Risk Of Rerupture Research Articles

Update on minimally-invasive treatment of Achilles tendon rupture

Percutaneous and minimally invasive suturing techniques are very important in the treatment of acute Achilles tendon ruptures because they combine the advantages of surgical treatment (low re-rupture rate) and non-opervative treatment (low risk of complications). In the authors' approach, the percutaneous, peritendineum-preserving technique with the Dresden instrument has proven itself as astandard treatment for 20years. Strict adherence to the original Dresden technique with posteromedial incision and subfascial preparation is crucial for the safe avoidance of the sural lesions regularly reported in percutaneous procedures. The rupture zone and the peritendineum should not be opened. By adding athird suture and using non-absorbable suture material, stability comparable to the open Krackow suture technique is achieved. Functional aftertreatment with protection in aspecial boot and appropriate supervision of the patient aims at early rehabilitation while minimizing the risk of re-rupture or loss of tension. The focus of future efforts should be to further improve treatment results through individualized postoperative treatment adapted to tendon healing.

Endovascular treatment of contained ruptured internal thoracic artery aneurysm mimicking a tumor in a patient with neurofibromatosis type 1: a case report

BackgroundAn internal thoracic artery aneurysm (ITAA) is an exceedingly rare condition, with approximately two-thirds of reported cases being iatrogenic pseudoaneurysms. The remainder are attributed to various causes, including vasculitis, connective tissue disease, and neurofibromatosis type 1 (NF-1). NF-1 is an autosomal dominant disorder characterized by distinct clinical manifestations that occasionally include life-threatening vascular complications. Although NF-1 patients may develop various vascular abnormalities, ruptured ITAA is rarely reported, with only seven published cases.Case presentationA 32-year-old man with NF-1 consulted for a three-day history of persistent left back and upper arm pain. Initial chest radiography indicated left pleural effusion and an opacity at the left lung apex. Computed tomography scan revealed a mass in the left upper mediastinum that was initially suspected to be a tumor. Subsequent contrast-enhanced computed tomography revealed the mass to be a subclavian artery aneurysm. Detailed contrast-enhanced computed tomography with 1-mm slices was performed for surgical planning, identifying the mass as a left ITAA with contained rupture. Given the risk of re-rupture, emergency angiography was performed, which confirmed rupture of the left ITAA without extravasation. The ITAA was successfully treated with multiple microcoils at the proximal and distal ends. The patient had an uneventful recovery and was discharged on the fourth postoperative day.ConclusionsThis case highlights the importance of considering vascular lesions in NF-1 patients who present with pleural effusion. It also emphasizes the challenges in diagnosing ITAA and the effectiveness of thin-slice contrast-enhanced computed tomography scans and endovascular treatment.

The option of transosseous distal suture placement during minimally invasive Achilles tendon repair for high-risk patients can improve outcomes, however does not prevent re-rupture

PurposeAchilles tendon ruptures (ATRs) close to the insertion, in high-level athletes, and in patients at high risk of re-rupture, may be better suited to operative repair. Minimally Invasive Repair (MIR) of the Achilles tendon has excellent outcome and low complication rates. Traditionally MIR has showed lower repair strength, failing due to suture pull-out from the distal tendon stump. The aim of this study was to describe the outcome of ATR patients who received transosseous distal suture placement using a standard technique as a reference.MethodsFollowing ATR, patients were evaluated for pre-injury activity level, body weight, location of the tear and size of the distal Achilles tendon stump. Patients considered to be at high-risk of re-rupture: Tegner level ≥ 8, body weight ≥ 105Kg and distal ATR, received transosseous (TO) distal suture placement (n = 20) rather than the usual transtendinous (TT) technique (n = 55). Patient reported outcome measures and functional evaluation was performed at 12 months following repair.ResultsAt 12 months follow up both methods resulted in good median (IQR) Achilles tendon Total Rupture Score TO 83.8 (74-88.3) vs. TT 90 (79–94), low increased relative Achilles Tendon Resting Angle TO -3.5˚ (3.6) vs. TT -3.5˚ (3.3) and mean (SD) Single leg Heel-Rise Height Index TO 88.2% (9.9) vs. TT 85.6% (9.9) (n.s.). There were 4 re-ruptures in the high-risk group and 2 in the group receiving TT distal suture placement. All but one of these were traumatic in nature. The mode of failure following TO distal suture placement was proximal suture pull out.ConclusionsTo distal suture placement during minimally-invasive Achilles tendon repair for higher-risk patients can lead to results equivalent to those in lower-risk patients treated with a standard TT MIR technique, except for the re-rupture rate which remained higher. There may be factors that have greater influence on outcome other than suture placement following ATR.

