Reliability of thoracolumbar burst fracture classification in the Swedish Fracture Register

BACKGROUND

The Swedish Fracture Register (SFR) is a national quality register for all types of fractures in Sweden. Spine fractures have been included since 2015 and are classified using a modified AOSpine classification. The aim of this study was to determine the accuracy of the classification of thoracolumbar burst fractures in the SFR.

METHODS

Assessments of medical images were conducted in 277 consecutive patients with a thoracolumbar burst fracture (T10-L3) identified in the SFR. Two independent reviewers classified the fractures according to the AOSpine classification, with a third reviewer resolving disagreement. The combined results of the reviewers were considered the gold standard. The intra- and inter-rater reliability of the reviewers was determined with Cohen's kappa and percent agreement. The SFR classification was compared with the gold standard using positive predictive values (PPV), Cohen's kappa and percent agreement.

RESULTS

The reliability between reviewers was  high (Cohen's kappa 0.70-0.97). The PPV for correctly classifying burst fractures in the SFR was high irrespective of physician experience (76-89%), treatment (82% non-operative, 95% operative) and hospital type (83% county, 95% university). The inter-rater reliability of B-type injuries and the overall SFR classification compared with the gold standard was low (Cohen's kappa 0.16 and 0.17 respectively).

CONCLUSIONS

The SFR demonstrates a high PPV for accurately classifying burst fractures, regardless of physician experience, treatment and hospital type. However, the reliability of B-type injuries and overall classification in the SFR was found to be low. Future studies on burst fractures using SFR data where classification is important should include a review of medical images to verify the diagnosis.

Nighttime versus Fulltime Brace Treatment for Adolescent Idiopathic Scoliosis: Which Brace to Choose? A Retrospective Study on 358 Patients

The purpose of this study is to retrospectively compare the effectiveness of fulltime Boston Brace (BB) and Providence Nighttime Brace (PNB) treatments in moderate scoliotic curves (20-40°) at a single institution and to carry out analyses for different subgroups. Inclusion criteria: idiopathic scoliosis, age ≥ 10 years, curve 20-40°, Risser ≤ 3 or Sanders stage ≤ 6 and curve apex below T6 vertebra. Exclusion criteria: incomplete radiological or clinical follow-up and previous treatment. The primary outcome was failure according to the SRS outcome assessment: increase in main curve > 5° and/or increase in main curve beyond 45° and/or surgery. The subgroup analyses were secondary outcomes. In total, 249 patients in the PNB and 109 in the BB groups were included. The BB showed a higher success rate compared to the PNB (59% and 46%, respectively) in both crude and adjusted comparisons (p = 0.029 and p = 0.007, respectively). The subgroup analyses showed higher success rates in pre-menarchal females, thoracic curves and curves > 30° in the BB group compared to the PNB group. Based on the findings, fulltime braces should be the treatment of choice for more immature patients and patients with larger and thoracic curves while nighttime braces might be sufficient for post-menarchal females and patients with lumbar and smaller curves.

Full-Endoscopic Lumbar Discectomy vs Standard Discectomy: A Noninferiority Study on Clinically Relevant Changes

BACKGROUND

Surgery for lumbar disc herniation (LDH) has had a remarkable technological development during the past 20 years. Microscopic discectomy has traditionally been the gold standard method to treat symptomatic LDH before the introduction of full-endoscopic lumbar discectomy (FELD). The FELD procedure allows unsurpassed magnification and visualization and is currently the most minimally invasive surgical technique. In this study, FELD was compared with standard surgery for LDH, with a focus on medically relevant changes in patient-reported outcome measures (PROMs).

PURPOSE

The purpose of this study was to investigate whether FELD is noninferior to other surgical methods for LDH surgery in the most common PROMs, including postoperative leg pain and disability, while still reaching the necessary thresholds for relevant clinical and medical improvements.

METHODS

Patients undergoing a FELD procedure at the Sahlgrenska University Hospital, Gothenburg, Sweden, between 2013 to 2018 were included. A total of 80 (41 men and 39 women) patients were enrolled. The FELD patients were matched 1:5 to controls from the Swedish spine register (Swespine) who had a standard microscopic or mini-open discectomy surgery. PROMs, including the Oswestry Disability Index (ODI) and the Numerical Rating Scale (NRS), as well as the patient acceptable symptom states (PASS) and the minimal important change (MIC), were used to compare the efficacy of the 2 surgical approaches.

RESULTS

The FELD group achieved medically relevant and significant improvements noninferior to standard surgery within the predefined thresholds of MIC and PASS. No differences could be found in disability measured by ODI FELD -28.4 (SD 19.2) vs standard surgery -28.7 (SD 18.9) or leg pain NRS_Leg FELD -4.35 (SD 2.93) vs standard surgery -4.99 (SD 3.12). All intragroup score changes were significant.

CONCLUSIONS

The FELD results are not inferior to standard surgery 1 year postoperatively after LDH surgery. There were no medically significant differences regarding MIC achieved or final PASS in any of the measured PROMs, including leg pain, back pain, or disability (ODI) between the surgical methods.

CLINICAL RELEVANCE

The present study highlights that FELD is noninferior to standard surgery in clinically relevant PROMs.

LEVEL OF EVIDENCE: 2

Providence nighttime brace is as effective as fulltime Boston brace for female patients with adolescent idiopathic scoliosis: A retrospective analysis of a randomized cohort

BACKGROUND

Progressive moderate scoliotic curves in patients with adolescent idiopathic scoliosis (AIS) are usually treated with a fulltime brace, e.g., the Boston brace (BB). The Providence nighttime brace (PNB), is an alternative which is designed to reach the same treatment effectiveness by nighttime wear only. Few studies compared treatment effectiveness between full and nighttime bracing with contradictory results.

METHODS

Immature female patients older than 10 years with progressive moderate AIS curves with an apex below T6 were randomized into PNB (n=62) or BB (n=49) treatment. Inclusion criteria were AIS, age ≥ 10 years, no previous treatment, main curve Cobb angle 20°-40° and skeletal immaturity. The increase of the main curve by > 5° of Cobb angle at the final follow-up was established as the primary outcome measure. Secondary outcome measures included (1) the Scoliosis Research Society assessment criteria of effectiveness for brace studies, (2) progression of secondary curves, (3) in-brace correction and (4) compliance to the treatment. The patients were followed until 1 year after reaching maturity.

