Achilles tendon rupture

NewsBot · Jan 15, 2024

ACUTE ACHILLES TENDON RUPTURE: THE IMPACT OF PHYSIOLOGICAL AND PSYCHOLOGICAL FACTORS ON FUNCTION AND RETURN TO ACTIVITY
UNNUR SÆDÍS JÓNSDÓTTIR
Thesis, Sweden

In summary, it is obvious that various physiological and psychological factors affect the return to activity. However, none of the factors examined in this thesis pointed the way towards a clear strategy. The effect of these factors appears to vary between individuals. It can thus be concluded that individualized treatment and rehabilitation are important, with frequent updates and evaluation of progress.
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NewsBot · Jan 17, 2024

Early Tendon Morphology as a Biomarker of Long-term Patient Outcomes After Surgical Repair of Achilles Tendon Rupture: A Prospective Cohort Study
Annukka Saarensilta et al
Orthop J Sports Med. 2023 Nov 6;11(11)

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.
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NewsBot · Jan 31, 2024

Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position
Thomas C Sanchez et al
JBJS Essent Surg Tech. 2023 Mar 9;13(1):e21.00070

Background: The mini-open approach with supine patient positioning is a useful technique to consider for acute Achilles rupture repair, ideally performed within 2 weeks from the time of injury. The traditional surgical approach is completed with the patient in the prone position with an extensile midline incision. Here we describe a mini-open approach with supine positioning that utilizes a single incision measuring approximately 3 to 4 cm in length and avoids the pitfalls of prone positioning, which include greater operative time and potential difficult airway management, vision loss, and brachial plexus palsies1.

Description: When positioning the patient supine, lower-extremity bolsters are placed beneath the contralateral hip and the operative ankle in order to allow for exaggerated external rotation of the ankle and improved medial visualization. A thigh tourniquet is then applied on the operative side in a standard sterile fashion.After appropriate draping, begin by palpating the tendon rupture site and mark a 3 to 4-cm incision line just medial to the tendon. Sharp dissection through the skin to the level of the paratenon is then performed. Incise the paratenon with a knife, separate the paratenon from the underlying Achilles tendon with a Freer elevator or scissors, subsequently remove any hematoma formation, and cut the paratenon proximally and distally with scissors or a knife. Debride any damaged tendon thoroughly.The steps of the procedure are performed under direct visualization. If the sural nerve is encountered, it is noted and retracted, and extra care is taken to avoid damaging it with instruments or suture.Now that the proximal and distal ends of the Achilles tendon are free, utilize a 4-stranded double Krackow locking stitch with two #2 FiberWires (Arthrex) on both the proximal and the distal stump. The stumps of the ruptured tendon are approximated by tying the free suture ends together with use of a simple surgeon's knot. A running epitendinous repair is performed with use of number-0 Vicryl (Ethicon) suture in a cross-stich weave technique to provide additional strength to the repair. Finally, test the integrity of the repair via an intraoperative Thompson test. The postoperative protocol includes non-weight-bearing with the operative limb in a posterior splint for 2 weeks. At the 2-week follow-up, stitches are removed and the limb is placed in a tall CAM (controlled ankle motion) walker boot with 2 heel wedges measuring 6.35 mm (0.25 inches) apiece. The patient can begin partial weight-bearing with crutches at 2 weeks postoperatively. At 4 weeks postoperatively, 1 heel wedge is removed, and at 6 weeks postoperatively, the second heel wedge is removed. Patients are instructed to begin gentle range-of-motion exercises at 2 weeks, with formal physical therapy scheduled to begin at 6 weeks. Most patients are out of the boot at 8 to 10 weeks postoperatively.

Alternatives: Nonoperative treatment of Achilles rupture includes functional bracing or casting with the foot resting in the equinus position and early weight-bearing and rehabilitation. As mentioned earlier, the traditional operative approach with prone positioning is a viable option but is associated with a higher incidence of procedural and anesthesia-related complications, as well as potentially increased cost1.

Rationale: Recent studies have shown that a mini-open approach will produce a repair that is comparable with the traditional open approach, while also minimizing the anesthesia and postural complications associated with prone positioning1. Previous studies focusing on supine positioning have generally utilized a larger incision more comparable with that of the traditional prone approach6. Other studies have utilized a minimally invasive approach but require >1 incision and often utilize specialized instrumentation, which may limit the technique to certain facilities7. The technique described in the present article utilizes a single 3 to 4-cm incision that requires no specialized instrumentation, has a minimal learning curve, and can be performed at any facility.

Expected outcomes: McKissack et al. demonstrated that the overall complication rate of the mini-open supine approach (7.7%) was lower than that of the traditional prone approach (9.3%), while the average cost of the prone approach exceeded that of the supine approach by $1,8231. This increased cost, although not significant, may be attributable to longer operating room and post-anesthesia care unit times. Additionally, no patient in either cohort experienced tendon rerupture within the first year after repair, further proving the effectiveness of this technique. We have utilized this mini-open supine technique for acute Achilles ruptures for over 9 years now, with good patient outcomes and satisfaction. Throughout this duration we have not had a single patient experience rerupture of the repaired tendon. In our experience, we find this technique to be effective, with fewer complications than prone positioning. Additionally, this approach may be associated with decreased financial and anesthesia burdens.

