Management Of Achilles Tendon Ruptures Research Articles

A Comparative Analysis of Outcomes using PROMIS after Operative vs Non-operative Treatment of Achilles Rupture

Introduction/Purpose: Achilles tendon rupture is a common injury in the adult population. The role of operative and non- operative management remains controversial with the development of functional rehabilitation programs. The purpose of this study is to evaluate and compare the patient-reported outcomes using Patient-Reported Outcomes Measurement Information System (PROMIS) after operative and non-operative treatment of acute Achilles rupture. PROMIS is a valid, reliable, and effective tool to evaluate patient outcomes after treatment for Achilles ruptures. Our hypothesis is that there is no significant difference in PROMIS scores between patients undergoing operative compared to non-operative treatment of Achilles rupture. Methods: Under an IRB-approved protocol, Achilles rupture was identified using ICD 9 and ICD10 codes of 727.67 and S86.0. Patients who underwent Achilles tendon primary repair were identified using CPT code 27650 (Repair, primary open or percutaneous, ruptured Achilles tendon). Revision Achilles repair and chronic Achilles ruptures were excluded. All patients treated non-operative underwent a strict functional rehabilitation protocol. We included patients treated between 1/1/2015 and 11/30/2022. PROMIS physical function (PF), pain interference (PI), and depression scores were routinely collected prospectively during the initial office visit and follow-up appointments. A distribution-based method used to determine the minimal clinically important difference (MCID), which was 1/2 standard deviation of each PROMIS domain. A medical records review was performed to collect patient demographic data. Statistical analysis was used to compare preoperative and postoperative scores and significance was indicated when P< 0.05. Results: 216 patients with Achilles tendon ruptured were included (115 Nonoperative versus 101 Operative). Patients treated non-operatively were older than those treated surgically (mean age: 45.1 vs 35.6; p< 0.001). The operative group had a lower BMI compared to non-operative group (27.8 vs. 29.5; p=0.004). There is no statistical difference in the Achilles tendon re-rupture rate between both groups (operative: 2% vs. 4.3%; p=0.344). Both groups are effective in improving PROMIS PF, PI, and depression scores (p < 0.001). The mean PROMIS PF change (pre- to post-treatment) is significantly greater in the operative, compared to the non-operative group (13.2 vs. 9.5; p=0.042). Both treatments had similar mean PROMIS PI change, mean PROMIS depression change, and rates of meeting MCID for all 3 PROMIS domains at 6 months. Conclusion: In patients with Achilles tendon rupture, operative management may lead to statistically significant higher improvements in physical function compared to non-operative management. However, non-operative management was associated with similar overall rates of re-rupture, PROMIS PI and depression outcomes, and chances of meeting MCID as those who underwent operative intervention. Nonoperative management of Achilles tendon rupture, similar to operative treatment, is a successful treatment option and leads to significant improvement in physical function, pain interference, and depression PROMIS scores.

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

There is growing interest in nonoperative treatment for the management of Achilles tendon ruptures (ATRs). However, nonoperative treatment is limited by the risk of tendon reruptures and low satisfaction rates. Recently, atelocollagen injections have been reported to have beneficial effects on tendon healing. To evaluate the beneficial effects of injected atelocollagen on Achilles tendon healing and investigate the mechanism of atelocollagen on tendon healing. Controlled laboratory study. Percutaneous tenotomy of the right Achilles tendon in 66 rats was performed. The animals were equally divided into the noninjection group (NG) and the collagen injection group (CG). At 1, 3, and 6 weeks, the Achilles functional index, cross-sectional area, load to failure, stiffness, stress, and the modified Bonar score were assessed. Transmission electron microscopy, western blotting, and immunohistochemistry were also performed. The Achilles functional index (-6.8 vs -43.0, respectively; P = .040), load to failure (42.1 vs 27.0 N, respectively; P = .049), and stiffness (18.8 vs 10.3 N/mm, respectively; P = .049) were higher in the CG than those in the NG at 3 weeks. There were no significant differences in histological scores between the 2 groups. Transmission electron microscopy analysis showed that the mean diameter of collagen fibrils in the CG was greater than that in the NG at 3 weeks (117.2 vs 72.6 nm, respectively; P < .001) and 6 weeks (202.1 vs 144.0 nm, respectively; P < .001). Western blot analysis showed that the expression of collagen type I in the CG was higher than that in the NG at 1 week (P = .005) and 6 weeks (P = .001). An atelocollagen injection had beneficial effects on the healing of nonoperatively treated Achilles tendon injuries. The Achilles tendon of CG rats exhibited better functional, biomechanical, and morphological outcomes compared with NG rats. The molecular data indicated that the mechanism of atelocollagen injections may be associated with an increased amount of collagen type I. An atelocollagen injection might be a good adjuvant option for the nonoperative treatment of ATRs.