RESULTS

A total of 105 patients (n=62 and n=43 in PNB and BB group, respectively) completed the follow-up (95%). In the PNB group, 71% patients were treated successfully compared to 65% patients in the BB group (p=.67). No significant difference of the curve progression was found between the groups (3.1°±6.3° and 2.6°±8.3° in PNB and BB group, respectively; p=.73). No significant differences were found for the thoracic or thoracolumbar/lumbar subgroups. PNB showed a superior in-brace correction for all curve types. One of four secondary curves progressed > 5°. The compliance to the treatment was significantly higher in the PNB than BB group.

CONCLUSIONS

Both brace regimes are equally effective in treating moderate AIS curves with apex of the main curve below T6 in immature female patients older than 10 years.

Revision Spinal Surgery at a University Hospital: Incidence, Causes, and Microbiological Agents in Infected Patients

BACKGROUND

The number of spinal surgeries performed worldwide have significantly increased over the past decade. However, to the best of our knowledge, there are no national or international studies that report the overall picture of complications following spinal surgery. This article sought to identify the incidence and causes of reoperations in patients undergoing spinal surgery, as well as the average time from index surgery to reoperation. Furthermore, the purpose was to identify the microbiological agents present in cultures from infected patients.

METHODS

This was a retrospective cohort study that used a university hospital's medical records as the data source. The study population comprised 2110 patients who underwent spinal surgery during a 40-month period between 2015 and 2018. All suspected reoperations were verified manually. Additional data collected for reoperations included cause, time from index surgery, and laboratory results from cultures. Descriptive analysis was used.

RESULTS

The incidence of reoperations during the study period was 11% (n = 232). The most common cause of reoperation was infection (28%, n = 65), followed by implant-related causes (19%, n = 44) and hemorrhage/hematoma (15%, n = 34). The time between index surgery and reoperation varied, but half of all reoperations occurred within 30 days. Coagulase-negative staphylococci were the most common type of bacteria (positive cultures in 39% of infected patients).

CONCLUSION

The number of reoperations in the studied hospital were high during the study period. Infections accounted for a large percentage of reoperations, suggesting that effective preventive measures might significantly reduce the total number of reoperations.

CLINICAL RELEVANCE

Postoperative infection causing reoperations after spinal surgeries is a large problem, and finding effective preventive measures should be a priority for caregivers.

LEVEL OF EVIDENCE: 3

Disappointment and frustration, but long-term satisfaction: patient experiences undergoing treatment for a chronic Achilles tendon rupture—a qualitative study

Background

Delayed treatment of Achilles tendon ruptures is generally due to either misdiagnosis or patient delay. When the treatment is delayed more than 4 weeks, the rupture is defined as “chronic”, and almost always requires more invasive surgery and longer rehabilitation time compared with acute Achilles tendon ruptures. There is insufficient knowledge of patient experiences of sustaining and recovering from a chronic Achilles tendon rupture.

Methods

To evaluate patients’ experiences of suffering a chronic Achilles tendon rupture, semi-structured group interviews were conducted 4–6 years after surgical treatment using a semi-structured interview guide. The data were analyzed using qualitative content analysis described by Graneheim and Lundman.

Results

The experiences of ten patients (65 ± 14 years, 7 males and 3 females) were summarized into four main categories: (1) “The injury”, where the patients described immediate functional impairments, following either traumatic or non-traumatic injury mechanisms that were misinterpreted by themselves or the health-care system; (2) “The diagnosis”, where the patients expressed relief in receiving the diagnosis, but also disappointment and/or frustration related to the prior misdiagnosis and delay; (3) “The treatment”, where the patients expressed high expectations, consistent satisfaction with the surgical treatment, and addressed the importance of the physical therapist having the right expertise; and (4) “The outcomes”, where the patients expressed an overall satisfaction with the long-term outcome and no obvious limitations in physical activity, although some fear of re-injury emerged.

Conclusions

An Achilles tendon rupture can occur during both major and minor trauma and be misinterpreted by both the assessing health-care professional as well as the patient themselves. Surgical treatment and postoperative rehabilitation for chronic Achilles tendon rupture results in overall patient satisfaction in terms of the long-term outcomes. We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03103-7.

Surgical treatment of chronic Achilles tendon rupture results in improved gait biomechanics

Background

Chronic Achilles tendon rupture is associated with persistent weakness at push-off with the affected foot and poor balance, resulting in significant alterations to normal gait. Surgical repair is the most common treatment for improving gait in patients with a Chronic Achilles tendon rupture, but, to date, the outcomes have not been quantified in the literature.

Methods

A total of 23 patients with a Chronic Achilles tendon rupture (mean age 61 ± 15 years) underwent three-dimensional gait analysis according to a standardized protocol using an optical tracking system. Data of spatiotemporal, kinematic and kinetic variables were collected preoperatively and one year postoperatively. In addition, the postoperative gait biomechanics were compared with the gait biomechanics of a control group consisting of 70 healthy individuals (mean age 49 ± 20 years). The prospectively collected data were analyzed by an independent t test.

Results

Postoperatively, increments were found in gait speed (mean difference − 0.12 m/s), stride length (− 0.12 m), peak ankle moment (− 0.64 Nm/kg), peak ankle power (− 1.38 W/kg), peak knee power (− 0.36 m) and reduced step width (0.01 m), compared with preoperative gait biomechanics (p < 0.014). Compared with the control group, patients with a Chronic Achilles tendon rupture exhibited slower postoperative gait speed (mean difference 0.24 m/s), wider step width (− 0.02 m), shorter stride length (0.16 m), longer relative stance phase (− 2.15%), lower peak knee flexion (17.03 degrees), greater peak knee extension (2.58 degrees), lower peak ankle moment (0.35 Nm/kg), peak ankle power (1.22 W/kg) and peak knee power (1.62 W/kg), (p < 0.010).

Conclusion

Surgical intervention and postoperative rehabilitation can be an effective treatment for alterations in gait after a Chronic rupture of the Achilles tendon. However, at one year postoperatively, patients still exhibit impairments in spatiotemporal variables and knee and ankle power compared with healthy controls.

Study protocol: The SunBurst trial-a register-based, randomized controlled trial on thoracolumbar burst fractures

BACKGROUND AND PURPOSE

The treatment for patients with thoracolumbar burst fractures without neurological deficit or complete rupture of the posterior ligament complex (PLC) is controversial and includes both surgical and non-surgical options. Current evidence on which treatment is optimal remains inconclusive. In this study we compare surgical with non-surgical treatment.