Important tips: Always palpate the tendon rupture site to determine the best incision placement.With ruptures close to the tendon insertion site, it can be notoriously difficult to mobilize the distal tendon stump, so extended incisions may be required.Test the integrity of the repair with use of the intraoperative Thompson test.This technique does not utilize any special equipment and thus can be performed at any facility.This supine approach decreases operating room turnover time, anesthesia burden, and complications associated with prone positioning.
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NewsBot · Feb 11, 2024

Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis
Braydon M Bak et al
J Foot Ankle Surg. 2024 Feb 1:S1067-2516(23)00337-X

Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.
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NewsBot · Feb 16, 2024

Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis
Braydon M. Bak et al
January 29, 2024

Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.
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NewsBot · Feb 20, 2024

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines
Shi-Ming Feng et al
J Orthop Surg Res. 2024 Feb 10;19(1):132

Background: Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

Methods: A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

Results: Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

Conclusion: Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.
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NewsBot · Feb 22, 2024

Tendon Elongation and Function After Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures: A Randomized Controlled Trial
Rikke Hoeffner et al
Am J Sports Med. 2024 Feb 14

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.
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NewsBot · Feb 24, 2024

An Apparent Achilles Heel of the NFL: Have Achilles Tendon Injuries Significantly Increased to Unacceptably High Incidence Levels in the NFL and if so, why? A Clinical Insight
Timothy E Hewett et al
Int J Sports Phys Ther. 2024 Feb 2;19(2):145-147

Many if not most of us watched in utter disbelief and horror last September 11th as Aaron Rogers, the newly acquired $75 million dollar quarterback with the New York Jets just 4 snaps into the new season, suffered an Achilles Tendon ruptures (ATR) in his inaugural game on nationally televised Monday Night Football with his new and excited team and demanding fanbase. With cell phones in hand, we watched as our X apps lit up with claims of an excess of ATRs in the NFL in recent years and much of the blame placed on the new rubberized turf surfaces in place in most of the NFL stadiums. That first week of the NFL season the NFL Players Association, the NFLPA, put out a statement to this effect that demanded removal of rubberized turf surfaces throughout the NFL! With Kirk Cousins devastating ATR a few weeks later, amongst 21 others this season, and Aaron Rogers return to practice after a mere seven to eight weeks post-injury, this conundrum remains foremost in our hyper-questioning minds!
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NewsBot · Feb 26, 2024

Reliability and validation of the German Achilles tendon Total Rupture Score
Dorothe Arbab et al
Knee Surg Sports Traumatol Arthrosc. 2024 Feb;32(2):454-460

Purpose: Patient-related outcome measures (PROMs) are important instruments to evaluate efficacy of orthopaedic procedures. The Achilles tendon Total Rupture Score (ATRS) is a PROM developed to evaluate outcomes after treatment of Achilles tendon ruptures (ATRs). Purpose of this study is to develop and culturally adapt the German version of the ATRS and to evaluate reliability and validity.

Methods: The ATRS was translated by forward-backward translation based on common guidelines. In this retrospective study, 48 patients with a surgical intervention after ATR were recruited. Reliability was evaluated by intraclass correlation coefficient (ICC) and Cronbach's alpha. Construct validity was valued by determining Pearson correlation coefficient with the German version of the Foot and Ankle Outcome Score (FAOS) and the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A).

Results: The German Version of the ATRS has an excellent internal consistency (Cronbach's alpha 0.96) as well as an excellent test-retest-reliability (ICC 0.98). It has a moderately strong correlation with the VISA-A (r = 0.73) as well as with the FAOS subclasses (r = 0.6-0.79).

Conclusion: The German version of the ATRS demonstrated good psychometric properties. It proofed to be a valid and reliable instrument for use in patients with Achilles tendon Rupture.
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NewsBot · Feb 29, 2024

Return to play after Achilles tendon rupture in elite athletes by Uchiyama surgical repair technique (Q１)
Eiji Uchiyama et al
JOS Case Reports ; 3 November 2023

Background
Modification of the Achilles tendon repair technique accomplish a high return-to-play rate at the early period.

Case presentation
This study involved sixteen elite athletes with Achilles tendon rupture were treated using the Uchiyama method, which adjusted the total tendon length via Tsuge and half-Bunnell sutures. Postoperative clinical outcomes, return-to-play time, accomplishment time of heel raise abilities were measured. The tendon functions were also evaluated: heel raise height difference (HRH) in single-leg heel raise and toe height distance (THD) between bilateral feet in the prone and knee-bended positions. The mean return-to-play time was 22.4 weeks. All athletes returned to their original activities, with 94 % (15/16) returning within seven months. The average achievement time of single-leg heel raise was 10.8 weeks. The average THD and HRH were 0.4 and 0.5 cm.

Conclusions
Elite athletes were able to accomplish a return-to-sports in the early period, with a reliable recovery of the heel-raise function by Uchiyama Achilles tendon repair technique.
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NewsBot · Mar 1, 2024

Early Tendon Morphology as a Biomarker of Long-term Patient Outcomes After Surgical Repair of Achilles Tendon Rupture: A Prospective Cohort Study.
Saarensilta A et al
Orthopaedic Journal of Sports Medicine, 06 Nov 2023, 11(11):23259671231205326

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.
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NewsBot · Mar 4, 2024

Testosterone replacement therapy is associated with increased odds of Achilles tendon injury and subsequent surgery: a matched retrospective analysis
J. Alex Albright, Mary Lou, Elliott Rebello, Jonathan Ge, Edward J. Testa, Alan H. Daniels & Michel Arcand
Journal of Foot and Ankle Research

Background
Prescription of testosterone replacement therapy (TRT) has increased in the United States in recent years, and though anabolic steroids have been associated with tendon rupture, there is a paucity of literature evaluating the risk of Achilles tendon injury with TRT. This study aims to evaluate the associative relationship between consistent TRT, Achilles tendon injury, and subsequent surgery.

