tendon ruptures.

LEVEL OF EVIDENCE

Level IV.

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

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.

Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair.

PURPOSE

The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time.

RESULTS

There were 10 RCTs that qualified for the meta-analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], -0.73 [95% CI, -1.70 to 0.25]; P = .14; I² = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I² = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I² = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I² = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I² = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I² = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I² = 15%).

CONCLUSION

Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.

Chronologic Changes in the Elastic Modulus of a Healing Achilles Tendon Rupture Measured Using Shear Wave Elastography

BACKGROUND

Shear wave elastography (SWE) has been used to examine the elasticity of a ruptured Achilles tendon; however, the healing process of a ruptured tendon has not been studied yet. This study aimed to detail the change in mechanical properties of a healing Achilles tendon rupture managed conservatively or surgically using SWE.

METHODS

Using a prospective cohort study design, we evaluated the patients treated conservatively (conservative group) and surgically (surgical group) with the "gift-box" technique for an isolated index acute Achilles tendon rupture during their healing process. SWE measurements were taken of both the injured and uninjured sides every 4 weeks up to 24, 36, and 48 weeks after treatment. Additionally, tendon thickness and power Doppler (PD) grade were measured at the same time points as SWE measurements. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot rating system score and Achilles tendon Total Rupture Score (ATRS) were compared at 24 and 48 weeks.

RESULTS

The ruptured Achilles tendon obtained an SWE value comparable with the unruptured side at 12 weeks in the conservative group and at 4 weeks with surgical group. The surgical group had significantly higher SWE values up to 24 weeks compared with the conservative group. Additionally, this group had a significantly larger increase in tendon thickness in nearly all periods. Both treatment groups were comparable regarding the PD grade, AOFAS score, and ATRS.

CONCLUSION

SWE is a convenient noninvasive method to determine the progress of the healing process after tendon injury. Our analysis using SWE has revealed the detailed chronologic changes in SWE values and related mechanical properties of a healing Achilles tendon rupture, which can be used for devising appropriate rehabilitation protocols.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

[Complications in repairing acute closed Achilles tendon rupture with micro-incision percutaneous Achilles tendon suture system]

OBJECTIVE

To analyze the causes, management and prevention of complications after micro-incision percutaneous repair of acute Achilles tendon rupture.

METHODS

A retrospective study indentyfied 279 patients with acute Achilles tendon rupture who underwent a mini-invasive procedure using the micro-incision percutaneous Achilles tendon suture system(MIPAS) from August 2008 to November 2019, including 269 males and 10 female;96 cases on the right side and 183 cases on the left side;aged from 18 to 64 years old with an average of (36.9±11.4 )years old. Surgery was performed 0.5 to 7 days with an average of(2.7±0.9 )days after injury. The incision-related complications, re-rupture, sural nerve injury, deep vein thrombosis, Achilles tendon adhesion, local pain, and ankle stiffness within 18 months after surgery were recorded, as well as the corresponding management and outcome, the causes and prevention measures were analyzed.

RESULTS

No superficial or deep infection was found in all patients, symptomatic Achilles tendon adhesion and ankle stiffness were not observed, delayed suture foreign-body reactions occurred in 2 cases (0.7%), re-rupture in 5 cases (1.8%), sural nerve injury in 3 cases (1.1%), 21 cases(7.5%) with skin invagination at puncture site, 2 cases (0.7%) with symptomatic vein thrombosis, and 45 cases (16.1%) of transient posterior medial malleolus pain. After individualized treatment, the function was good. American Orthopeadic Foot & Ankle Sciety(AOFAS) score was 93 to 100 with an average of(98.9±5.4) scores.

CONCLUSION

Despite the occurrence of unique complications with MIPAS, it shows low functionally-related complications rates, such as incision-related complications, re-rupture, sural nerve injury, deep vein thrombosis and ankle stiffness.

Achilles tendon gait dynamics after rupture: A three-armed randomized controlled trial comparing an individualized treatment algorithm vs. operative or non-operative treatment

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.

Validity and reliability of the Thai version of the Achilles tendon total rupture score

PURPOSE

The purpose of this study was to translate and cross-culturally adapt the Achilles Tendon Total Rupture Score (ATRS), a patient-reported outcome measurement (PROM) designed specifically to assess outcomes in patients with Achilles tendon rupture, into the Thai language and then determine its validity and reliability.

METHODS

The ATRS was translated into the Thai version (Thai-ATRS) according to internationally recognized guidelines. The study included 50 patients with Achilles tendon rupture from 2003 to 2017. The web-based online assessments were conducted two weeks apart. Construction validity was determined by assessing the correlation between the Thai-ATRS and the Thai version of the Foot and Ankle Outcome Score (Thai-FAOS). Reliability was determined with Cronbach's alpha and intraclass correlation coefficients (ICC).

RESULTS

The validity test displayed a strong correlation between the Thai-ATRS and the Thai-FAOS (r = 0.87). The reliability test showed good internal consistency with a Cronbach's alpha of 0.95 and excellent internal consistency with an ICC of 0.95, which represented excellent test-retest reliability. The MDC was 10.7 at the individual level and 1.5 at the group level.

CONCLUSION

The Thai-ATRS was demonstrated to be valid and reliable for assessing functional outcomes in Thai patients with Achilles tendon rupture.

LEVEL OF EVIDENCE

II.

A registry study of 1304 patients from the Danish Achilles tendon database

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

BACKGROUND AND OBJECTIVE

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

MATERIAL AND METHODS

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

INCLUSION CRITERIA

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

RESULTS

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

CONCLUSIONS

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

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

BACKGROUND AND OBJECTIVE

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

MATERIAL AND METHODS

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

INCLUSION CRITERIA

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

RESULTS

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

CONCLUSIONS

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