Surgical Repair Of Achilles Tendon Research Articles

Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison.

Background: the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy. Methods: 33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery. Results: At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups. Conclusions: fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.

Nanostructured fibrin-based hydrogel membranes for use as an augmentation strategy in Achilles tendon surgical repair in rats.

Hydrogels are polymeric biomaterials characterised by their promising biological and biomechanical properties, which make them potential alternatives for use in tendon repair. The aim of the present study was to generate in vitro, and determine the therapeutic efficacy in vivo, of novel nanostructured fibrin-based hydrogels to be used as an augmentation strategy for the surgical repair of rat Achilles tendon injuries. Fibrin, fibrin-agarose and fibrin-collagen nanostructured hydrogels (NFH, NFAH and NFCH, respectively) were generated and their biomechanical properties and cell-biomaterial interactions characterised ex vivo. Achilles tendon ruptures were created in 24 adult Wistar rats, which were next treated with direct repair (control group) or direct repair augmented with the generated biomaterials (6 rats/group). After 4 and 8 weeks, the animals were euthanised for macroscopical and histological analyses. Biomechanical characterisation showed optimal properties of the biomaterials for use in tendon repair. Moreover, biological analyses confirmed that tendon-derived fibroblasts were able to adhere to the surface of the generated biomaterials, with high levels of viability and functionality. In vivo studies demonstrated successful tendon repair in all groups. Lastly, histological analyses disclosed better tissue and extracellular matrix organisation and alignment with biomaterial-based augmentation strategies than direct repair, especially when NFAH and NFCH were used. The present study demonstrated that nanostructured fibrin-collagen hydrogels can be used to enhance the healing process in the surgical repair of tendon ruptures.

Biomechanical Effects of Δ9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD), the Major Constituents of Cannabis, in a Sprague Dawley Rat Achilles Tendon Surgical Repair Model: A Pilot Study

Background: The use of cannabis is common among athletes and the US population at large. Cannabinoids are currently being evaluated as alternatives to opioid medications for chronic pain management. However, the effects of recreational and/or medical use of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) on musculoskeletal injury and healing remain largely unknown. Hypothesis/Purpose: The purpose of this study was to evaluate the biomechanical effects of CBD and THC on tendon-to-tendon healing in a rat Achilles tendon repair model. The hypothesis was that rats administered CBD would demonstrate decreased tensile load to failure of surgically repaired Achilles tendons compared with the THC and control groups. Study Design: Controlled laboratory study. Methods: A total of 33 Sprague Dawley rats underwent Achilles tendon surgical transection and repair and were randomized to receive subcutaneous injection of THC, CBD, or vehicle once daily starting on the day of surgery and for 5 total days. After sacrifice, biomechanical tensile load-displacement testing was performed to determine Achilles tendon load to failure and stiffness. Data were analyzed by 1-way analysis of variance. Results: The THC group demonstrated the highest median load to failure, 18.7 N (95% CI, 15.3-19.2 N); the CBD group had the second highest at 16.9 N (95% CI, 15.1-19.8 N), and the control group had the lowest at 14.4 N (95% CI, 12.1-18.3 N). Stiffness was highest in the THC group at 4.1 N/mm (95% CI, 2.7-5.1 N/mm) compared with 3.6 N/mm (95% CI, 2.9-4.1 N/mm) for the CBD group and 3.6 N/mm (95% CI, 2.8-4.3 N/mm) for the control group. No statistically significant differences for strength and stiffness were observed between the groups. Conclusion: In this pilot study using an animal tendon-to-tendon repair model, neither THC nor CBD resulted in altered biomechanical characteristics compared to control. Clinical Relevance: Cannabinoids do not appear to adversely affect Achilles tendon healing.