Methods
This is a one-to-one matched retrospective cohort study utilizing the PearlDiver database. Records were queried for patients aged 35–75 who were prescribed at least 3 consecutive months of TRT between January 1, 2010 and December 31, 2019. Achilles tendon injuries and subsequent surgeries were identified using ICD-9, ICD-10, and CPT billing codes. Multivariable logistic regression was used to compare odds of Achilles tendon injury, Achilles tendon surgery, and revision surgery, with a p-value < 0.05 representing statistical significance.

Results
A sample of 423,278 patients who filled a TRT prescription for a minimum of 3 consecutive months was analyzed. The 2-year incidence of Achilles tendon injury was 377.8 (95% CI, 364.8–391.0) per 100,000 person-years in the TRT cohort, compared to 245.8 (95% CI, 235.4–256.6) in the control (p < 0.001). The adjusted analysis demonstrated TRT to be associated with a significantly increased likelihood of being diagnosed with Achilles tendon injury (aOR = 1.24, 95% CI, 1.15–1.33, p < 0.001). Of those diagnosed with Achilles tendon injury, 287/3,198 (9.0%) of the TRT cohort subsequently underwent surgery for their injury, compared to 134/2,081 (6.4%) in the control cohort (aOR = 1.54, 95% CI, 1.19–1.99, p < 0.001).

Conclusions
There is a significant association between Achilles tendon injury and prescription TRT, with a concomitantly increased rate of undergoing surgical management. These results provide insight into the risk profile of TRT and further research into the science of tendon pathology in the setting of TRT is an area of continued interest.
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NewsBot · Mar 4, 2024

iTRAQ-based proteomics reveals potential markers and treatment pathways for acute Achilles tendon rupture
Bayixiati Qianman, Aikeremu Wupuer, Tuomilisi Jiasharete, Biao Luo, Meihua Nihemaiti & Jiasharete Jielile
Journal of Orthopaedic Surgery and Research

Background
Due to its limited blood supply and irregular mechanical loading, the Achilles tendon is the most frequently ruptured tendon. Despite the rising incidence of acute Achilles tendon rupture (AATR), the optimal treatment remains controversial. Missed diagnoses and delayed treatments lead to poor outcomes and limited treatment options. This study aimed to identify potential biomarkers for diagnosing and developing therapies for AATR.

Methods
We employed the coupled isobaric tag for relative and absolute quantitation-liquid chromatography–electrospray ionization-tandem mass spectrometry approach to investigate protein expression in tissues from AATR patients. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were conducted to identify differentially expressed proteins (DEPs) between AATR patients and healthy individuals. A protein–protein interaction (PPI) network of DEPs was constructed using the Search Tool for the Retrieval of Interacting Genes. The screened hub genes were selectively verified by immunohistochemical staining.

Results
We identified 410 DEPs between AATR patients and controls. The DEPs were significantly enriched in GO terms such as the extracellular region, extracellular region part, and defense response, as well as KEGG pathways, including complement and coagulation cascades, focal adhesion, and regulation of actin cytoskeleton. The main hub nodes in the PPI network comprised fibronectin 1 (FN1), major histocompatibility complex, class I, B (HLA-B), filamin A (FLNA), heat shock 27-kDa protein 1 (HSPB1), heat shock protein family A member 5 (HSPA5), apolipoprotein A4 (APOA4), and myosin IC (MYO1C). Although APOA4 and collagens I, II, and III were detectable in healthy tendons, immunohistochemical staining confirmed higher expression of these proteins in the acutely ruptured Achilles tendon.

Conclusions
Our findings lay a foundation for further molecular studies of AATR. Inflammation and age-related degeneration may contribute to the pathogenesis of AATR. Moreover, the identified DEPs could be potential biomarkers for AATR diagnosis and treatment.
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NewsBot · Mar 5, 2024

Rare Case of Traction Sural Neuropathy due to Acute Achilles Tendon Rupture
Heather Lystad et al
Source

Sural nerve injury (SNI) is a reported complication of acute Achilles tendon rupture (ATR), primarily iatrogenic in operatively managed cases. The sural nerve typically runs along the lateral border of the Achilles tendon. Its branches provide sensory information from the lateral foot and ankle. Given its proximity to the Achilles tendon, sural nerve-related complications in operatively managed cases are a known adverse outcome. However, the incidence of SNI in conservatively managed cases is thought to be much less common. Most patients recover to normal sensation by one year of injury to the sural nerve. CASE DESCRIPTION: A previously healthy 30 y.o. male presented with acute onset right posterior lower leg pain that occurred while running. He was clinically diagnosed with a complete ATR. Additionally, the patient reported numbness and tingling in the right lateral hindfoot since the time of injury. CLINICAL COURSE: The patient opted to pursue conservative management for his ATR with an accelerated functional rehabilitation protocol. However, he continued to endorse minimally improved sensory deficits in the sural nerve distribution nearly one year post-injury. The patient felt these symptoms were negatively impacting his return to full physical function, prompting further testing. Nerve conduction studies were consistent with an isolated right sural sensory neuropathy that was chronic and axonal in nature. Nonsurgical management and conservative treatment were recommended, including a discussion regarding the natural history of nerve healing and the available treatment options for nerve injuries. CONCLUSION: SNI associated with ATR likely results from traction on the nerve at the time of injury. Prior literature has focused on the incidence of sural nerve injury in the setting of operative repair of ATR. This case highlights the rarity of SNI in the absence of surgical repair and the importance of assessing for SNI in all cases of acute ATR.
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NewsBot · Mar 5, 2024