Does Suture Type or Configuration Matter in Percutaneous Achilles Tendon Repairs?

Category: Trauma; Sports Introduction/Purpose: The human Achilles tendon is functionally important for dynamic activities and is a common site of injury, resulting in pain, weakness, and removal from sport. While treatment options vary and the opinions regarding optimal management are not uniform, percutaneous repair through commercially available guides is one option that has been used in the United States. The purpose of this study was to test the mechanical properties of four suture permutations. Methods: This biomechanical study included Porcine toe flexor tendons as an analogue for the human Achilles tendon. Simulated rupture was performed and tendons repaired using a percutaneous guide. Technique was uniform with pre-determined allotment into one of four groups based on suture configuration (single or double locked) and type (round or flat) with a total of 10 specimens in each group. Specimen then underwent static creep test, a dynamic load creep test, and finally load to failure test. An analysis of variance test was performed, followed by pairwise comparisons using independent t-tests to assess inter-group differences if significant effects were found, adjusted for multiple comparisons. Results: No significant differences were seen between conditions for the creep tests. The suture configuration used was determined to have a significant effect on the maximum load to failure of the constructs (p = 0.018) and maximum stress in the construct during the load to failure test (p = 0.019). Double Tape had a significantly greater load to failure than the Single Round (66N (0.021, [25, 107]) and Single Tape (72N (0.037, [18, 126]) conditions, and reached greater stresses before failure (0.1N/mm^2 (0.04, [0.03, 0.17] and 0.1N/mm^2 (0.04, [0.02, 0.18], respectively). No significant differences were found between the double tape and double round techniques, nor the Double Round and either of the Single techniques for any of the load to failure variables. Conclusion: Currently, there is no compelling data to support surgical over non-surgical management of Achilles tendon ruptures. However, by patient or surgeon preference, many patients undergo operative intervention, and percutaneous repair through a guide is a popular modality. The results of this study, using a porcine model to simulate a minimally invasive technique for Achilles tendon repairs, suggest that the use of a double locked tape suture configuration leads to a stronger overall construct. The clinical implications of these findings will be the subject of future work.

Return to sport after surgical repair of the Achilles tendon.

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

Functional Outcome in Percutaneous Achilles Tendon Repair.

Rupture of the Achilles tendon is a considerable cause of morbidity with reduced function following injury. Randomized studies have so far failed to show a difference in outcome between operative and nonoperative management of Achilles tendon rupture, provided that no re-rupture occurs. Percutaneous Achilles repair has been suggested to result in superior patient satisfaction compared with open repair in patients with an acute Achilles tendon rupture. To assess and evaluate the functional outcome after percutaneous repair in patients of the acute and closed Achilles tendon ruptures. It was a prospective study conducted on patients diagnosed as having rupture of the Achilles tendon. A total of 25 patients with mean age of 44.4 (range 19-65) years were taken, who underwent percutaneous Achilles tendon repair. The number of patients who reported excellent or good scores (ATRS > 80) at 3, 6 and 12months were 0%, 16% and 100%, respectively. The mean AOFAS hind foot score at 3-, 6- and 12-month follow-ups was 77.9 ± 4.3, 92.04 ± 2.4 and 96.16.32 ± 1.1, respectively. The number of patients who reported excellent or good scores (AOFAS > 74) at 3, 6 and 12months were 76%, 100% and 100%, respectively. Most of the patients in our study showed no complications, and only 2 (8%) of patients had the features of sural nerve injury which was resolved in the subsequent follow-ups. Percutaneous repair of the Achilles tendon is an effective procedure which gives excellent functional outcome with very few complications. The percutaneous technique gives an additional advantage of less operative time, no wound complications, less damage to the soft tissues, and improved cosmesis as compared to the open repair.