METHODS

The study is a nationwide, multicenter, register-based randomized controlled trial (R-RCT). Patients with a thoracolumbar burst fracture will be identified by the Swedish Fracture Register. The admitting physician will be notified during the registration process and the patient will be screened for eligibility. Patients, 18 to 66 years old without neurologic deficit to more than a single nerve root and without complete rupture of the PLC, are eligible for the study. 202 patients will be randomized in a 1:1 relation to either surgical or non-surgical treatment. Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI) and radiological data, will be collected at the time of injury, after 3-4 months, and after 1 year. Additional data from national health registries will be collected after 1 year.

OUTCOME

The primary outcome is the ODI 1 year after injury. Secondary outcomes include additional PROMs, adverse events, drug consumption, sick leave, healthcare consumption, and imaging data.

INTERPRETATION

The primary outcome is the ODI 1 year after injury. Secondary outcomes include additional PROMs, adverse events, drug consumption, sick leave, healthcare consumption, and imaging data. Estimated duration - The study started on September 1, 2021 and will continue for approximately 4 years. Trial registration - The trial is registered at www.clinicaltrials.com, NCT05003180.

Correction to: Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis

An amendment to this paper has been published and can be accessed via the original article.

Association of extended duration of sciatic leg pain with worse outcome after lumbar disc herniation surgery: a register study in 6216 patients

OBJECTIVE

Sciatica is the hallmark symptom of a lumbar disc herniation (LDH). Up to 90% of LDH patients recover within 12 weeks regardless of treatment. With continued deteriorating symptoms and low patient quality of life, most surgeons recommend surgical discectomy. However, there is not yet a clear consensus regarding the proper timing of surgery. The aim of this study was to evaluate how the duration of preoperative leg pain (sciatic neuralgia) is associated with patient-reported levels of postoperative leg pain reduction and other patient-reported outcome measures (PROMs) in a prospectively collected data set from a large national cohort.

METHODS

All patients aged 18-65 years undergoing a lumbar discectomy during 2013-2016 and registered in Swespine (the Swedish national spine registry) with 1 year of postoperative follow-up data were included in the study (n = 6216). The patients were stratified into 4 groups according to preoperative pain duration: < 3, 3-12, 12-24, or > 24 months. Patient results assessed with the numeric rating scale (NRS) for leg pain (rated from 0 to 10), global assessment of leg pain, EQ-5D, Oswestry Disability Index (ODI), and patient satisfaction with the final surgical outcome were analyzed and compared with preoperative values and between groups.

RESULTS

A significant improvement was seen 1 year postoperatively regardless of preoperative pain duration (change in NRS score: mean -4.83, 95% CI -4.73 to -4.93 in the entire cohort). The largest decrease in leg pain NRS score (mean -5.59, 95% CI -5.85 to -5.33) was seen in the operated group with the shortest sciatica duration (< 3 months). The patients with a leg pain duration in excess of 12 months had a significantly higher risk of having unchanged radiating leg pain 1 year postoperatively compared with those with < 12-month leg pain duration at the time of surgery (OR 2.41, 95% CI 1.81-3.21, p < 0.0001).

CONCLUSIONS

Patients with the shortest leg pain duration (< 3 months) reported superior outcomes in all measured parameters. More significantly, using a 12-month pain duration as a cutoff, patients who had a lumbar discectomy with a preoperative symptom duration < 12 months experienced a larger reduction in leg pain and were more satisfied with their surgical outcome and perception of postoperative leg pain than those with > 12 months of sciatic leg pain.

Successful Introduction of Full-Endoscopic Lumbar Interlaminar Discectomy in Sweden

BACKGROUND

The introduction of full-endoscopic lumbar discectomy (FELD) procedures has made it possible to challenge microscopic discectomy as the gold standard method to treat lumbar disc herniations.

PURPOSE

The aim of the present study is to investigate the introductory-phase postoperative clinical improvement for FELD patients regarding leg pain, patient-reported outcome measurements (PROMs), complications, reoperations, and learning curve analysis.

METHODS

All patients who underwent FELD at Sahlgrenska University Hospital, Sweden, were prospectively included during 2013- 2017. A total of 92 patients were enrolled and followed up for 1 year. The characteristics of the study population, degree of leg pain, complications, learning curve, and PROMs were retrieved from patient records and the National Quality Register for Spine Surgery (Swespine).

RESULTS

The postoperative results demonstrated major improvements; leg pain measured by a numerical rating scale (0-10) decreased from 7.4 ± 2.25 to 2.76 ± 2.70, with a mean improvement of -4.54, (-3.62-5.46) 95% confidence interval (CI). The Oswestry Disability Index decreased by 30.48 (-36.27-23.73) with a 95% CI, and the EuroQol-5D increased by 0.39 (0.21-0.57) 95% CI. An assessment of the final surgical result showed that 91.6% ranked their general situation as better or much better. Specifically, regarding postoperative leg pain, 87% regarded their leg pain as completely gone, much better, or somewhat better, while 13% regarded their leg pain as unchanged or worse. A learning curve analysis showed that for every 10th FELD procedure performed; the duration of surgery decreased by 2 minutes.

CONCLUSIONS

In our study, the introduction of FELD as a safe, quick procedure for the treatment of lumbar disc herniations can yield significant gains in patient-reported outcome measurements and pain reduction. The rate of recurrence and complications is comparable to that of standard surgery.

The economic cost and patient-reported outcomes of chronic Achilles tendon ruptures

Purpose

While most Achilles tendon ruptures are dramatic and diagnosed quickly, some are missed, with a risk of becoming chronic. A chronic Achilles tendon rupture is defined as a rupture that has been left untreated for more than 4 weeks. By mapping the health economic cost of chronic Achilles tendon ruptures the health-care system might be able to better distribute resources to detect these ruptures at an earlier time.

Method

All patients with a chronic Achilles tendon rupture who were treated surgically at Sahlgrenska University Hospital or Kungsbacka Hospital between 2013 and 2018 were invited to participate in the study. The patients were evaluated postoperatively using the validated Achilles tendon Total Rupture Score (ATRS). The health-care costs were assessed using clinical records. The production-loss costs were extracted from the Swedish Social Insurance Agency. The cost of chronic Achilles tendon ruptures was then compared with the cost of acute ruptures in a previous study by Westin et.al.

Results

Forty patients with a median (range) age of 66 (28–86) were included in the study. The mean total cost (± SD) for the patients with a chronic Achilles tendon rupture was 6494 EUR ± 6508, which is 1276 EUR higher than the mean total cost of acute ruptures. Patients with chronic Achilles tendon ruptures reported a mean (min-max) postoperative ATRS of 73 (14–100).

Conclusion

Missing an Achilles tendon rupture will entail higher health-care costs compared with acute ruptures. Health-care resources can be saved if Achilles tendon ruptures are detected at an early stage.

Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis

BACKGROUND

While numerous clinical studies have compared the surgical and non-surgical treatment of acute Achilles tendon rupture (ATR), there are no studies that have performed a non-inferiority analysis between treatments.

METHODS

Data from patients who were included in five randomised controlled trials from two different centres in Sweden were used. Outcomes at 1 year after ATR consisted of the patient-reported Achilles tendon Total Rupture Score (ATRS) and the functional heel-rise tests reported as the limb symmetry index (LSI). The non-inferiority statistical 10% margin was calculated as a reflection of a clinically acceptable disadvantage in ATRS and heel-rise outcome when comparing treatments.

RESULTS

A total of 422 patients (350 males and 72 females) aged between 18 and 71 years, with a mean age of 40.6 (standard deviation 8.6), were included. A total of 363 (86%) patients were treated surgically. The ATRS (difference (Δ) = - 0.253 [95% confidence interval (CI); - 5.673;5.785] p = 0.36) and LSI of heel-rise height (difference = 1.43 [95% CI; - 2.43;5.59] p = 0.81), total work (difference = 0.686 [95% CI; - 4.520;6.253] p = 0.67), concentric power (difference = 2.93 [95% CI; - 6.38;11.90] p = 0.063) and repetitions (difference = - 1.30 [95% CI; - 6.32;4.13] p = 0.24) resulted in non-inferiority within a Δ - 10% margin for patients treated non-surgically.

CONCLUSION

The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes.

Low lordosis is a common finding in young lumbar disc herniation patients

Purpose

The sagittal alignment of the lumbar spine and pelvis can be classified into several subtypes. It has been suggested that the risk of developing certain pathologies, such as a lumbar disc herniation (LDH) is affected by spinal sagittal profiles. The main aim of this study was to investigate the sagittal profile in young patients surgically treated for a lumbar disc herniation and if a discectomy would alter the sagittal parameters.

Methods

Sixteen active young patients (mean age 18.3 ± 3.2 SD) with a lumbar disc herniation having a discectomy were included. A classification according to Roussouly of the sagittal parameters was made by two senior spinal surgeons, both pre-operatively and post-operatively on radiographs. The distribution of sagittal parameters and spinopelvic profiles were analysed and compared to a previous established healthy normal population.

Results

This series of active young patients with LDH exhibited a low lumbar lordosis dominance, with Roussouly sagittal profiles type 1 and type 2 accounting for more than 75% of the examined patients. An analysis of the erect radiographs revealed no significant changes in the post-operative sagittal profile.

Conclusions

This study showed that sagittal spinal alignment according to Roussouly in a young population with LDH is skewed compared with a normal population cohort. Furthermore, the lack of post-operative correction is suggestive of a non-ephemeral response to a LDH. Roussouly type 2 spinal sagittal profile may be a risk factor in young individuals suffering a disc herniation.

A model for evaluation of the electric activity and oxygenation in the erector spinae muscle during isometric loading adapted for spine patients

BACKGROUND

Simultaneous measurement of electromyography (EMG) and local muscle oxygenation is proposed in an isometric loading model adjusted for patients that have undergone spinal surgery.

METHODS

Twelve patients with degenerative lumbar spinal stenosis (DLSS) were included. They were subjected to a test protocol before and after surgery. The protocol consisted of two parts, a dynamic and an isometric Ito loading with a time frame of 60 s and accompanying rest of 120 s. The Ito test was repeated three times. EMG was measured bilaterally at the L4 level and L2 and was recorded using surface electrodes and collected (Biopac Systems Inc.). EMG signal was expressed as RMS and median frequency (MF). Muscle tissue oxygen saturation (MrSO₂) was monitored using a near-infrared spectroscopy (NIRS) device (INVOS® 5100C Oxymeter). Two NIRS sensors were positioned bilaterally at the L4 level. The intensity of the leg and back pain and perceived exertion before, during, and after the test was evaluated with a visual analogue scale (VAS) and Borg RPE-scale, respectively.

RESULTS

All patients were able to perform and complete the test protocol pre- and postoperatively. A consistency of lower median and range values was noted in the sensors of EMG1 (15.3 μV, range 4.5-30.7 μV) and EMG2 (13.6 μV, range 4.0-46.5 μV) that were positioned lateral to NIRS sensors at L4 compared with EMG3 (18.9 μV, range 6.5-50.0 μV) and EMG4 (20.4 μV, range 7.5-49.0 μV) at L2. Right and left side of the erector spinae exhibited a similar electrical activity behaviour over time during Ito test (60 s). Regional MrSO₂ decreased over time during loading and returned to the baseline level during recovery on both left and right side. Both low back and leg pain was significantly reduced postoperatively.

CONCLUSION

Simultaneous measurement of surface EMG and NIRS seems to be a promising tool for objective assessment of paraspinal muscle function in terms of muscular activity and local muscle oxygenation changes in response to isometric trunk extension in patients that have undergone laminectomy for spinal stenosis.

Comparison of concomitant injuries and patient-reported outcome in patients that have undergone both primary and revision ACL reconstruction-a national registry study

BACKGROUND

Anterior cruciate ligament (ACL) revision surgery has been associated with inferior outcome compared with primary ACL reconstruction. However, this has rarely been investigated in a consecutive cohort limited to patients that have undergone both primary and revision ACL reconstruction. This study aimed to assess differences in outcome and concomitant injuries between primary and revision ACL reconstruction in such a cohort, and to identify predictors of the patient-reported outcome after ACL revision.

METHODS

Patients who had undergone both primary and revision ACL reconstruction were identified in the Swedish National Knee Ligament Registry. Patients aged 13-49 years with hamstring tendon primary ACL reconstruction and data on the Knee Injury and Osteoarthritis Outcome Score (KOOS) on at least one occasion (preoperative or one year postoperatively) at both surgeries were eligible. Concomitant injuries and the KOOS were compared between each patient's primary and revision ACL reconstruction. Linear regression analyses were performed to determine predictors of the one-year KOOS after ACL revision.

RESULTS

A total of 1014 patients were included. Cartilage injuries increased at ACL revision (p < 0.001), as 23.0% had a cartilage injury at ACL revision that was not present at primary ACL reconstruction. The 1-year KOOS was lower after ACL revision compared with primary ACL reconstruction, with the largest difference in the KOOS sports and recreation (5.2 points, SD 32.2, p = 0.002). A posterolateral corner (PLC) injury at ACL revision was a negative predictor of KOOS, with the largest effect on the sports and recreation subscale (β = - 29.20 [95% CI - 50.71; - 6.69], p = 0.011). The use of allograft for ACL revision was an independent predictor of a poorer KOOS QoL (β = - 12.69 [95% CI - 21.84; - 3.55], p = 0.0066) and KOOS₄ (β = - 11.40 [95% CI - 19.24; - 3.57], p = 0.0044).