Quantitative Assessment of Calf Muscle Volume, Strength, and Quality After Achilles Tendon Rupture Repair: A 1-Year Prospective Follow-up Study
Shota Mashimo
Volume 51, Issue 14

Background:
A number of studies have reported that calf muscle atrophy is a common long-term problem after Achilles tendon repair; however, there is still a lack of data concerning early postoperative morphological changes in the calf muscle after surgery.
Purpose:
To investigate changes over time in calf muscle volume and fatty degeneration during 1 year after Achilles tendon repair.
Study Design:
Cohort study; Level of evidence, 2.
Methods:
A prospective 1-year serial magnetic resonance imaging study was carried out with 20 patients who underwent tendon repair for unilateral acute Achilles tendon rupture. The magnetic resonance imaging assessment in addition to clinical and functional evaluations was performed at 1, 3, 6, and 12 months after surgery. The muscle volume of the medial and lateral gastrocnemius, soleus, and flexor hallucis longus (FHL) and fatty degeneration of the medial and lateral gastrocnemius and soleus were measured for the calf muscles, and the relative volume and fatty degeneration changes in the affected leg compared with the healthy contralateral leg were calculated as a percentage ([injured/healthy control] × 100) to assess structural changes over time.
Results:
Muscle volumes of the medial gastrocnemius, lateral gastrocnemius, soleus, and FHL were 92.3%, 92.8%, 84.6%, and 95.9% at 12 months after surgery, respectively. Medial and lateral gastrocnemius and FHL muscle volumes improved over time and recovered to almost equal to that of the healthy side at 12 months after surgery. The soleus muscle volume did not recover significantly over time and was statistically significantly smaller than that of the healthy side at 12 months (P = .029). Fatty degeneration rates of the medial gastrocnemius, lateral gastrocnemius, and soleus were 118.2%, 113.9% and 121.1% at 12 months after surgery, respectively. Fatty degeneration of the medial and lateral gastrocnemius did not change significantly, but there was a statistically significant increase in fatty degeneration of the soleus over time (P < .001).
Conclusion:
Within the triceps surae muscle, the soleus was the most negatively affected by injury and repair for both muscle volume and fatty degeneration. Postoperative management to recover the soleus muscle function before a return to sporting activities should be considered in the future.
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NewsBot · Mar 6, 2024

Tendon Elongation and Function After Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures: A Randomized Controlled Trial
Rikke Hoeffner et al
Source

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.
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NewsBot · Mar 6, 2024

Strength and Functional Outcomes Following Achilles Tendon Reconstruction With Hamstring Tendon Autograft Augmentation
Stephanie K Eble et al
Foot Ankle Int. 2024 Mar 3

Background: The proposed advantages of hamstring autograft reconstruction when compared to alternative procedures, such as flexor hallucis longus (FHL) transfer, V-Y lengthening, and allograft reconstruction, are improved healing and reproduction of normal tendon biomechanics and reduced morbidity within the foot and ankle. In this study, we examined the effect of Achilles tendon reconstruction using hamstring autografts on strength and functional outcomes.

Methods: Patients who underwent Achilles repair with a hamstring autograft for insertional or midsubstance tendinopathy, delayed diagnosis of rupture, or infection after primary repair were evaluated for inclusion. Forty-six patients were identified; 12 further augmented with an FHL transfer are included in the analysis. Isokinetic testing was completed with a Biodex dynamometer under supervision of a physical therapist masked to surgical side. Pre- and postoperative Foot and Ankle Outcome Scores (FAOS, before March 2016) or Patient-Reported Outcomes Measurement Information System (PROMIS, after March 2016) surveys were collected.

Results: For knee flexion, peak torque was not significantly different when comparing operative and nonoperative sides at 180 degrees/second (45.38 Nm vs 45.96 Nm; P = .69) nor at 300 degrees/second (44.2 Nm vs 47.02 Nm; P = .069). Knee extension absolute peak torque was only found to be significantly weaker on the operative side at the faster testing (75.5 Nm vs 79.56 Nm; P < .05). Peak ankle plantarflexion torque was significantly weaker on the operative side at both the slower speed (60 degrees/second: 39.9 Nm vs 48.76 Nm; P < .005) and the faster speed (120 degrees/second: 31.3 Nm vs 40.7 Nm; P < .001). Average power for ankle plantarflexion did not differ significantly from the operative side to the nonoperative side in the slower test (26.46 W vs 27.48 W; P = .60) but did significantly differ on the faster test (32.13 W vs 37.63 W; P = .041). At an average of 19.9 months postoperation, all physical function and pain-related patient-reported outcome scores showed clinically and statistically significant improvement.

Conclusion: Achilles reconstruction with a hamstring autograft ± FHL transfer allowed patients with severe Achilles pathology to return to good subjective function, with modest deficits in calf strength compared with the uninjured side. Overall knee flexion strength did not appear impaired. These results suggest that hamstring autograft reconstruction is a viable method to treat these complex cases involving a lack of healthy tissue, allowing patients to return to symptom-free physical function and athletic activity.
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NewsBot · Mar 9, 2024

Comparison of rerupture rates after operative and nonoperative management of Achilles tendon rupture in older populations: Systematic review and meta-analysis
Daniel Acevedo et al
J Orthop. 2024 Feb 22

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.
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NewsBot · Mar 24, 2024

Evaluation of Costs Associated With Acute Achilles Tendon Repair
Kade Wagers et al
Foot Ankle Orthop. 2024 Mar 19;9(1):24730114241238215

Background: Increasing attention is being paid to the costs associated with various orthopaedic surgeries. Here, we studied the factors that influence costs associated with surgically treated acute Achilles tendon tears.