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Rupture: A Propensity Score-Matched Analysis of a Large National Dataset.

No consensus exists regarding the superiority of operative versus nonoperative management for Achilles tendon ruptures, as multiple randomized controlled trials conducted since the advent of early mobilization protocols have found outcomes for these 2 interventions to be more similar than were previously held. To use a large national database to (1) compare reoperation and complication rates between operative and nonoperative treatment of acute Achilles tendon ruptures and (2) evaluate trends in treatment and cost over time. Cohort study; Level of evidence, 3. The MarketScan Commercial Claims and Encounters database was used to identify an unmatched cohort of 31,515 patients who sustained primary Achilles tendon ruptures between 2007 and 2015. Patients were stratified into operative and nonoperative treatment groups, and a propensity score-a matching algorithm-was used to establish a matched cohort of 17,996 patients (n = 8993 per treatment group). Reoperation rates, complications, and aggregate treatment costs were compared between groups with an alpha level of .05. A number needed to harm (NNH) was calculated from the absolute risk difference in complications between cohorts. The operative cohort experienced a significantly larger total number of complications within 30 days of injury (1026 vs 917; P = .0088). The absolute increase in cumulative risk was 1.2% with operative treatment, which resulted in an NNH of 83. Neither 1-year (1.1% [operative] vs 1.3% [nonoperative]; P = .1201) nor 2-year reoperation rates (1.9% [operative] vs 2% [nonoperative]; P = .2810) were significantly different. Operative care was more expensive than nonoperative care at 9 months and 2 years after injury; however, there was no difference in cost between treatments at 5 years. Before matching, the rate of surgical repair for Achilles tendon rupture remained stable, from 69.7% to 71.7% between 2007 and 2015, indicating little change in practice in the United States. Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. Operative management was associated with an increased risk of complications and higher initial costs, which dissipated over time. Between 2007 and 2015 the proportion of Achilles tendon ruptures managed operatively remained similar despite increasing evidence that nonoperative management of Achilles tendon rupture may provide equivalent outcomes.

Operative vs Nonoperative Management of Achilles Tendon Rupture: A Cost Analysis.

Achilles tendon rupture (ATR) is a common injury with a growing incidence rate. Treatment is either operative or nonoperative. However, evidence is lacking on the cost comparison between these modalities. The objective of this study is to investigate the cost differences between operative and nonoperative treatment of ATR using a large national database. Patients who received treatment for an ATR were abstracted from the large national commercial insurance claims database, Marketscan Commercial Claims and Encounters Database (n = 100 825) and divided into nonoperative (n = 75 731) and operative (n = 25 094) cohorts. Demographics, location, and health care charges were compared using multivariable regression analysis. Subanalysis of costs for medical services including clinic visits, imaging studies, opioid usage, and physical therapy were conducted. Patients who underwent secondary repair were excluded. Operative treatment was associated with increased net and total payments, coinsurance, copayment, deductible, coordination of benefits (COB) / savings, greater number of clinic visits, radiographs, magnetic resonance imaging (MRI) scans, and physical therapy (PT) sessions, and with higher net costs due to clinic visits, radiographs, MRIs, and PT (P < .001). Operative repair at an ambulatory surgical center was associated with a lower net and total payment, and a significantly higher deductible compared to in-hospital settings (P < .001). Both cohorts received similar numbers of opioid prescriptions during the study period. Yet, operative patients had a significantly shorter duration of opioid use. After controlling for confounders, operative repair was also independently associated with lower net costs due to opioid prescriptions. Compared with nonoperatively managed ATR, surgical repair is associated with greater costs partially because of greater utilization of clinic visits, imaging, and physical therapy sessions. However, surgical costs may be reduced when procedures are performed in ambulatory surgery centers vs hospital facilities. Nonoperative treatment is associated with higher prescription costs secondary to longer duration of opioid use. Level III, retrospective cohort study.

The Statistical Fragility of Operative vs Nonoperative Management for Achilles Tendon Rupture: A Systematic Review of Comparative Studies.