CONCLUSION

Patients undergoing ACL revision reported a 1-year outcome that was slightly inferior to the 1-year outcome after their primary ACL reconstruction. An ACL revision was associated with an increase in cartilage injuries. A PLC injury at ACL revision and the use of allograft for ACL revision predicted a clinically relevant poorer KOOS one year after ACL revision.

Strength in numbers? The fragility index of studies from the Scandinavian knee ligament registries

PURPOSE

The fragility index (FI) is a metric to evaluate the robustness of statistically significant results. It describes the number of patients who would need to change from a non-event to an event to change a result from significant to non-significant. This systematic survey aimed to evaluate the feasibility of applying the FI to findings related to anterior cruciate ligament (ACL) reconstruction in the Scandinavian knee ligament registries.

METHODS

The PubMed, EMBASE, Cochrane Library and AMED databases were searched. Studies from the Scandinavian knee ligament registers were eligible if they reported a statistically significant result (p < 0.05) for any of the following dichotomous outcomes; ACL revision, contralateral ACL reconstruction or the presence of postoperative knee laxity. Only studies with a two-arm comparative analysis were included. Eligibility assessment, data extraction and quality assessment were performed by two independent reviewers. The dichotomous analyses were stratified according to the grouping variable for the two comparative arms as follows; age, patient sex, activity at injury, graft choice, drilling technique, graft fixation, single- versus double-bundle, concomitant cartilage injury and country. The two-sided Fisher's exact test was used to calculate the FI of all statistically significant analyses.

RESULTS

From 158 identified studies, 13 studies were included. They reported statistical significance for a total of 56 dichotomous analyses, of which all but two had been determined by a time-to-event analysis. The median sample size for the arms was 5540 (range 92-38,666). The mean FI for all 56 dichotomous analyses was 80.6 (median 34.5), which means that a mean of 80.6 patients were needed to change outcome status to generate a non-significant result instead of a significant one. Seventeen analyses (30.4%) immediately became non-significant when performing the two-sided Fisher's exact test and, therefore, had an FI of 0. The analyses related to age were the most robust, with a mean FI of 178.5 (median 116, range 1-1089). The mean FI of the other grouping variables ranged from 0.5 to 48.0.

CONCLUSION

There was large variability in the FI in analyses from the Scandinavian knee ligament registries and almost one third of the analyses had an FI of zero. The FI is a rough measurement of robustness when applied to registry studies, however, future studies are needed to determine the most appropriate metric for robustness in registry studies. The use of the FI can provide clinicians with a deeper understanding of significant study results and promotes an evidence-based approach in the clinical care of patients.

LEVEL OF EVIDENCE

Systematic review of prospective cohort studies, Level II.

Understanding limitations in sport 1 year after an Achilles tendon rupture: a multicentre analysis of 285 patients

PURPOSE

The purpose of this study was to determine patient-related and treatment-related predictors of superior and inferior function in sport and recreational activities 1 year after an Achilles tendon rupture.

METHODS

This study is based on a multicentre cohort from 4 previous randomised controlled trials. All the patients who had responded to the Foot and Ankle Outcome Score (FAOS) at the 1-year follow-up were included. All the patients had a clinically verified Achilles tendon rupture and patients who underwent surgery were treated within 96 h of the time of rupture. Patients were excluded in the event of a previous Achilles tendon rupture or the presence of other lifestyle diseases. The primary outcomes of the study were reported in the 20th and 80th percentiles of the FAOS subscale, function in sports and recreational activities.

RESULTS

A total of 285 (84% men) patients with an average age of 40.0 (SD 8.4) years were included. Smoking increased the odds of superior self-reported FAOS sport and recreation [OR 4.59 (95% CI 1.58-13.32), p = 0.005] compared with non-smoking, while being female [OR 0.38 (95% CI 0.16-0.93), p = 0.035] and every increment of one unit in BMI [OR 0.89 (95% CI 0.81-0.99), p = 0.029] reduced the odds. No variable was statistically significant when attempting to predict which patients report inferior FAOS sport and recreation. The recovery of symmetry in heel-rise tests had no effect on 1-year FAOS sport and recreation. Patient-reported outcomes had a good-to-excellent explanatory capacity of superior and inferior 1-year function in sport and recreational activities (AUC = 0.87-0.93).

CONCLUSION

BMI is a modifiable risk factor, which, when lowered, may be associated with less impairment in sports 1 year after an Achilles tendon rupture. Females appear to perceive more limitations than males. Unexpectedly, smokers experience less limitations in foot and ankle function. Patients who report no functional limitation in sport are characterised by an overall perception of adequate foot, ankle and Achilles function, despite not having recovered symmetry in the heel-rise test.

LEVEL OF EVIDENCE

I.

Graft Fixation and Timing of Surgery Are Predictors of Early Anterior Cruciate Ligament Revision: A Cohort Study from the Swedish and Norwegian Knee Ligament Registries Based on 18,425 Patients

The identification of surgical risk factors for early anterior cruciate ligament (ACL) revision is important when appropriate treatment for patients undergoing primary ACL reconstruction is selected. The purposes of this study were to determine the short-term ACL revision rate of patients undergoing primary ACL reconstruction and to identify surgical risk factors for ACL revision within 2 years of primary ACL reconstruction.

Outcome After Anterior Cruciate Ligament Revision

PURPOSE OF REVIEW

To describe the current literature related to anterior cruciate ligament (ACL) revision in terms of surgical aspects, graft choices, concomitant injuries, patient-reported outcome, return to sport, and objective measurement outcome.

RECENT FINDINGS

An ACL rupture is a common knee injury, and the number of primary ACL reconstructions is increasing, implying a subsequent increase of ACL revisions in the future. It is widely accepted that an ACL revision is surgically challenging with a myriad of graft options to choose from. In many cases, simultaneous injuries to the index limb including meniscal and chondral lesions, respectively, are observed in the setting of a secondary ACL injury. Furthermore, the general understanding is that an ACL revision results in inferior outcome compared with a primary ACL reconstruction. Surgical treatment of an ACL revision can be performed as one-stage or two-stage procedure depending on, for example, the presence of limb malalignments, concomitant injuries, and tunnel widening. Nonirradiated allografts and autologous patella tendon, hamstring tendon, and quadriceps tendon are feasible options for ACL revision. Concomitant injuries to the affected knee such as intraarticular chondral lesions are more common in the setting of an ACL revision compared with primary ACL reconstruction while a lower presence of concomitant meniscal pathology is reported at ACL revision. Patients undergoing ACL revision have lower clinical and patient-reported outcome and lower rates of return to sport when compared with primary ACL surgery cases. However, long-term follow-ups with large study cohorts evaluating outcome of ACL revision are limited. Further research is needed to confirm the present findings of this review.