Impact of Psychological Factors on Rehabilitation After Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Anterior cruciate ligament (ACL) tears are a common orthopaedic injury, and the incidence of ACL reconstruction (ACLR) continues to increase. Current clinical practice guidelines (CPGs) recognize the role of psychological factors in rehabilitation, but patient-reported outcome measures (PROs) and psychological readiness are rarely incorporated into rehabilitation. The purpose of this review was to highlight the importance of psychological health after ACL injury, understand the current metrics used to monitor psychological recovery, and outline how psychological recovery can be better incorporated in current CPGs. A systematic review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines (PRISMA); 63 studies were identified with a PubMed search using the term "ACL Injuries/psychology". Exclusion criteria included lack of consideration of psychological effects or studies validating PROs after ACLR. Studies were reviewed by multiple reviewers, and a total of 38 studies were included after applying exclusion criteria. Systematic review. Level 3b. Two independent reviewers analyzed the included articles to extract sample size, psychological readiness scale or other measures used, and key results. Psychological outcomes, especially kinesiophobia and fear of reinjury, are seen commonly after ACLR. Psychological factors were shown to impede return to sport (RTS), alter measurable knee biomechanics, and potentially increase the risk for re-rupture. Targeted interventions such as kinesiotaping, knee bracing, and imagery training can help improve psychological and functional testing after ACLR. ACLR is often complicated by psychological factors. Psychological readiness is a crucial yet often unincorporated part of rehabilitation. Patients with higher levels of kinesiophobia and lower psychological readiness to RTS specifically should be identified to allow for administration of interventions, such as imagery training, knee bracing, or kinesiotaping, that can mitigate the negative effects of psychological outcomes and improve recovery.

Evaluation of flow diverter use in acutely ruptured vertebral artery dissecting Aneurysms: A focus on safety and efficacy for rapid Aneurysm obliteration

ObjectiveFlow diverter device (FDD) has emerged as the reconstruction technique for treating ruptured dissecting vertebral artery Aneurysms (VADA), but data on feasibility regarding re-rupture risk and timing of Aneurysm obliteration following FDD treatment is still limited. Therefore, this study aimed to evaluate the safety and efficacy of FDD in the treatment of VADAs presenting with subarachnoid hemorrhage (SAH). MethodsWe retrospectively reviewed patients with ruptured VADA presenting with subarachnoid hemorrhage who underwent FDD placement at our institution between 2015 and 2023. Patient demographic data, Aneurysm configuration, and occlusion status were analyzed. ResultsThirteen patients with SAH from VADA rupture underwent FDD implantation. The average size of the largest diameter of the Aneurysm was 11.2 mm (range 6.5–21 mm). Eight of 13 (61.5 %) patients had their Aneurysms completely obliterated within 2 weeks after the procedure. The small dissecting Aneurysm (d = 0.636, p = 0.002) and degree of intra-Aneurysmal contrast stasis (d = 0.524, p = 0.026) were associated with rapid Aneurysm occlusion, according to the Somer’s d coefficient. There were no ischemic or hemorrhagic complications at the average clinical follow-up of 28.4 months (range 5–67 months) and average angiographic follow-up of 20.1 months (range 3–60 months). A favorable outcome (mRS 0–2) was achieved in 12 patients (92.3 %). ConclusionsFDD is safe and effective for the reconstruction of acutely ruptured VADAs. In addition, our study emphasizes that small dissecting Aneurysms tend to be rapidly obliterated after flow diversion, which eliminates the risk of re-rupture during the acute phase of subarachnoid hemorrhage.

An anteromedial stabilization procedure has the most protective effect on the anterior cruciate ligament in tibial external rotation. A human knee model study

IntroductionAnterior cruciate ligament (ACL) reconstruction remains associated with the risk of re-rupture and persisting rotational instability. Additional extraarticular anterolateral stabilization procedures stabilize the tibial internal rotation and lead to lower ACL failure rate and improved knee stability. However, data for additional stabilization of tibial external rotation is lacking and the importance of an anteromedial stabilization procedure is less well evaluated. Aim of this study is to investigate the influence of an extraarticular anteromedial stabilization procedure for the stabilization of the tibial external rotation and protection of the ACL from these rotational forces.MethodsInternal and external rotations of the tibia were applied to a finite element (FE) model with anatomical ACL, posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL) and intact medial and lateral meniscus. Five additional anatomic structures (Anteromedial stabilization/anteromedial ligament, AML, augmented superficial medial collateral ligament, sMCL, posterior oblique ligament, POL, anterolateral ligament, ALL, and popliteal tendon, PLT) were added to the FE model separately and then combined. The force histories within all structures were measured and determined for each case.ResultsThe anteromedial stabilization or imaginary AML was the main secondary stabilizer of tibial external rotation (90% of overall ACL force reduction). The AML reduced the load on the ACL by 9% in tibial external rotation which could not be achieved by an augmented sMCL (-1%). The AML had no influence in tibial internal rotation (-1%). In the combined measurements with all additional structures (AML, ALL, PLT, POL) the load on the ACL was reduced by 10% in tibial external rotation.ConclusionThis study showed that an additional anteromedial stabilization procedure secures the tibial external rotation and has the most protective effect on the ACL during these external rotational forces.