Background:The statistical significance of randomized controlled trials (RCTs) and comparative studies is often conveyed utilizing the P value. However, P values are an imperfect measure and may be vulnerable to a small number of outcome reversals to alter statistical significance. The interpretation of the statistical strength of these studies may be aided by the inclusion of a Fragility Index (FI) and Fragility Quotient (FQ). This study examines the statistical stability of studies comparing operative vs nonoperative management for Achilles tendon rupture.Methods:A systematic search was performed of 10 orthopaedic journals between 2000 and 2021 for comparative studies focusing on management of Achilles tendon rupture reporting dichotomous outcome measures. FI for each outcome was determined by the number of event reversals necessary to alter significance (P < .05). FQ was calculated by dividing the FI by the respective sample size. Additional subgroup analyses were performed.Results:Of 8020 studies screened, 1062 met initial search criteria with 17 comparative studies ultimately included for analysis, 10 of which were RCTs. A total of 40 outcomes were examined. Overall, the median FI was 2.5 (interquartile range [IQR] 2-4), the mean FI was 2.90 (±1.58), the median FQ was 0.032 (IQR 0.012-0.069), and the mean FQ was 0.049 (±0.062). The FI was less than the number of patients lost to follow-up for 78% of outcomes.Conclusion:Studies examining the efficacy of operative vs nonoperative management of Achilles tendon rupture may not be as statistically stable as previously thought. The average number of outcome reversals needed to alter the significance of a given study was 2.90. Future analyses may benefit from the inclusion of a fragility index and a fragility quotient in their statistical analyses.

Revision Achilles Tendon Repair Using Posterior Tibial Tendon Allograft and Flexor Hallucis Longus Transfer

Achilles tendon ruptures are common injuries seen by orthopaedic surgeons. A myriad of surgical options have been used in the management of Achilles tendon ruptures, but currently no gold standard exists. Re-rupture of Achilles tendon injuries occurs 1.7% to 5.6% of the time, and there has been no direct relationship demonstrated between complications and repair techniques used. The aim of this technique is to provide a method of fixation for the patient with an Achilles tendon re-rupture that provides a stable repair construct and mitigates the potential sequela of re-rupture. We describe the treatment of an Achilles tendon re-rupture with the use of a flexor hallucis longus tendon transfer and posterior tibial tendon allograft for repair of an 8.5 cm tendon gap.

Biomechanical comparisons of three minimally invasive Achilles tendon percutaneous repair suture techniques

BackgroundWhile no gold standard exists for the management of Achilles tendon ruptures, surgical repair is common in healthy and active patients. Minimally invasive repair methods have become increasingly popular, while biomechanical equivalency hasn't been proven yet. MethodsA mid-substance Achilles tendon rupture was created 6 cm proximal to the calcaneal insertion in 27 fresh-frozen cadaveric ankles. Specimens were randomly allocated to 1 of 3 repair techniques: Huttunen et al. (2014) (1) PARS Achilles Jig System, Nyyssönen et al. (2008) (2) Achilles Midsubstance SpeedBridge™, Schipper and Cohen (2017) (3) Dresdner Instrument and subsequently subjected to cyclic loading with 250 cycles each at 1 Hz with 4 different loading ranges (20–100 N, 20–200 N, 20–300 N, and 20–400 N). FindingsAfter 250 cycles no significant differences in elongation were observed between PARS and Dresdner Instrument(p = 1.0). Furthermore, SpeedBridge™ repairs elongated less than either Dresdner Instrument (p = 0.0006) or PARS (p = 0.102). Main elongation (85%) occurred within the first 10 cycles with a comparable elongation in between 10 and 100 and 100–250 cycles. While all repairs withstood the first 250 cycles of cyclic loading from 20 to 100 N, only the PARS (468 ± 175) and Midsubstance SpeedBridge™ (538 ± 208) survived more cycles. Within all 3 groups suture cut out was seen to be the most common failure mechanism. InterpretationWithin all groups early repair elongation was seen. While this was least obvious within the SpeedBridge™ technique, ultimate strengths of repairs (cycles to failure) were comparable across PARS and SpeedBridge™ with a decline in the Dresdner Instrument group.