The Influence of Age, Gender and Religion on Willingness to be an Organ Donor: Experience of Religious Muslims Living in Sweden

The transplantation of organs is one of the most successful medical advances in recent decades, and transplantation is the treatment of choice for severe organ failure worldwide. Despite this situation and the general acknowledgment of organ donation (OD) as a global priority, the demand for organs outstrips the supply in virtually every country in the world. The study aims to elucidate whether age, gender and religion influence decision-making about organ donation in religious Muslims living in Sweden Data were collected through three group interviews using open-ended questions and qualitative content analysis. Twenty-seven participants, 15 males and 12 females from four countries, participated in the focus group interviews. The analysis of the collected data resulted in three main categories: "Information and knowledge about organ donation," "The priorities when deciding about organ donation" and "The religious aspects of organ donation," including a number of subcategories. Good information about and knowledge of OD, priorities in OD, importance of the fact that religion must be studied and taught daily and religious education were only a few of the factors informants emphasized as predictors of the total and successful donation of organs. Age, gender or religion did not have an impact on organ donation. High levels of education through religious education and good information via various media, as well as a good knowledge of the Swedish language, are predictors of improved OD. In order to overcome religious ideology as a source of misinformation relating to OD and to promote increased OD in the future, specific intervention studies and the improved involvement of religious communities and education in schools and the healthcare system are vital and must be a starting point for improved OD.

Older Age Predicts Worse Function 1 Year After an Acute Achilles Tendon Rupture: A Prognostic Multicenter Study on 391 Patients

Background

There is limited evidence regarding the patient-related factors that influence treatment outcomes after an acute Achilles tendon rupture.

Purpose/Hypothesis

The purpose of this study was to determine the predictors of functional and patient-reported outcomes 1 year after an acute Achilles tendon rupture using a multicenter cohort and to determine patient characteristics for reporting within the top and bottom 10% of the Achilles tendon Total Rupture Score (ATRS) and heel-rise height outcomes. The hypothesis was that older age, greater body mass index (BMI), and female sex would lead to inferior outcomes.

Study Design

Cohort study; Level of evidence, 2.

Methods

Patients were selected by combining 5 randomized controlled trials from 2 different centers in Sweden. Functional outcomes were assessed using validated heel-rise tests (height, number of repetitions, total work, and concentric power) for muscular endurance and strength, and the relationship between injured and uninjured legs was calculated as the limb symmetry index (LSI). Patient-reported outcomes were measured using the ATRS. All outcomes were collected at the 1-year follow-up. Independent predictors included were patient sex, smoking, BMI, age, and surgical versus nonsurgical treatment.

Results

Of the 391 included patients, 307 (79%) were treated surgically. The LSI of heel-rise height at the 1-year follow-up decreased by approximately 4% for every 10-year increment in age (beta, -3.94 [95% CI, -6.19 to -1.69]; P = .0006). In addition, every 10-year increment in age resulted in a 1.79-fold increase in the odds of being in the lowest 10% of the LSI of heel-rise height. Moreover, a nonsignificant superior LSI of heel-rise height was found in patients treated surgically compared with nonsurgical treatment (beta, -4.49 [95% CI, -9.14 to 0.16]; P = .058). No significant predictor was related to the ATRS. Smoking, patient sex, and BMI did not significantly affect the 1-year results for the LSI of the heel-rise tests.

Conclusion

Older age at the time of injury negatively affected heel-rise height 1 year after an Achilles tendon rupture. Irrespective of age, a nonsignificant relationship toward the superior recovery of heel-rise height was seen in patients treated surgically. None of the factors studied affected patient-reported outcomes.

Young age and high BMI are predictors of early revision surgery after primary anterior cruciate ligament reconstruction: a cohort study from the Swedish and Norwegian knee ligament registries based on 30,747 patients

PURPOSE

To analyse patient-related risk factors for 2-year ACL revision after primary reconstruction. The hypothesis was that younger athletes would have a higher incidence of an early ACL revision.

METHODS

This prospective cohort study was based on data from the Norwegian and Swedish National Knee Ligament Registries and included patients who underwent primary ACL reconstruction from 2004 to 2014. The primary end-point was the 2-year incidence of ACL revision. The impact of activity at the time of injury, patient sex, age, height, weight, BMI, and tobacco usage on the incidence of early ACL revision were described by relative risks (RR) with 95% confidence intervals (CI).

RESULTS

A total of 58,692 patients were evaluated for eligibility and 30,591 patients were included in the study. The mean incidence of ACL revision within 2 years was 2.82% (95% CI 2.64-3.02%). Young age (13-19) was associated with an increased risk of early ACL revision (males RR = 1.54 [95% CI 1.27-1.86] p < 0.001 and females RR = 1.58 [95% CI 1.28-1.96] p < 0.001). Females over 1 SD in weight ran an increased risk of early ACL revision (RR = 1.82, [95% CI 1.15-2.88] p = 0.0099). Individuals with a BMI of over 25 ran an increased risk of early ACL revision (males: RR = 1.78, [95% CI 1.38-2.30] p < 0.001 and females: RR = 1.84, [95% CI 1.29-2.63] p = 0.008).

CONCLUSION

Young age, a BMI over 25, and overweight females were risk factors for an early ACL revision.

LEVEL OF EVIDENCE

II.

Mapping functions in health-related quality of life: mapping from the Achilles Tendon Rupture Score to the EQ-5D

PURPOSE

Health state utility values are derived from preference-based measurements and are useful in calculating quality-adjusted life years (QALYs), which is a metric commonly used in cost-effectiveness studies. The purpose of this study was to convert the Achilles Tendon Rupture Score (ATRS) to the preference-based European Quality of Life-5 Dimension Questionnaire (EQ-5D) by estimating the relationship between the two scores using mapping.

METHODS

Data were collected from a randomised controlled trial, where 100 patients were treated either surgically or non-surgically for Achilles tendon rupture. Forty-three and forty-four patients in surgical group and non-surgical group completed the ATRS and the EQ-5D alongside each other during follow-up at three time points. Different models of the relationship between the ATRS and the EQ-5D were developed and analysed based on direct mapping and cross-validation. The model with the lowest mean absolute error was observed as the one with the best fit.