Neuromechanical activation of triceps surae muscle remains altered at 3.5\xa0years following open surgical repair of acute Achilles tendon rupture

PurposeTo assess whether the neuromuscular activation pattern following Achilles tendon rupture and repair may contributes to the observable functional deficits in this severe and increasingly frequent injury.MethodsIn this study, the neuromuscular activation using surface EMG of n = 52 patients was assessed during a battery of functional performance tasks to assess potential alterations of muscular activation and recruitment. We analyzed the injured leg vs. the contralateral healthy leg at a mean of 3.5 years following open surgical repair. The testing battery included isokinetic strength testing, bipedal and single-legged heel-rise testing as well as gait analysis.ResultsDuring isokinetic testing, we observed a higher activation integral for all triceps surae muscles of the injured side during active dorsiflexion, e.g., eccentric loading on the injured leg, while concentric plantarflexion showed no significant difference. Dynamic heel-rise testing showed a higher activation in concentric and eccentric loading for all posterior muscles on the injured side (not significant); while static heel-rise for 10 sec. revealed a significantly higher activation. Further analysis of frequency of fast Fourier-transformed EMG revealed a significantly higher median frequency in the injured leg. Gait analysis revealed a higher pre-activation of the tibialis anterior before ground contact, while medial and lateral gastrocnemius muscles of the injured leg showed a significantly higher activation during push-off phase.ConclusionsThe results of this study provide evidence on the neuromuscular changes 3.5 years following open surgical Achilles tendon repair. These complex neuromuscular changes are manifested to produce the maximum force output whilst protecting the previously injured tendon. The observed alterations may be related to an increased recruitment of type II muscle fibers which could make the muscles prone to fatigue.Level of evidenceIII.

Coordination variability in runners after surgical Achilles tendon repair

The purpose of this study was to compare lower extremity coordination variability between runners with history of Achilles tendon rupture and healthy controls. Twenty participants, 10 Achilles tendons repaired and 10 controls, were recruited. The groups were matched according to age, sex, volume of running, speed, body mass, height, and footfall type. Achilles tendon mechanical properties were determined using a sonographic technique. A motion capture system was used to record running kinematics. A vector coding technique was used to investigate segment coordination variability and the mean phase angle. Statistical parametric mapping was used to examine the relationship in coordination variability between groups. Higher foot eversion and shank internal rotation coordination variability were found in participants with a history of Achilles tendon rupture compared to healthy controls during the portion of the stance phase between 47.2% and 50.3% when the maximal ground reaction force occurs. The current study provides the empirical evidence for increased coordination variability in a specifically affected group of runners. Altered coordination variability between the foot and shank may indicate a risk of abnormal loading of the musculoskeletal structures of the lower extremity in runners with a history of Achilles tendon rupture.

Biomechanical Effects of Δ9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD), the Major Constituents of Cannabis, in a Sprague Dawley Rat Achilles Tendon Surgical Repair Model

Category:Sports; HindfootIntroduction/Purpose:Use of Cannabis is common amongst athletes and the U.S. population at large. Use of Cannabinoid Oil is being increasingly utilized for a number of different pathologies, injuries, and ailments due to anecdotal evidence of its efficacy. Due to the current United States Opioid crisis, Δ9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD), the two major constituents of cannabis, are currently being evaluated as potential safer alternatives to narcotic pain medicines. The effects of recreational and/or therapeutic THC and CBD on musculoskeletal injury and healing however remain largely unknown. Our purpose was to evaluate the biomechanical effects of THC and CBD on tendon to tendon healing in a Sprague Dawley Achilles Tendon injury and surgical repair model.Methods:33 Sprague Dawley rats were randomly assigned into control (1 ml/kg/day of vehicle containing 5% Cremaphor, 5% ethanol, and 0.9% saline n=12), THC (3 mg/kg/day n = 12), or CBD (3 mg/kg/day n=9) treatment groups. Surgical transection and repair of the Achilles tendon was performed and all rats began subcutaneous administration of their respective drug treatment the day of surgery and for 4 subsequent days, followed by sacrifice. Load to failure and stiffness were calculated from load displacement data during tensile load testing on a MTS machine. One-way ANOVA with heterogeneous variance was utilized for evaluation. Means and 95% confidence intervals were also determined.Results:The CBD group demonstrated the highest mean load to failure of 17.5 N (15.1-19.8 N), with the THC group having the second highest mean load to failure at 17.3 N (15.3-19.2 N), and the control group reporting the lowest at 15.2 N (12.1-18.3 N). No statistical difference was observed between CBD/control (p = 0.25), THC/control (p = 0.29), or CBD/THC groups (p = 0.92, Figure 1A). The THC group reported the highest mean stiffness of 3.9 N/mm (2.7-5.1 N/mm). The CBD and control groups demonstrated mean stiffness values of 3.5 N/mm (2.9-4.1 N/mm) and 3.5 N (2.7-4.3 N/mm), respectively. No statistically significant differences were observed between THC/control (p = 0.51), THC/CBD (p = 0.50), or CBD/control groups (p = 0.96) for stiffness (Figure 1B).Conclusion:Our investigation demonstrates that subcutaneous administration of CBD resulted in the highest mean load to failure, while THC administration resulted in the highest mean stiffness of the three groups. This did not result however in a statistically significant difference between groups. In our small animal tendon-to-tendon repair model, use of THC or CBD did not result in decreased biomechanical characteristics, and there was a trend toward improved ultimate strength and stiffness as compared to control. Further evaluation with larger numbers of animals, and evaluating the potential synergistic effects of THC and CBD administered together are warranted.