Methods: We retrospectively identified patients with surgically repaired acute Achilles tendon tears, excluding insertional ruptures or chronic tendon issues. Using the Value Driven Outcome (VDO) tool from our institution, we assessed total direct costs as well as facility costs. Briefly, the VDO tool includes an item-level database that can capture detailed cost data-costs are then reported as relative mean data. Cost variables were adjusted to 2022 US dollars, and total direct cost was compared with patient characteristics using gamma regressions to report cost ratios with 95% CIs.

Results: Our cohort consisted of 224 patients with Achilles tendon tears surgically repaired by one of 4 fellowship-trained orthopaedic foot and ankle surgeons. There were no differences in demographics, total direct costs, or facility costs based on surgical positioning (prone n = 156, supine n = 68). Open repairs (n = 215), compared with percutaneous techniques (n = 9) that used commercially available instrumentation, had 37% less total direct costs (P < .001, 95% CI 0.55-0.72). Compared with surgery at a main academic hospital (n = 15), procedures at an ambulatory care center (n = 207) had 19% lower total direct costs (P = .040, 95% CI 0.66-0.99) and 41% lower facility costs (P < .001, 95% CI 0.5-0.7).

Conclusion: Improving cost-effective orthopaedic care remains an increasingly important goal. Patient positioning for Achilles tendon repair does not appear to have meaningful impacts on cost. When clinically appropriate, considering surgery location at an ambulatory center appears to reduce surgical costs.
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NewsBot · Apr 3, 2024

Hyperuricemia as an independent risk factor for achilles tendon rupture in male: a case-control study
Dongliang Chen et al
J Orthop Surg Res. 2024 Apr 1;19(1):215

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.
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NewsBot · Apr 15, 2024

Current treatment concepts for Achilles tendon rupture
Wang, Chen-Chiea, et al
Tzu Chi Medical Journal 36(1) 46-52, Jan–Mar 2024. | DOI: 10.4103/tcmj.tcmj_113_23

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.
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NewsBot · Apr 15, 2024

Modified gastro-soleus turn-down flap for chronic or neglected achilles tendon ruptures
Mohamed A A Ibrahim et al
J Orthop Surg Res. 2024 Mar 6;19(1):168

Background: Achilles' tendon chronic rupture is a common entity that is usually misdiagnosed or mistreated. Hence, she was presented to us later or with complications affecting her gait. Surgical resection is needed to either bridge the gap or reinforce the strength of the tendon repair.

Objectives: Our study's goal was to assess the clinical results of repairing chronic Achilles' tendon lesions employing the middle segment of the proximal portion of the tendon (gastro-soleus), as a turn-down flap.

Methods: Our prospective interventional single arm study included 18 patients with chronic Achilles' tendon rupture attending at Al-Azhar university hospitals in Cairo, Egypt from May 2020 to April 2023. Diagnosis of the patients was confirmed by radiographic and clinical investigations. They were all treated with the same open reconstruction procedure using a modified GSF. The average follow-up was 12 months. The results of this study were assessed by the Achilles tendon rupture score (ATRS), American Orthopedic Foot and Ankle Society (AOFAS) score, and capacity to perform repeated heel raises on the affected side.

Results: The mean operative time was 72.77 min. The median (IQR) time of reconstruction was 10 (8-12) after the injury. The median (IQR) length of flab was 4.5 (4.3-5) 9 (Table 2). No intraoperative complications occurred. The typical follow-up period was 12 months (6-18 months). In terms of the ATRS, we found a significant reduction from 82.8 ± 3 preoperatively to 20.8 ± 6.7 at 12 months postoperatively (P value = 0.001). As regards the AOFAS score, it was increased from 49.5 ± 10 preoperatively to 83.8 ± 8.5 12 months postoperatively (P = 0.001). In terms of the post operative complications, there was no re-rupture. Two patients experienced superficial wound infection which improved with daily dressing and antibiotics. Additionally, two patients had slight ankle stiffness four months after the operation, which improved after programmed rehabilitation at the sixth month.

Conclusion: The modified GSTF is a simple, safe, well-tolerated and effective method of treatment with excellent functional results and greater patient content.
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NewsBot · Apr 16, 2024

Feasibility of Blood Flow Restriction Exercise in Adults with a Non-surgically Treated Achilles Tendon Rupture; a Case Series
ANDREAS BENTZEN et al
International Journal of Exercise Science 17(3): 140-153, 2024.

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.
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NewsBot · Apr 24, 2024

Females present larger deficit in heel-rise height at 3 months following an Achilles tendon rupture compared with males
Elin Larsson et al
Knee Surg Sports Traumatol Arthrosc. 2024 Apr 23.

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.
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NewsBot · Apr 24, 2024

Feasibility of an early progressive resistance exercise program for acute Achilles tendon rupture
Marianne Christensen et al
Pilot Feasibility Stud. 2024 Apr 22;10(1):66.