RESULTS

Among the competing models, mapping based on using a combination of the ATRS items four, five, and six associated with limitation due to pain, during activities of daily living and when walking on uneven ground, produced the best predictor of the EQ-5D score.

CONCLUSIONS

The present study provides a mapping algorithm to enable the derivation of utility values directly from the ATRS. This approach makes it feasible for researchers, as well as medical practitioners, to obtain preference-based values in clinical studies or settings where only the ATRS is being administered. The algorithm allows for the calculation of QALYs for use in cost-effectiveness analyses, making it valuable in the study of acute Achilles tendon ruptures.

LEVEL OF EVIDENCE

II.

Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures

PURPOSE

The aim of this study was to perform a long-term follow-up of patients treated for an Achilles tendon re-rupture, using established outcome measurements for tendon structure, lower extremity function and symptoms, and to compare the results with those for the uninjured side. A secondary aim was to compare the outcome with that of patients treated for primary ruptures. The hypotheses were that patients with a re-rupture recover well, and have similar long-term outcome as primary ruptures.

METHODS

Twenty patients (4 females) with a mean (SD) age of 44 (10.9) years, ranging from 24 to 64, were included. The patients were identified by reviewing the medical records of all Achilles tendon ruptures at Sahlgrenska University Hospital and Kungsbacka Hospital, Sweden, between 2006 and 2016. All patients received standardised surgical treatment and rehabilitation. The mean (SD) follow-up was 51 (38.1) months. A test battery of validated clinical and functional tests, patient-reported outcome measurements and measurements of tendon elongation were performed at the final follow-up. This cohort was then compared with the 2-year follow-up results from a previous randomised controlled trial of patients treated for primary Achilles tendon rupture.

RESULTS

There were deficits on the injured side compared with the healthy side in terms of heel-rise height (11.9 versus 12.5 cm, p = 0.008), repetitions (28.5 versus 31.7, p = 0.004) and drop-jump height (13.2 versus 15.1 cm, p = 0.04).  There was a significant difference in calf circumference (37.1 versus 38.4 cm, p =< 0.001) and ankle dorsiflexion on the injured side compared with the healthy side (35.3° versus 40.8°, p = 0.003). However, no significant differences were found in terms of tendon length 22.5 (2.5) cm on the injured side and 21.8 (2.8) cm on the healthy side. Compared with primary ruptures, the re-rupture cohort obtained significantly worse results for the Achilles tendon total rupture score, with a mean of 78 (21.2) versus 89.5 (14.6) points, (p = 0.007). The re-ruptures showed a higher mean LSI heel-rise height, 94.7% (9.3%) versus 83.5% (11.7%) (p = < 0.0001), and superior mean LSI eccentric-concentic power, 110.4% (49.8%) versus 79.3% (21%) (p = 0.001), than the primary ruptures.

CONCLUSION

The results of this study indicate that patients with an Achilles tendon re-rupture had continued symptoms and functional deficits on the injured side, after a long-term follow-up. Patients with an Achilles tendon re-rupture had worse patient-reported outcomes but similar or superior functional results compared with patients with primary ruptures.

LEVEL OF EVIDENCE

Case series, Level IV.

Correction to: Patients with an Achilles tendon re-rupture have long-term functional deficits and worse patient-reported outcome than primary ruptures

Unfortunately, the title of the article contained a mistake in the online publication of the article.

Increased odds of patient-reported success at 2 years after anterior cruciate ligament reconstruction in patients without cartilage lesions: a cohort study from the Swedish National Knee Ligament Register

PURPOSE

To investigate whether the surgical technique of single-bundle anterior cruciate ligament (ACL) reconstruction, the visualization of anatomic surgical factors and the presence or absence of concomitant injuries at primary ACL reconstruction are able to predict patient-reported success and failure. The hypothesis of this study was that anatomic single-bundle surgical procedures would be predictive of patient-reported success.

METHODS

This cohort study was based on data from the Swedish National Knee Ligament Register during the period of 1 January 2005 through 31 December 2014. Patients who underwent primary single-bundle ACL reconstruction with hamstring tendons were included. Details on surgical technique were collected using an online questionnaire comprising essential anatomic anterior cruciate ligament reconstruction scoring checklist items, defined as the utilization of accessory medial portal drilling, anatomic tunnel placement, the visualization of insertion sites and pertinent landmarks. A univariate logistic regression model adjusted for age and gender was used to determine predictors of patient-reported success and failure, i.e. 20th and 80th percentile, respectively, in the Knee injury and Osteoarthritis Outcome Score (KOOS), 2 years after ACL reconstruction.

RESULTS

In the 6889 included patients, the surgical technique used for single-bundle ACL reconstruction did not predict the predefined patient-reported success or patient-reported failure in the KOOS₄. Patient-reported success was predicted by the absence of concomitant injury to the meniscus (OR = 0.81 [95% CI, 0.72-0.92], p = 0.001) and articular cartilage (OR = 0.70 [95% CI, 0.61-0.81], p < 0.001). Patient-reported failure was predicted by the presence of a concomitant injury to the articular cartilage (OR = 1.27 [95% CI, 1.11-1.44], p < 0.001).

CONCLUSION

Surgical techniques used in primary single-bundle ACL reconstruction did not predict the KOOS 2 years after the reconstruction. However, the absence of concomitant injuries at index surgery predicted patient-reported success in the KOOS. The results provide further evidence that concomitant injuries at ACL reconstruction affect subjective knee function and a detailed knowledge of the treatment of these concomitant injuries is needed.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures

PURPOSE

An Achilles tendon rupture is a common injury that typically affects people in the middle of their working lives. The injury has a negative impact in terms of both morbidity for the individual and the risk of substantial sick leave. The aim of this study was to investigate the cost-effectiveness of surgical compared with non-surgical management in patients with an acute Achilles tendon rupture.

METHODS

One hundred patients (86 men, 14 women; mean age, 40 years) with an acute Achilles tendon rupture were randomised (1:1) to either surgical treatment or non-surgical treatment, both with an accelerated rehabilitation protocol (surgical n = 49, non-surgical n = 51). One of the surgical patients was excluded due to a partial re-rupture and five surgical patients were lost to the 1-year economic follow-up. One patient was excluded due to incorrect inclusion and one was lost to the 1-year follow-up in the non-surgical group. The cost was divided into direct and indirect costs. The direct cost is the actual cost of health care, whereas the indirect cost is the production loss related to the impact of the patient's injury in terms of lost ability to work. The health benefits were assessed using quality-adjusted life years (QALYs). Sampling uncertainty was assessed by means of non-parametric boot-strapping.