Postoperative Noncompliance following Repair of Acute Achilles Tendon Ruptures

Category:Trauma; Ankle; Hindfoot; SportsIntroduction/Purpose:Patient compliance with postoperative instructions is an important aspect of the orthopaedic surgery treatment regimen and can be a substantial deciding factor in achieving good outcomes. The postoperative period following acute Achilles tendon repairs requires diligent patient compliance in order to achieve optimal outcomes. The purpose of this study was to report the incidence of postoperative noncompliance and determine independent predictive factors of noncompliance following surgical management of acute Achilles tendon ruptures.Methods:A retrospective review of patients undergoing primary open repair of acute Achilles tendon ruptures with a single fellowship-trained orthopaedic foot & ankle surgeon at a single surgical location from 2010-2017 was performed. Patients <18 years of age, those who underwent surgical repair >21 days from the date of injury, those whose repair required a V-Y advancement, or those with bilateral tendon ruptures were excluded. Patient records were reviewed for collection of patient data and postoperative chart notes were reviewed to document instances of noncompliance. Instances were subcategorized into non- accidental or accidental. Multivariable regression analysis was performed to determine independent predictors of noncompliance. Regression coefficients with 95% confidence intervals [95% CI] and p-values were reported for significant findings. Mann-Whitney U tests were used to compare Foot and Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and -Sports scores and Visual Analog Scale (VAS) pain scores between compliant and noncompliant groups.Results:Of 232 patients meeting the inclusion criteria, 19 (8.2%) patients had 21 documented instances of noncompliance during the first 12 postoperative weeks, with 7/21 (33.3%) occurring during the first 2 postoperative weeks, 8 (38.1%) between weeks 3- 6, and 6 (28.6%) between weeks 7 and 12. Sixteen of the 21 (76.2%) instances of noncompliance were determined to be non- accidental, while 5 (23.8%) were accidental. Multivariable analysis demonstrated male sex (0.10 [0.00, 0.19]; p=0.0498) to be an independent predictor of non-accidental noncompliance. Age, BMI, a history of depression or diabetes, mechanism of injury, and timing of surgery following injury were not predictive of postoperative compliance. At mean 4.7 (range, 2.0-8.3) years postoperatively, the groups did not differ in FAAM-ADL (p=0.4311), FAAM-Sports (p=0.4258), or VAS pain (p=0.5050) scores.Conclusion:Postoperative noncompliance following surgical Achilles tendon repair occurs in nearly 1 out of every 12 patients, based on our cohort. Males, who make up the majority of Achilles tendon ruptures, have increased rates of non-accidental noncompliance. Patient noncompliance is an issue for orthopaedic surgeons of all subspecialties, and further investigations of incidence and risk factors should take place across a variety of commonly performed surgeries.