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.
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NewsBot · Apr 25, 2024

Risk factors and clinical characteristics of surgical site infections in athletes undergoing Achilles tendon repair surgery.
Guo C et al
International Wound Journal, 01 Mar 2024, 21(3):e14666

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.
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NewsBot · Apr 26, 2024

Ultrasound assessment of acute Achilles tendon
rupture and measurement of the tendon gap
Michelle Fenech et al
Source

Achilles tendon rupture is a common sports-related injury which can carry significant morbidity to patients. Ultrasound remains the
workhorse of imaging as it can confirm and localise the extent of Achilles tendon injury. The sonographic anatomy, both normal
and ruptured sonographic appearances, as well as sonographic technique must be appreciated to accurately image and report findings, critical to patient management. Particular attention should be applied to the measurement of the diastasis between acutely
ruptured tendon ends as this information can assist with informing the decision of conservative vs. operative management. Further
work is necessary to standardise the measurement technique including correlating the degree of plantarflexion of the foot with
the sonographic tendon gap measures.
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NewsBot · May 2, 2024

Ultrasound assessment of acute Achilles tendon rupture and measurement of the tendon gap
Michelle Fenech, Aiyapa Ajjikuttira, Heath Edwards
17 April 2024 https://doi.org/10.1002/ajum.12384

Achilles tendon rupture is a common sports-related injury which can carry significant morbidity to patients. Ultrasound remains the workhorse of imaging as it can confirm and localise the extent of Achilles tendon injury. The sonographic anatomy, both normal and ruptured sonographic appearances, as well as sonographic technique must be appreciated to accurately image and report findings, critical to patient management. Particular attention should be applied to the measurement of the diastasis between acutely ruptured tendon ends as this information can assist with informing the decision of conservative vs. operative management. Further work is necessary to standardise the measurement technique including correlating the degree of plantarflexion of the foot with the sonographic tendon gap measures.
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NewsBot · May 22, 2024

News Release 21-May-2024
Ruptured Achilles tendon shows faster repair amid plasma irradiation treatment
Promising results of helium plasma jet therapy on rats after surgery widen scope of method’s medical applications

What is the largest ligament in the human body? It might surprise some people that it is the Achilles tendon. Even though it is also considered the toughest ligament, the Achilles tendon can rupture, with many such injuries involving sports enthusiasts in their 30s or 40s. Surgery might be required, and a prolonged period of rest, immobilization, and treatment can be difficult to endure.

Seeking to shorten the recovery time, a research team led by Osaka Metropolitan University Graduate School of Medicine’s Katsumasa Nakazawa, a graduate student in the Department of Orthopedic Surgery, Associate Professor Hiromitsu Toyoda, and Professor Hiroaki Nakamura, and Graduate School of Engineering Professor Jun-Seok Oh has focused on non-thermal atmospheric-pressure plasma as a treatment method.

This study is the first to show that such plasma irradiation can accelerate tendon repair. The team ruptured then sutured the Achilles tendon of lab rats. For one group of rats, the sutured area was irradiated with a helium plasma jet. The plasma-irradiated group exhibited faster tendon regeneration and increased strength at two, four, and six weeks after surgery compared to the untreated group.

“We have previously discovered that irradiation of non-thermal atmospheric-pressure plasma has the effect of promoting bone regeneration. In this study, we discovered that the technology also promotes tendon regeneration and healing, showing that it has applications for a wide range of fields,” Professor Toyoda declared. “Combined with current tendon treatments, it is expected to contribute to more reliable tendon regeneration and shorter treatment time.”

NewsBot · May 23, 2024

Short-term outcomes of all-inside endoscopic running locked stitch technique for acute achilles tendon ruptures
B Y Zhenget al
Zhonghua Wai Ke Za Zhi. 2024 Apr 29;62(6):549-555

Objective: To evaluate the short-term outcomes of all-inside endoscopic running locked stitch technique for acute Achilles tendon ruptures. Methods: This is a retrospective case series study. Forty cases with acute Achilles tendon rupture were treated with the all-inside endoscopic running locked stitch technique from April 2020 to March 2022. There were 44 males and 4 females, aged (34.8±7.4) years (range: 24 to 50 years). Body mass index was (21.2±2.4)kg/m2 (range: 18 to 26 kg/m2); There were 29 cases (60.4%) on the left side and 19 cases (39.6%) on the right side. Under endoscopic control, the proximal tendon stumps were stitched with the running locked method using a semi-automatic flexible suture passer. The threads of the high-strength suture were grasped through the paratenon sub-space and then fixed into calcaneal insertion with a knotless anchor. MRI of Achilles tendon, surgical time and complications were assessed. Achilles tendon total rupture score (ATRS), Achilles tendon resting angle, and heel rise height scale were utilized to evaluate final clinical outcomes. The differences of bilateral limbs were compared using the paired t test. Results: The follow-up time was (24.1±3.5)months (range:18 to 32 months). Appropriate tendon regeneration was observed on MRI at post-operative 12 months. The median ATRS score (M(IQR)) was 95.0 (4.7) points. Furthermore, there was no significant difference between the injured and contralateral side in the Achilles tendon resting angle ((17.1±2.4)° vs. (17.4±2.6)°, t=1.92,P=0.062) and heel rise height ((14.2±1.7)cm vs. (14.4±1.5)cm, t=1.71,P=0.094). No nerve injuries, infection, deep vein thrombosis and re-ruptures were encountered. Sports activity resumed six months postoperative in 46 patients. One patient had a slight anchor cut-out, due to an addition injury, which was removed after 5 months. Conclusions: All-inside endoscopic running locked stitch technique for acute Achilles tendon ruptures shows promising results. It provides stable connection of the tendon stumps with a low risk of complications.
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NewsBot · May 23, 2024

Socioeconomic Status and Race Are Rarely Reported in Randomized Controlled Trials for Achilles Tendon Pathology in the Top 10 Orthopaedic Journals: A Systematic Review
Grayson M. Talaski et al
Source

Background:
Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals.
Methods:
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high–impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details.
Results:
Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA.
Conclusion:
This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results.
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NewsBot · May 23, 2024

Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis
Braydon M. Bak et al
January 29, 2024DOI:https://doi.org/10.1053/j.jfas.2023.12.008

Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.
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NewsBot · May 27, 2024

The learning curve for minimally invasive Achilles repair using the "lumbar puncture needle and oval forceps" technique
Yanrui Zhao et al
BMC Musculoskelet Disord. 2024 May 11;25(1):373

Introduction: An acute Achilles tendon rupture represents a common tendon injury, and its operative methods have been developed over the years. This study aimed to quantify the learning curve for the minimally invasive acute Achilles tendon rupture repair.