Outcomes and Complications of Open vs Minimally Invasive Surgical Repair of Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Category:Ankle; Sports; TraumaIntroduction/Purpose:Traditionally, open surgical repair has provided improved functional outcomes, reduced re-rupture rates, and quicker recovery and return to activities at the expense of increased wound complications of infection and skin necrosis compared to nonoperative management. Ma and Griffith in 1977 introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes to the open repair. The current study aims to provide updated level I evidence comparing the open and minimally invasive (MIS) through a comprehensive search of literature published in English, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included studies.Methods:Following the PRISMA guidelines, two independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open and MIS Achilles tendon repairs. The primary outcomes were (1) Sural nerve injury, (2) Skin complications, (3) Infection (deep/superficial), whereas the secondary outcomes were (1) AOFAS/ATRS score, (2) surgical time, (3) re-rupture (4) adhesions (5) ankle range of motion. Population: Achilles tendon rupture Intervention: MIS repair Control: Open repair Outcomes: Primary: (1) Sural nerve injury, (2) Skin complications, (3) Infection (deep/superficial) Secondary: (1) AOFAS/ATRS score, (2) surgical time, (3) re-rupture, (4) adhesions, (5) ankle range of motion (6) other complications.Results:Ten RCTs qualified for the meta-analysis with a total of 522 patients. 260(49.8%) patients had open repair while 262(50.2%) had MIS repair. The mean total complication rate was 15.5% (0-36.4%) in open repair vs. 10.4% (0-45.5%) in MIS repair, with non-significant statistical difference (RR= 1.50,CI=0.87-2.57,p= 0.14;I2=40%). The mean re-rupture rate was 2.5% (0-6.8%) in open repair vs. 1.53% (0-4.6%) with MIS repair, with non-significant statistical difference (RR=1.56,CI=0.42-5.70,p= 0.50;I2=0%).No cases of sural nerve injury were reported in the open repair group. The mean sural nerve injury was 3.4%(0-7.3%) in the MIS group, that was statistically significant (RR= 0.16,CI=0.03-0.46,p=0.02;I2=0%). The mean deep infection rate in the open group was 1.4% (0-5%) while no deep infection was reported in MIS, with no statistically significant difference (RR= 3.24,CI=0.48-20.54,p= 0.23;I2=0%). The mean superficial infection rate was 6.04% (0-18.2%) and 0.40% (0-4.5%) for open and MIS repairs, respectively, with statistically significant difference (RR= 5.70,CI=1.80-18.02,p< 0.001;I2=0%).Conclusion:Open Achilles tendon repair is associated with longer surgical time, higher risk of superficial infection, and ankle stiffness, while MIS repair is associated with a greater risk of temporary sural nerve palsy. Re-rupture rate and functional outcomes are mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for the management of Achilles tendon rupture.

A Technique Update For A Minimally Invasive Operative Approach To Achilles Tendon Repair

The management of Achilles tendon rupture has remained a contentious topic. Non-operative management has gained popularity due to the problems associated with traditional open repair. This paper outlines a minimally invasive approach, that intends to minimise the rate of re-rupture, and is not associated with the more inconvenient complications of open repair.

Achilles Tendon Rupture Treatment: Operative Versus Nonoperative

Acute Achilles tendon ruptures are common injuries with increasing incidence. Management of acute ruptures is controversial. Early evidence suggested that nonoperative treatment led to a significantly higher rerupture rate; however, operative modalities have also been shown to have a higher risk of wound complications. Advances in therapeutic protocols have normalized the rerupture rate between operative and nonoperative modalities, and many have recommended nonoperative treatment becuase of the mitigated complication profile. The purpose of this review is to report contemporary management of Achilles tendon ruptures and provide our preferred technique of management. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The reliability, reproducibility and utilization of the radiographic Achilles Tendon Loading Angle in the management of Achilles Tendon rupture