Biomechanical Effects of Δ9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD), the Major Constituents of Cannabis, on Tendon to Tendon Healing in a Sprague Dawley Rat Achilles Tendon Surgical Repair Model

Objectives:Use of Cannabis is common amongst athletes and the U.S. population at large. Use of Cannabinoid Oil is being increasingly utilized for a number of different pathologies, injuries, and ailments due to anecdotal evidence of its efficacy. Due to the current United States Opioid crisis, Δ9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD), the two major constituents of cannabis, are currently being evaluated as potential safer alternatives to narcotic pain medicines. The effects of recreational and/or therapeutic THC and CBD on musculoskeletal injury and healing however remain largely unknown. Our purpose was to evaluate the biomechanical effects of THC and CBD on tendon to tendon healing in a Sprague Dawley Achilles Tendon injury and surgical repair model.Methods:33 Sprague Dawley rats were randomly assigned into control (1 ml/kg/day of vehicle containing 5% Cremaphor, 5% ethanol, and 0.9% saline n=12), THC (3 mg/kg/day n = 12), or CBD (3 mg/kg/day n=9) treatment groups. Surgical transection and repair of the Achilles tendon was performed and all rats began subcutaneous administration of their respective drug treatment the day of surgery and for 4 subsequent days, followed by sacrifice. Load to failure and stiffness were calculated from load displacement data during tensile load testing on a MTS machine. One-way ANOVA with heterogeneous variance was utilized for evaluation. Means and 95% confidence intervals were also determined.Results:The CBD group demonstrated the highest mean load to failure of 17.5 N (15.1-19.8 N), with the THC group having the second highest mean load to failure at 17.3 N (15.3-19.2 N), and the control group reporting the lowest at 15.2 N (12.1-18.3 N). No statistical difference was observed between CBD/control (p = 0.25), THC/control (p = 0.29), or CBD/THC groups (p = 0.92, Figure 1A). The THC group reported the highest mean stiffness of 3.9 N/mm (2.7-5.1 N/mm). The CBD and control groups demonstrated mean stiffness values of 3.5 N/mm (2.9-4.1 N/mm) and 3.5 N (2.7-4.3 N/mm), respectively. No statistically significant differences were observed between THC/control (p = 0.51), THC/CBD (p = 0.50), or CBD/control groups (p = 0.96) for stiffness (Figure 1B).Conclusion:Our investigation demonstrates that subcutaneous administration of CBD resulted in the highest mean load to failure while THC administration resulted in the highest mean stiffness of the three groups. This did not result however in a statistically significant difference between groups. In our small animal tendon-to-tendon repair model, use of THC or CBD did not result in decreased biomechanical characteristics, and there was a trend toward improved ultimate strength and stiffness as compared to control. Further evaluation with larger numbers of animals, and evaluating the potential synergistic effects of THC and CBD administered together are warranted.Figure 1.

Vaporized vs Combusted Nicotine: A Biomechanical Comparison of Achilles Tendon Healing in a Rat Model

Category:Basic Sciences/BiologicsIntroduction/Purpose:The negative effects of smoking have been well documented following orthopedic injury. Though nicotine has been shown to be detrimental to musculoskeletal tissue healing, nicotine in the form of “Vaping” is being increasingly used as a perceived healthier alternative to actual smoking and may theoretically obviate many of the harmful volatiles and chemicals contained within combusted tobacco that are additionally harmful to musculoskeletal healing. Our objective was to evaluate the biomechanical and histological effects on Achilles tendon repair between rats that inhaled combusted tobacco, versus those with isolated nicotine exposure via vaping, versus a control group.Methods:54 Sprague Dawley rats were randomly placed in a control, vaping, or cigarette cohort. Each group contained 17 rats and exposure occurred six days per week. The smoking cohort was exposed to 2 unfiltered University of Kentucky research cigarettes in a previously validated smoking chamber (Figure 1). The vaping group was exposed to e-cigarette vapor with equivalent nicotine exposure over ten minutes at a flow rate of 2.4 L/min. The control group was placed in the smoking chamber with room air flowing through the chamber. All rats received their respective daily exposures for 4 weeks prior to surgery when surgical transection and repair of the Achilles tendon was performed. Following surgery, the rats continued 2 additional weeks of smoking, vaping, or control exposure. After sacrifice, Achilles tendons were harvested and tested with controlled tension to failure. Histology (n = 2 per group) was performed with a standard H&E protocol.Results:Tensile load testing evaluated maximum force to rupture and tissue stiffness amongst the three cohorts. The control group demonstrated highest mean tensile strength of 41.0 N (18.3-55.1 N), with the cigarette cohort having the second highest mean tensile strength at 37.3 N (14.0-54.7 N), and finally the vaping group had the lowest at 32.28 8 N (17.8-45.1 N). One-way ANOVA with heterogeneity of variance was used for evaluation. There was a significant difference detected in load to failure when comparing controls to e-cigarettes (p=0.026). No statistical difference was seen between controls vs cigarettes (p=0.35). Histological analysis demonstrated no difference among groups.Conclusion:Our investigation demonstrates that, in a rat model, isolated nicotine exposure via ”vaping” significantly impedes biomechanical healing properties of Achilles tendon surgical repair. Though smoking resulted in a lower maximum force to failure as compared to control in these samples, this difference was not significant. While E-cigarettes are often utilized as a perceived “safer” alternative to smoking combusted tobacco, this study suggests that use of e-cigarettes may be more detrimental to tendon healing than combusted tobacco in a rat Achilles model.