Methods: From May 2020 to June 2022, sixty-seven patient cases who received minimally invasive tendon repair were reviewed. Baseline data and operative details were collected. The cumulative summation (CUSUM) control chart was used for the learning curve analyses. Achilles tendon rupture score (ATRS), American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score, and visual analog scale (VAS) at 3/6/9/12 months were calculated to assess the clinical outcomes.

Results: Thirty-six cases underwent at least a year of follow up and were enrolled in this study. The gender ratio and average age were 80.5% and 32.5 years. The linear equation fitted well (R2 = 0.95), and CUSUM for operative time peaked in the 12th case, which was divided into the learning phase (n = 12) and master phase (n = 24). No significant difference was detected between the two groups in clinical variables, except for the operative time (71.1 ± 13.2 min vs 45.8 ± 7.2 min, p = 0.004). Moreover, we detected one case with a suture reaction and treated it properly.

Conclusion: Minimally invasive Achilles repair provides an opportunity for early rehabilitation. Notably, the learning curve showed that the "lumbar puncture needle and oval forceps" technique was accessible to surgeons
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NewsBot · May 27, 2024

Audit of a revised pathway aimed at expediting diagnosis and treatment for suspected Achilles tendon rupture.
Miss Kirsty Cole et al
May 11, 2024

Treatment outcomes for Achilles tendon ruptures depend upon prompt diagnosis and management. A local study in 2018 highlighted inefficiencies in patient management, and a revised protocol was introduced allowing investigation and referral to be initiated by other healthcare professionals. This retrospective audit evaluates the impact of this on the timescale from presentation to treatment. It analyzes all suspected Achilles tendon ruptures within one District General Hospital from April 2021 to March 2022. Data regarding patient timelines was compared to the 2018 study. Over 12 months, 99 patients were referred to Virtual Fracture Clinic, 87.8% (n=87) of which had a complete or partial tear on ultrasound scan (USS). In comparison to 2018, the average time from presentation to USS request reduced from 2.9 to 1.1 days (p<0.01). 95% were scanned within one week of USS request and 31.3% within 48 hours (81% and 18% previously). The average time from USS request to scan went from 6.8 to 3.2 days (p<0.01). The time from presentation to treatment decision reduced from 10.9 to 6.2 days (p<0.01) and the percentage of patients with a definitive treatment plan within one week increased from 34.5% to 74.2% (p<0.01). Patients required 0.8 fewer appointments (p<0.01) giving an estimated total saving of $10,110 ($128 per patient) during the analysed period. The Achilles Tendon Rupture Pathway has significantly improved the proportion of patients undergoing USS within 48 hours and receiving a treatment decision within one week. This study demonstrates an efficient, cost-saving and replicable pathway for Achilles tendon ruptures.
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NewsBot · May 28, 2024

Long-term patient outcome is affected by deep venous thrombosis after Achilles tendon rupture repair
Susanna Aufwerber et al
Knee Surg Sports Traumatol Arthrosc. 2024 May 26

Purpose: The aim of the study was to examine the impact of a deep venous thrombosis (DVT) on patient outcomes 3 years after Achilles tendon rupture (ATR) repair and if there were continued improvements between 1 and 3 years after surgery. A secondary aim was to determine risk factors associated with impaired patient outcomes in the long term.

Methods: This cohort study consisted of 181 ATR-repaired patients, from two large randomized clinical trials, who attended a 3-year follow-up evaluation. Patients were postoperatively randomized to two different weight-bearing interventions compared with immobilization in a below-knee plaster cast for 2 weeks. During immobilization, screening for DVT was performed with Doppler ultrasound. At 1 and 3 years postoperatively, functional- and patient-reported outcomes were evaluated by the validated heel-rise test and self-reported questionnaire, Achilles tendon Total Rupture Score (ATRS).

Results: In total, 76 out of 181 (42%) patients exhibited a DVT at the 2- or 6-week screening after ATR surgery. Suffering from a DVT during immobilization resulted at 3 years in a worse limb symmetry index (LSI) of heel-rise total work compared to patients without DVT, adjusted for age (DVT mean LSI 68% vs. no DVT 78%, p = 0.027). At 3 years, patients with a DVT during immobilization displayed lower ATRS (DVT median 88 vs. no DVT 93, p = 0.046), which was not significant after adjustment for age. However, patients with DVT exhibited an improvement in ATRS, LSI total work, and LSI maximum height between 1 and 3 years, which was not seen among patients without DVT. Independent risk factors for reduced patient functional outcomes at 3 years were older age, greater calf muscle hypotrophy, and suffering a DVT.

Conclusions: DVT during immobilization affects patients' long-term functional outcomes 3 years after ATR repair. Clinicians should adequately address risk factors contributing to impaired patient outcomes in the long term, including calf muscle hypotrophy, DVT, and older age.
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NewsBot · May 29, 2024

The Influence of Patient Characteristics and Social Determinants of Health on Postoperative Complications Following Achilles Tendon Rupture
Joris R H Hendriks et al
Foot Ankle Int. 2024 May 26

Background: The influence of social determinants of health (SDH) on postoperative complications has been investigated in several studies, although correlation with Achilles tendon rupture (ATR) repair remains uninvestigated. SDH encompasses several factors, including insurance status and area-based measurements, including the Area Deprivation Index (ADI) and Social Vulnerability Index (SVI), which ranks neighborhoods by social disadvantage. This study investigated the correlation between patient demographics, SDH, and complications following ATR repair.