BackgroundDuring management of Achilles tendon rupture, determination of tendon-end approximation, either clinically or by ultrasound is difficult, following brace application of during loading.The Radiographic Achilles Tendon Loading Angle (RadATLA) is proposed as a method of measuring ankle position whilst loading in a brace during the management of Achilles tendon rupture. This study aims to determine the reliability and reproducibility of the RadATLA. MethodsA loaded true lateral ankle radiograph including the fifth metatarsal head was taken when wearing a brace at the 6-week time point in 18 patients (19 ankles). following Achilles tendon repair or reconstruction. The RadATLA was compared with the Tibio-talar angle, other radiographic and clinical measures used to quantify foot and ankle position during the first 6 weeks of early rehabilitation in a resting position and during loading. ResultsThe intra-rater reliability of both angles was found to be good (>0.8). The RadATLA was found to have an excellent intra-rater reliability with Intra-class correlation of (ICC) 0.992−0.996 (95%CI 0.889−0.999), standard error of the measurement (SEM) 1.03–3.65 and Minimal Detectable Change (MDC) 2.86−10.12. The inter-rater reliability was good with ICC of 0.798−0.969 (95%CI−0.03 to 0.964), SEM 2.9–7.6, and MDC 8.1–20.9.The RadATLA loaded at 6 weeks in all patients was at mean (SD) (range) 41.9˚ (16.5), (18.5−75.9). There was a significant difference between the patients in the Repair group compared with patients in the Reconstruction group both in RadATLA loaded at 6 weeks: 35.6˚ (11.2), (18.5−56.5) versus 55.5˚ (19), (20−75.9), (p = 0.01). The amount loaded in all patients was at mean (SD) (range) 29.2Kg (17.7), (2−56) and the percentage Body Weight was 30.7% (19), (2.1−63.2). There were no differences between the groups neither in amount loaded nor in percentage Body weight (p = 0.614−0.651). ConclusionsThe RadATLA is a reliable and reproducible angle and can be used to determine the position of the ankle, when loaded in a brace during rehabilitation following Achilles tendon rupture.

Predictors of Functional Outcomes following Operative Treatment of Acute Achilles Tendon Ruptures

Category:Trauma; Ankle; HindfootIntroduction/Purpose:Previous studies involving operative and nonoperative management of Achilles tendon ruptures have attempted to determine if patient factors influence treatment outcomes, with female sex, older age, and greater body mass index associated with inferior results. However, to our knowledge, no previous study has attempted to identify predictors of functional outcomes in patients exclusively undergoing surgical repair of acute Achilles tendon ruptures. The purpose of this study is to determine if any injury or patient variables were predictive of functional outcomes following operative 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 2010-2016 was performed. Patients <18 years of age, those who underwent surgical repair >21 days from the date of injury, and those whose repair required a V-Y advancement were excluded. Patient demographics (age, sex, BMI), comorbidities (diabetes mellitus, depression, anxiety), mechanism of injury (sports versus non-sports), and date of injury were collected. Postoperative chart notes were reviewed to document patient noncompliance. Included patients >=2 years removed from surgery were contacted to complete the Foot & Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and -Sports subscales, and visual analog scale (VAS) for pain. Multivariable regression analysis was performed to determine significant independent predictors of functional outcomes. Regression coefficients with 95% confidence intervals [95% CI] and p-values were reported for significant findings.Results:Of the 195 Achilles tendon repairs meeting the inclusion criteria, 140 (71.8%) were contacted to complete 2-year follow-up and analyzed. No patients (0%) experienced tendon re-ruptures. On multivariable analysis, female sex was independently associated with lower FAAM-Sports score (-10.11 [-19.73, -0.50]) and a lower Single Assessment Numeric Evaluation (SANE) score from the FAAM-Sports subscale (-13.79 [-26.28, -1.30]; p=0.0325). A history of anxiety was related to a lower FAAM-ADL score (-29.02 [-45.68, -12.36]; p=0.0009), FAAM-Sports score (-33.41 [-64.46, -2.37]; p=0.0368), and a higher VAS pain score (19.83 [4.43, 35.23]; p=0.0128). Age, BMI, a history of depression or diabetes mellitus, mechanism of injury, timing of repair, and patient compliance were not independently predictive of functional outcomes.Conclusion:Females and patients with anxiety have significantly poorer functional outcomes following acute Achilles tendon repair. To our knowledge, this is the first study to investigate and identify variables predictive of patient functionality in a population of surgically managed acute Achilles tendon ruptures. Further study is indicated to determine whether these factors are also predictive of outcomes of Achilles tendon ruptures treated non-surgically, and how this may affect surgical indications in this patient population.