Comparison of Achilles Tendon Healing After Exposure to Combusted Tobacco, Vaping, and Control in a Rat Model

Objectives: The negative effects of smoking have been well documented following orthopedic injury. Though nicotine has been shown to be detrimental to musculoskeletal tissue healing, nicotine in the form of “Vaping” is being increasingly used as a perceived healthier alternative to actual smoking. It may theoretically obviate many of the harmful volatiles and chemicals contained within combusted tobacco that are additionally harmful to musculoskeletal healing, beyond just nicotine. The literature has yet to establish the benefits, or lack thereof, to exposure of e-cigarettes and their effect on tendon healing when compared to traditional combusted tobacco. Our objective was to evaluate the biomechanical and histological effects on Achilles tendon repair between inhaled combusted tobacco versus isolated nicotine exposure via vaping versus a control group in a small animal (Sprague Dawley Rat) model. Methods: 54 Sprague Dawley rats were randomly placed in a control, vaping, or cigarette cohort. Each group contained 17 rats for exposure and they were exposed six days per week. The smoking cohort was exposed to 2 unfiltered University of Kentucky research cigarettes in a smoking chamber (Image 1). The vaping group was exposed to e-cigarette vapor with equivalent nicotine exposure as compared to the cigarette group, over ten minutes at a flow rate of 2.4 L/min. The control group was placed in the smoking chamber with room air flowing through the chamber. All rats received their respective daily exposures for 4 weeks prior to surgery where transection and repair of the Achilles tendon was performed. Following surgery, the rats received 2 additional weeks of smoking vs vaping vs control exposure. After sacrifice, Achilles tendons were harvested and tested with tensile and a load to failure model (Image 2). Histological samples were sent for analysis. Results: Tensile load testing evaluated maximum force to rupture and tissue stiffness amongst the three cohorts. The control group demonstrated highest mean tensile strength of 41.0 N (18.3-55.1 N), with the cigarette cohort having the second highest mean tensile strength at 37.3 N (14.0-54.7 N), and finally the vaping group had the lowest at 32.28 N (17.8-45.1 N). One-way ANOVA with heterogeneous of variance was used for evaluation. There was a significant difference noted in load to failure when comparing controls to e-cigarettes (p=0.026). No statistical difference was seen between controls vs cigarettes (p=0.35). Histological analysis is in progress. Conclusion: Our investigation demonstrates that in a rat model, isolated nicotine exposure via ”vaping” significantly impedes biomechanical healing properties of Achilles tendon surgical repair. Though smoking resulted in a lower maximum force to failure as compared to control, this difference was not significant. While E-cigarettes are often utilized as a perceived “safer” alternative to smoking combusted tobacco, this study suggests that use of e-cigarettes may be more detrimental to tendon healing than combusted tobacco in a rat Achilles model.