Methods: A retrospective cohort study was conducted on 521 patients who presented with acute ATR and met the inclusion criteria, including age ≥18 years, a minimum of 30-day follow-up, and repair within 28 days of rupture. We reviewed patient demographics, time to surgery (TTS), and postoperative complications, including venous thromboembolism (VTE), rerupture, surgical site infection (SSI), wound dehiscence, and sural nerve injury. SDH variables included race, smoking status, insurance status, level of education, ADI, and SVI. Univariate regression tested the correlation between complications and SDH indicators. Significant variables (P < .05) were included in a multivariate regression.

Results: Sixty-eight complications occurred in 59 patients (11.3%). Multivariate regression showed that a higher ADI, that is, socially deprived individuals, was associated with lower rates of VTE (OR = 0.41, P = .04). Higher body mass index (BMI) was associated with rerupture (OR = 8.73, P < .01). Male patients had lower rates of wound dehiscence (OR = 0.31, P = .03) and VTE (OR = 0.32, P = .02) compared with women. Longer TTS correlated with sural nerve injuries (OR = 2.23, P < .01) and shorter TTS with reruptures (OR = 0.02, P = .02).

Conclusion: Some measures of SDH were associated with postoperative complications. Gender also may have an effect, with male sex associated with lower rates of wound dehiscence and VTE. BMI was associated with higher rates of reruptures and overall general complications.
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NewsBot · Jun 2, 2024

Salvage Reconstruction of a 12-cm Tendon Defect Following Chronic Achilles Rerupture-15-Year Follow-Up: A Case Report
Wesley J Manz, Jason Bowman, Tee Pongastron, Scot Sherwood, Sameh A Labib
JBJS Case Connect. 2024 May 31;14(2)

Case: A 39-year-old man with a chronic Achilles rupture status post (1) failed primary repair and (2) secondary xenograft repair with graft rejection, resulting in a 12-cm Achilles tendon defect, which was reconstructed utilizing an Achilles bone block allograft and flexor hallucis longus (FHL) tendon transfer. At 15-year follow-up, the patient reported good functionality and satisfaction with the repair, with positive patient-reported outcome measures. Physical examination revealed excellent strength and range of motion. Magnetic resonance imaging confirmed the integrity and incorporation of the Achilles/FHL graft composite.

Conclusion: This case study provides valuable insight into successful long-term management of complex chronic Achilles ruptures with large defects.
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NewsBot · Jun 3, 2024

Achilles tendon rupture preceded by normal asymptomatic imaging in a collegiate gymnast: A case report
Daniel M. Cushman et al
Radiology Case Reports; Volume 19, Issue 8, August 2024, Pages 3470-3472

Female gymnasts are the athletes that are most likely to experience Achilles tendon rupture, due to the high energy and eccentric load place on their Achilles tendon related to their sport. It is postulated that degenerative changes, watershed vascular supply, calcifications, and high amounts of inflammatory cells may play a role. This case report highlights an athlete with an asymptomatic Achilles tendon that was visualized to be normal utilizing ultrasound. She was found to have no evidence of underlying tendon pathology. The athlete then ruptured her Achilles tendon 8 months later during a gymnastic meet with no proceeding symptoms. This case report challenges the accepted theory that preexisting tendinosis or pathology proceeds Achilles tendon rupture. In this case, it is postulated that tendon rupture may be secondary to significant mechanical force even without underlying pathology.
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NewsBot · Jun 4, 2024

Endoscopic peroneus brevis tendon transfer for chronic ruptures of the Achilles tendon: surgical technique
Nicola Poeta, Nicola Maffulli, Fabrizio Bucolo, Christel Charpail, Filippo Migliorini & Stéphane Guillo
Journal of Orthopaedic Surgery and Research volume 19, Article number: 131 (2024)

Chronic Achilles tendon rupture is usually defined as a rupture diagnosed 4–6 weeks after injury. The management of chronic Achilles tendon rupture (CATR) is a topic of hot debate, and no consensus has been achieved. Surgical management of CATR is recommended. Several approaches, techniques, and grafts have been described. Open techniques carry a high risk of wound breakdown, infection, and necessitate long rehabilitation times. Surgical techniques with smaller incisions to reduce the risk of scar fibrosis, pain, and infection are becoming common. The ipsilateral tendon of the hallux flexor longus and the peroneus brevis is commonly used. Endoscopic transfer of the peroneus brevis tendon is an innovative alternative to other procedures, with comparable results of other autografts even in elite athletes. The tendon of the peroneus brevis is harvested by tendoscopy before performing a calcaneal tendon endoscopy and fixing the graft in a calcaneal tunnel using an interference screw. After surgery, an anterior splint is placed for 3 weeks with immediate forefoot weight bearing. The rehabilitation starts on the 15th postoperative day.
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NewsBot · Jun 4, 2024

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines
Shi-Ming Feng, Nicola Maffulli, Francesco Oliva, Amol Saxena, Yue-Feng Hao, Ying-Hui Hua, Hai-Lin Xu, Xu Tao, Wei Xu, Filippo Migliorini & Chao Ma
Journal of Orthopaedic Surgery and Research volume 19, Article number: 132 (2024)

Background
Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

Methods
A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

Results
Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

Conclusion
Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.
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