Post-Operative Rehabilitation in Ankle and Hindfoot/Midfoot Fusion and Reconstruction Surgery: A Scoping Survey of UK Foot and Ankle Surgeons and Allied Health Professionals

Category:Ankle; Hindfoot; Midfoot/Forefoot; SportsIntroduction/Purpose:Ankle, hind and midfoot fusion/ reconstructive surgery is performed to treat a range of foot and ankle conditions. A prolonged period of immobilisation in plaster is usually advised following this type of surgery. More recently, there has been a paradigm shift in the management of Achilles tendon rupture/ ankle fracture rehabilitation with emphasis on early mobilisation. However there is little in the literature or guidelines on the post-operative rehabilitation for foot/ ankle reconstructive surgery, in particular, with regards to the period of immobilisation. The aim of this work was to scope the current practice of UK (United Kingdom) foot and ankle surgeons, and allied health professionals (AHPs) managing this patient group.Methods:An online survey (10 questions) was designed (using survey monkey) following a qualitative synthesis of published literature and sent to surgeons via BOFAS (British Orthopaedic Foot & Ankle Society) and AHPs via AFAP (Association of Foot & Ankle Physiotherapist & AHPs). Participants had 1 month to respond and reminder emails were sent out periodically by BOFAS/ AFAP. Results were collated via the online system and data were extracted in the form of tables and graphs. Raw data was also available to transfer to Excel for analysis. Free text responses were analysed using thematic analysis [10]. Data was coded manually to produce qualitative themes by 2 authors.Results:117 surgeons and 55 AHPs responded and there was good agreement between the 2 groups. Almost 50% reported that they followed a local post-operative rehabilitation protocol. There was a wide variation in the time point when patients were instructed to weight-bear (2 weeks to >12-weeks). 57% reported that not all patients were routinely referred for post-operative rehabilitation. Non-union was a concern of early mobilisation as highlighted by 60% of the surgeons surveyed yet more than half (59%) believed that starting some weight-bearing at 2-weeks would reduce the risk of venous thromboembolism. Qualitative themes identified: treatment tailored to individual patients, lack of knowledge about the patient journey, treatment tailored to surgeon preferences, lack of a pathway, variation in practice (quotes in table 1).Conclusion:There is wide variation in the post-op rehabilitation of patients undergoing hind mid-foot surgery in the UK, with a lack of published research/ guidance in this area. Early rehabilitation could improve patient outcomes, yet the risk of non-union is a major concern. In recent years, there has been a paradigm shift in the management of Achilles tendon rupture and ankle fracture with an emphasis on early mobilisation, This is a treatment model we propose to replicate in hind/ mid-foot fusion populations.Further research in the form of a multicentre trial is warranted to inform international guidance in this area.

Return to Play after Open Repair for Achilles Rupture in Recreational Athletes

Category:SportsIntroduction/Purpose:The management of Achilles tendon ruptures in recreational athletes can be challenging. This study assessed the average time to return to sport after open repair for Achilles rupture in recreational athletes.Methods:Twenty one recreational athletes with prodromal tendinous problems sustained an acute tear of the AT and surgical repair with Krachow method from June 2013 to April 2017. Their average age was 39.7 years, and the average follow-up time was53.2 months. Each patient was evaluated for postoperative ATRS (Achilles Tendon Total Rupture Score), complication and time to return to sports.Results:The mean postoperative ATRS was 85.1. The mean length of time to return to sports was 8 months. Eighteen patients of 21 athletes returned to full sport participation. Eleven athletes returned to the original sports. Seven athletes changed their sports due to fear of re-rupture (four athletes), discomfort during running or jumping (one athlete), general weakness (one athlete), dissuade of family (one athlete). Three athletes didn’t return to sport participation due to thickening of Achilles tendon (two athletes) and personal reason (one athlete).Conclusion:The return to play was 85 % at 8 months postoperatively. The results provide reference data for sports physician in evaluation surgical results and informing athletes about expectations after surgery in terms of timing of return to sports in recreational athletes.

Achilles Injury and Access to Care in South Florida.