Eccentric Training Effects on Functionality and Neuromechanical Properties After Achilles Tendon Surgical Repair

Eccentric Training Effects on Functionality and Neuromechanical Properties After Achilles Tendon Surgical Repair

Validity and Reliability of Mini-Invasive Surgery Assisted by Ultrasound in Achilles Tendon Rupture.

Introduction:The surgical treatment for Achilles tendon rupture has become very popular in the last years, because of the good outcomes and the low re-rupture rate. Aim:The aim of this study is to compare the results between open surgery and percutaneous ultrasound-assisted surgery.Methods:All patients who underwent an Achilles tendon surgical repair in the last 3 years were included, resulting in a total of 56 patients (40 M and 16 F) with an average age of 53 years. Of these patients, 36 were treated with an open suture, while 20 with a mini invasive ultrasound assisted suture. At a minimum follow-up of one year, patients were evaluated echografically, using both the Achilles Tendon Rupture Total score (ATRS) and the McComis score, and performing the ultrasounds bilaterally to assess both the structure and the diameter of tendons. Results:Both groups of patients showed an average ATRS score >80. The McComis score was 54.18 vs. 56.25 (p>0.05). Plantar flexion and dorsal flexion work were not similar (p>0.05). On average, the calf circumference of the operated side was decreased compared to the healthy side between the groups (p>0.05). The thickness of the operated tendons evaluated with ultrasound measurement compared to the average tendon, (p <0.05). Conclusion:The ultrasound-assisted tenorrhaphy is a reliable treatment with good clinical and functional outcomes; anyway, the percutaneous technique and the open surgery show similar results.

Knee Joint Kinematics and Kinetics During Walking and Running After Surgical Achilles Tendon Repair.

Background:Despite the increasing incidence of Achilles tendon (AT) ruptures, there is a lack of information on the possible risks associated with regular running and walking for exercise after an injury. There are some known kinematic gait changes after an AT rupture, especially at the knee. However, it is not clear whether runners with AT ruptures may be at risk for secondary knee injuries during shod or barefoot running/walking.Purpose/Hypothesis:The purpose of this study was to compare the kinematics and kinetics of barefoot walking and barefoot and shod running between athletes with a history of AT ruptures and a healthy control group. We hypothesized that there would be increased knee joint loads in the affected limb of the AT rupture group, especially during shod running.Study Design:Controlled laboratory study.Methods:Ten patients who had undergone surgical treatment of a unilateral acute AT rupture (6.1 ± 3.7 years postoperatively ) and 10 control participants were matched according to age, sex, physical activity, weight, height, and footfall type. The kinematics and kinetics of barefoot walking and barefoot and shod running were recorded using a high-speed motion capture system synchronized with force platforms.Results:The main outcome measures were lower extremity joint angles and moments during the stance phase of walking and running. After AT repair, athletes had increased internal knee abduction moments during shod and barefoot running compared with the healthy control group (P < .05, η2 > 0.14). There were no significant differences in kinematics and kinetics during walking between the AT rupture and healthy control groups (P ≥ .05).Conclusion:After an AT rupture, athletes had increased internal knee abduction moments during running compared with the healthy control group.Clinical Relevance:The increased abduction loads on the knee in patients with an AT rupture could lead to further running-related injuries. However, barefoot walking may be used as a proprioceptive exercise without an increased risk of overuse injuries in these patients.

Complications of Supine Surgical Achilles Tendon Repair.

Open Achilles tendon surgery with the patient in the supine position potentially avoids the complications of the prone position, but the safety and viability of the supine position for this procedure are not known. The aim of this study was to test the hypothesis that supine positioning for open repair of acute Achilles tendon ruptures would be safe, with low wound and neurologic complication rates. Supine position safety in acute Achilles tendon repair was investigated. Consecutive cases of supine Achilles tendon surgical repair performed by one surgeon from 2010 to 2015 were retrospectively reviewed. Patients were included if they were surgically treated with primary repair in the supine position within 15 days of injury and did not undergo concomitant surgery. A paramedian incision 1 cm medial to the Achilles sheath was used. Initial chart review identified 161 patients who underwent any type of Achilles tendon surgery in the supine position, of whom 45 patients met the inclusion criteria. This group included 39 men and 6 women with an average age of 41 years (range, 20-66 years). Median length of follow-up was 116 days (range, 25-1,589 days). Average body mass index was 29 kg/m2 (range, 23-36 kg/m2). There were no infections, sural nerve injuries, or reruptures. The supine position was safe for primary open Achilles tendon repair, with no wound or neurologic complications. Level IV, case series.