RESULTS

Pre-injury, the groups were comparable in terms of demographic data and health-related quality of life (HRQoL). The mean cost of surgical management was €7332 compared with €6008 for non-surgical management (p = 0.024). The mean number of QALYs during the 1-year time period was 0.89 and 0.86 in the surgical and non-surgical groups respectively. The (incremental) cost-effectiveness ratio was €45,855. Based on bootstrapping, the cost-effectiveness acceptability curve shows that the surgical treatment is 57% likely to be cost-effective at a threshold value of €50,000 per QALY.

CONCLUSIONS

Surgical treatment was more expensive compared with non-surgical management. The cost-effectiveness results give a weak support (57% likelihood) for the surgical treatment to be cost-effective at a willingness to pay per QALY threshold of €50,000. This is support for surgical treatment; however, additionally cost-effectiveness studies alongside RCTs are important to clarify which treatment option is preferred from a cost-effectiveness perspective.

LEVEL OF EVIDENCE

I.

Adolescents and female patients are at increased risk for contralateral anterior cruciate ligament reconstruction: a cohort study from the Swedish National Knee Ligament Register based on 17,682 patients

PURPOSE

The impact of different surgical techniques in index ACL reconstruction for patients undergoing contralateral ACL reconstruction was investigated.

METHODS

The study was based on data from the Swedish National Knee Ligament Register. Patients undergoing index ACL reconstruction and subsequent contralateral ACL reconstruction using hamstring graft under the study period were included. The following variables were evaluated: age at index surgery, gender, concomitant meniscal or cartilage injury registered at index injury, transportal femoral bone tunnel drilling and transtibial femoral bone tunnel drilling. The end-point of primary contralateral ACL surgery was analysed as well as the time-to-event outcomes using survivorship methods including Kaplan-Meier estimation and Cox proportional hazards regression models.

RESULTS

A total of 17,682 patients [n = 10,013 males (56.6%) and 7669 females (43.4%)] undergoing primary ACL reconstruction from 1 January 2005 through 31 December 2014 were included in the study. A total of 526 (3.0%) patients [n = 260 males (49.4%) and 266 females (50.6%)] underwent primary contralateral ACL reconstruction after index ACL reconstruction during the study period. Females had a 33.7% greater risk of contralateral ACL surgery [HR 1.337 (95% CI 1.127-1.586); (P = 0 0.001)]. The youngest age group (13-15 years) showed an increased risk of contralateral ACL surgery compared with the reference (36-49) age group [HR 2.771 (95% CI 1.456-5.272); (P = 0.002)]. Decreased risk of contralateral ACL surgery was seen amongst patients with concomitant cartilage injury at index surgery [HR 0.765 (95% CI 0.623-0.939); (P = 0.010)]. No differences in terms of the risk of contralateral ACL surgery were found between anatomic and non-anatomic techniques of primary single-bundle ACL reconstruction, comparing transportal anatomic technique to transtibial non-anatomic, anatomic and partial-anatomic.

CONCLUSION

Age and gender were identified as risk factors for contralateral ACL reconstruction; hence young individuals and females were more prone to undergo contralateral ACL reconstruction. Patients with concomitant cartilage injury at index ACL reconstruction had lower risk for contralateral ACL reconstruction. No significant differences between various ACL reconstruction techniques could be related to increased risk of contralateral ACL reconstruction.

LEVEL OF EVIDENCE

Retrospective Cohort Study, Level III.

Acute Ultrasonography Investigation to Predict Reruptures and Outcomes in Patients With an Achilles Tendon Rupture

Background:

The optimal treatment for acute Achilles tendon ruptures is still an ongoing debate. Acute ultrasonography (US) investigation to measure the diastasis between the tendon ends has previously been used to classify acute Achilles tendon ruptures; however, no study has used US to predict reruptures and functional outcomes.

Purpose:

To investigate whether acute US can be used to predict the risk of reruptures and outcomes after treatment of an acute Achilles tendon rupture.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Forty-five patients (37 men, 8 women) with a mean age of 39 ± 9.2 years (range, 23-59 years) from a cohort of 97 patients participating in a randomized controlled study comparing surgical and nonsurgical treatment were included. US was performed within 72 hours from the index injury. Diastasis between the tendon ends was documented. Reruptures were documented, and the patients’ functional outcomes were measured 12 months after injury.

Results:

Patients with a diastasis of >10 mm treated nonsurgically had a higher degree of rerupture. In the nonsurgically treated group, 3 of 4 patients with a diastasis of >10 mm suffered from rerupture (P < .001). Moreover, in the nonsurgical group, there was significantly worse outcomes in patients with a diastasis of >5 mm in terms of patient-reported outcomes using the Achilles tendon Total Rupture Score (ATRS) (P = .004) and heel-rise height at 12 months (P = .048) compared with the group with a lesser degree of tendon separation.

Conclusion:

US may be a useful tool to predict the risk of rerupture and greater degree of functional deficit. It may be an important measure in a clinical treatment algorithm for deciding whether a patient will benefit from surgical intervention after an acute Achilles tendon rupture.

Development of a Swedish Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for adult patients with attention-deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) in adults is a phenomenon that attracts a lot of attention in society today. Advances in research have made it clear that many conditions that make people seek medical and psychiatric care may have pervasive deficits in attention, motor control and impulsivity at their roots. Since ADHD in adults is a relatively new and very versatile concept, there is a great need for systemized classification of the ramifications of the deficit that extends into every aspect of these patients' lives.

AIMS

To develop a Swedish Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for adult patients with ADHD.

METHODS

A national expert survey was conducted using the Delphi technique and a formal consensus conference. Forty-two experts from different professions and organizations, including psychiatrists and physicians, psychologists, occupational therapists, a counsellor, a specialist nurse, representatives from a patient organization and representatives from the Swedish Social Insurance Agency, participated in the Delphi process and 28 participants from the expert group attended the consensus conference.

RESULTS

At the formal consensus conference, 66 categories from the ICF were identified and included in the national Comprehensive Core Set for ADHD: 21 categories from the component body functions, 26 categories from the component activities and participation, and 19 categories from the component environmental factors.

CONCLUSION

The Comprehensive Core Set for ADHD should be regarded as national and preliminary, and should be further tested and evaluated by experts in ADHD in clinical settings in Sweden.