Introduction. Despite the amount of orthopaedic research evaluating access to care based on insurance status, no study quantifies the effects of insurance status on the care of acute Achilles tendon ruptures. Methods. Using Current Procedural Terminology codes, we identified all patients who underwent surgical management of Achilles tendon rupture between December 31, 2013, and December 31, 2018, and followed-up at either a county hospital-based orthopaedic surgery clinic and/or private university-based clinic. Inclusion criteria included patients who (1) underwent surgical management of an Achilles tendon rupture during this time period and (2) were at least 18 years of age at the time of surgery. A univariate 2-tailed t test was used to compare various groups. Statistical significance was set at P < 0.05. Results. When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of injury to first clinic visit (14.5 days vs 5.2 days, P < .001), first clinic visit to surgery (34.6 days vs 4.8 days, P < .002), injury to surgery date (48.9 days vs 9.8 days, P < .001), initial presentation to when magnetic resonance imaging was obtained (48.1 days vs 1.9 days, P < .002). Conclusions. Disparities in access to care for Achilles tendon ruptures are intimately related to insurance status. Uninsured and Medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance.Levels of Evidence: Level III: Prognostic, retrospective.

Results of Surgical Management of Achilles Tendon Rupture Using the Modified Lindholm Procedure.

ObjectivesAchilles tendon rupture (ATR) in adults often results from sporting activities, especially in young adults. There is no consensus in the literature on the best treatment approach in the treatment of these ruptures. The objective of this study was to evaluate the clinical long-term results of the augmented ATR repair using the modified Lindholm procedure (MLP).MethodsPatients who underwent MLP due to ATR in the orthopedics and traumatology clinic of our hospital between 2007 and 2014 were retrospectively evaluated. Medical history of the patients was noted, and preoperative physical examination was routinely performed using the Thompson compression test. Patients’ demographic data such as age and gender, tendon rupture side, postoperative follow-up duration, and gap range values were recorded and evaluated.ResultsThe mean age of the patients was 29.43 ± 7.10 years. The mean postoperative follow-up duration was 50.1 ± 8.20 months. Of the patients, 16 were injured during football, 10 during basketball, 2 during volleyball, and the remaining 8 during other sporting activities. When Arner-Lindholm scores were evaluated during follow-up, excellent outcome was achieved in 30 patients and good outcome was achieved in 6 patients, whereas there was no patient with poor outcome. None of the patients developed tendon re-rupture. At the end of the fourth postoperative month, the range of ankle motion was 100% in all patients.ConclusionsIn patients with spontaneous AT tendon rupture, MLP seems to prevent the re-rupture in the long-term period and should be considered as a safe procedure to repair ATR.

Post-operative rehabilitation in ankle and hindfoot/midfoot fusion and reconstruction surgery - A scoping survey of UK foot and ankle surgeons and allied health professionals

ObjectiveThere has recently been a paradigm shift in the management of Achilles tendon rupture and ankle fracture rehabilitation with emphasis on early mobilisation. There is, however, no consensus on post-operative rehabilitation for hind/mid-foot fusion and reconstructive surgery.The aim was to scope the post-operative rehabilitation practices of UK foot and ankle surgeons and allied health professionals (AHPs). MethodsA 10 question online survey was sent to UK surgeons and AHPs via specialist interest groups in February 2019. Quantitative and qualitative data were analysed. Results117 surgeons and 55 AHPs responded. There was good agreement between survey responses in the 2 groups. Fifty percent reported that they followed a local post-operative rehabilitation protocol. More than half of respondents (57%) reported that not all patients were referred for post-operative rehabilitation. There was a wide variation in the time point at which patients were instructed to weight bear (2 weeks to >12-weeks). Non-union was a concern of early mobilisation as highlighted by 62% of respondents. Qualitative themes identified were: treatment tailored to individual patients, lack of knowledge about the patient journey, treatment tailored to surgeon preferences, lack of a pathway, variation in practice. ConclusionsThere is a wide variation in the post-op rehabilitation of patients undergoing this surgery in the UK, with a lack of published research in this area. Early rehabilitation could improve patient outcomes, yet the risk of non-union is a major concern. Further research in the form of a multicentre trial is warranted to answer this research question.