Rates of Acute and Delayed Achilles Repair

Category: Sports, Trauma Introduction/Purpose: The need for repair of the ruptured achilles tendon has been discussed extensively in recent literature. A landmark paper in 2010 (Willits JBJS) outlined that the re-rupture rates were similar in surgical and non surgically treated Achilles tendon ruptures. However concern has to be raised as to the strength of the muscle tendon complex if the tendon is too long, potentially increasing the rate of late repair. This paper analyses the rate of acute achilles tendon repair and delayed repair before and after the 2010 publication of the Willits paper. Methods: Using the published billings from the Province of British Columbia, the rates per year of surgical repair of achilles tendon and delayed repair were determined. The population of British Columbia has increased over the years from 3.9 million in 1997 to 4.7 million in 2016. The rates of acute and chronic surgery were plotted prior to 2010, and since 2010. The rates were fitted against time using a linear and binomial plot. The rates in the years before and after 2010 were compared with ANOVA and the change of rate in time compared with Pearson’s correlation. Results: The rate of acute repair increased from 271 repairs in 1997 to over 400 repairs per year in 2009. The rate of acute repair has since dropped to just over 300 repairs per year. This is reflected in the enclosed binomial plot. There was a significant increase until 2010 (p&lt;0.001), and a significant decrease since 2010 p&lt;0.05). An average of 374 repairs per year (95% CI 349 to 398) were performed before 2010, decreasing to 328 since (95% CI 294 to 360), p&lt;0.05. The rate of late repair has increased from 48 per year (CI 40 to 56) to 80 (CI 70 to 91) since 2010. The rate of late repair increased both prior to (r2 prior to 2010 .5, p&lt;0.01) and since 2010. Conclusion: The landmark 2010 paper has resulted in a reduction of acute repair. However the increase in late repair is concerning and indicates that the muscle tendon weakness observed in the 2010 paper on strength testing at 1 year review in the non surgical group may be causing an increased rate of late repair. Further evaluation and development of both surgical and non surgical technique is required if the need for late repair is going to be avoided that likely reflects poor patient outcomes.

Variability and Quality of Physical Therapy Protocols after Surgical Repair for Achilles Tendon Rupture Available Online for Patient and Therapist Education

Category: Sports, Trauma Introduction/Purpose: The Internet has gained popularity in patient education and communication with physical therapists. Orthopaedic practices post information on physical therapy exercises and post-surgical caution online. This includes the case for rehabilitation after Achilles tendon repair. Therefore, it is important to assess the consistency within the online available protocols and determine if they retain current evidence-based principles. The purpose of the current study was to evaluate the consistency and quality of online physical therapy protocols after Achilles tendon surgical repair available to patients and physical therapists. Methods: Protocols were searched on Google by using the term “(achilles AND repair) AND (rehabilitation OR physical therapy) AND (protocol OR guidelines)” on three different computers. Methodical protocols on rehabilitation after Achilles tendon rupture repair from the first 100 websites with each search were collected. Duplicated protocols and non-operative treatment protocols were excluded. A comprehensive, custom scoring system was created to assess the source and each rehabilitation components of the protocols, including ankle immobilization, weight bearing status, range of motion, strengthening exercises, proprioceptive activities, functional return, as well as the time line for each component. Results: Fifty-three protocols were included in the current study (35.8% academic). Orthopaedic surgeon-affiliated websites accounted for 86.8% (Fig. 1). Thirty-six studies (67.9%) advised non-weight-bearing immediately after surgery. The timeline of weight bearing advancement varies among protocols and is illustrated in Fig.2. Forty-four protocols (83.0%) mentioned utilization of heel lifts throughout the protocol with different recommendations on specific timing (Fig.3). Non-ankle specific exercises were recommended in forty-three (81.1%) protocols. Considerable variation existed in the types and time line of recommended exercises, including the ones for range of motion, strength, proprioception, overall function, and functional return (Figs 4-8). Conclusion: Considerable variation existed in many components of physical therapy protocols for Achilles tendon repair after rupture, which subsequently could lead to confusion and misinterpretation among patients, and even therapist. Greater effort should be paid to create more evidence-based protocols that are both easy for patients and physical therapists to understand and execute.

Presence of Bacteria in Spontaneous Achilles Tendon Ruptures

Background: The structural pathology of Achilles tendon (AT) ruptures resembles tendinopathy, but the causes remain unknown. Recently, a number of diseases were found to be attributed to bacterial infections, resulting in low-grade inflammation and progressive matrix disturbance. The authors speculate that spontaneous AT ruptures may also be influenced by the presence of bacteria. Hypothesis: Bacteria are present in ruptured ATs but not in healthy tendons. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients with spontaneous AT ruptures and patients undergoing anterior cruciate ligament (ACL) reconstruction were recruited for this study. During AT surgical repair, excised tendinopathic tissue was collected, and healthy tendon samples were obtained as controls from hamstring tendon grafts used in ACL reconstruction. Half of every sample was reserved for DNA extraction and the other half for histology. Polymerase chain reaction (PCR) was conducted using 16S rRNA gene universal primers, and the PCR products were sequenced for the identification of bacterial species. A histological examination was performed to compare tendinopathic changes in the case and control samples. Results: Five of 20 AT rupture samples were positive for the presence of bacterial DNA, while none of the 23 hamstring tendon samples were positive. Sterile operating and experimental conditions and tests on samples, controlling for harvesting and processing procedures, ruled out the chance of postoperative bacterial contamination. The species identified predominantly belonged to the Staphylococcus genus. AT rupture samples exhibited histopathological features characteristic of tendinopathy, and most healthy hamstring tendon samples displayed normal tendon features. There were no apparent differences in histopathology between the bacterial DNA–positive and bacterial DNA–negative AT rupture samples. Conclusion: The authors have demonstrated the presence of bacterial DNA in ruptured AT samples. It may suggest the potential involvement of bacteria in spontaneous AT ruptures.

Early functional rehabilitation versus traditional immobilization for surgical Achilles tendon repair after acute rupture: a systematic review of overlapping meta-analyses

Several meta-analyses comparing early functional rehabilitation and traditional immobilization following surgical Achilles tendon repair after acute rupture have been published. However, they have led to conflicting conclusions. The aims of this systematic review were to select high-quality meta-analyses from multiple discordant meta-analyses and to provide a postoperative rehabilitation strategy following surgical repair using currently available evidence. We performed a comprehensive search using the PubMed and Embase databases and the Cochrane Library. Assessment of Multiple Systematic Reviews (AMSTAR) instrument was used to assess the methodological quality. Three investigators independently applied the Jadad decision algorithm. Their results were then compared to ensure selection of a meta-analysis that provided the highest quality of evidence. Six meta-analyses met the eligibility criteria. AMSTAR scores ranged from 6 to 10. According to the Jadad decision algorithm, a high-quality meta-analysis with a greater number of RCTs was selected. This meta-analysis showed that early functional rehabilitation was superior to cast immobilization in terms of patient satisfaction and the time to return to pre-morbid sporting levels. There were no differences regarding major complications or the time before return to prior employment and sporting activity. Thus, we recommend early functional rehabilitation as the postoperative strategy for acute Achilles tendon ruptures.

Twelve-month outcomes following surgical repair of the Achilles tendon

Abstract Introduction Incidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient’s health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon. Methods Two hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers. Results At 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D-3L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period. Conclusions Overall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management.

Twelve-month outcomes following surgical repair of the Achilles tendon

IntroductionIncidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient’s health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon. MethodsTwo hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers. ResultsAt 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D-3L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period. ConclusionsOverall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management.