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

ObjectiveThe results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results. HypothesesThere is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols. MethodsThis was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review. ResultsFour hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07). ConclusionsThis study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes. Level of evidenceIII; retrospective comparative, non-randomized.

Risk Factors for Rerupture After Proximal Hamstring Avulsion Injury Including the Optimal Timing for Surgery

Background: Despite the prevalence of proximal hamstring avulsion injuries (PHAIs), the understanding of rerupture risk factors and the influence of injury chronicity on these rates remain limited. Purpose: To investigate the rerupture rate after PHAI repair and identify its associated risk factors and the optimal time to primary surgery. Study Design: Case-control study; Level of evidence, 3. Method: This is a retrospective analysis of prospectively collected data from the French Proximal Hamstring Avulsion Surgery Cohort Study targeting patients surgically treated for PHAI between 2002 and 2022. The primary outcome measure of this study was the rerupture rate of PHAI repair. The secondary outcome measures included the assessment of the potential risk factors for rerupture as well as the investigation of the incidence rate of rerupture for 100 person-years depending on various injury-surgery delay definitions. Results: This study analyzed 740 patients with a mean age of 45.9 years (SD, 13.6 years) and followed up for a mean of 4.9 years (SD, 3.9 years). The rerupture rate was 4.59% (34/740). Most reruptures (75%) occurred within the first 6 months after surgery (median, 88.5 days; interquartile range, 39.5-182 days), and 74% were atraumatic. Univariate analysis identified potential risk factors: longer initial surgery delay (hazard ratio [HR], 1.03; 95% CI, 1.01-1.04; P = .04) and initial complete ruptures (HR, 4.47; 95% CI, 1.07-18.7; P = .04). Receiver operating characteristic curve analysis found the optimal injury-surgery delay cutoff predicting rerupture to be 32 days (area under the curve, 0.62; 95% CI, 0.53-0.71). The relative Youden index was calculated at 0.24, corresponding to a sensitivity of 65% and a specificity of 59%. Surpassing this cutoff showed the highest HR (2.56), narrowest 95% CI (1.27-5.17), and highest incidence of rerupture (1.42 per 100 person-years) (P = .01). In the multivariate analysis, an injury-surgery delay of >32 days (HR, 2.5; 95% CI, 1.24-5.06; P = .01) and initial complete ruptures (HR, 4.33; 95% CI, 1.04-18.08; P = .04) emerged as significant risk factors for rerupture. Conclusion: This study found a 4.59% rerupture risk after PHAI repair. Most reruptures (75%) occurred within the first 6 months after surgery. Risk factors for rerupture included chronicity and initial complete injury. The optimal threshold for chronicity of PHAI lesions, based on rerupture rate, was marked by an injury-surgery delay of >32 days.

Contributing factors to hand flexor tendon rerupture

Purpose: This retrospective study aimed to identify factors influencing hand flexor tendon rerupture and to develop preventive strategies for patients who have undergone hand flexor tendon repair.Methods: In total, 287 patients who underwent hand flexor tendon repair between January 2011 and June 2022 were included. Patients with thumb injuries, amputations, bone injuries, extensor tendon injuries, and those with less than 3 months of follow-up were excluded. Patients were divided into rerupture and non-rerupture groups. Events leading to ruptures were also investigated. The two groups were compared according to sex, age, occupation, smoking status, history of diabetes mellitus, injury characteristics, core suture method, and timing of the rehabilitation course.Results: Of the 287 patients, 19 experienced rerupture (6.6%). The mean time to rerupture was 25.3 days. Reruptures occurred due to unknown causes in nine cases (47.4%), noncompliance with medical recommendations in seven cases (36.8%), and trauma in three cases (15.8%). Among the investigated factors, little finger injury and concurrent flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) ruptures were significantly associated with rerupture. Little difference was noted in the core suture methods and timing of the rehabilitation course between the two groups.Conclusion: To minimize the risk of rerupture, patients should strictly adhere to medical recommendations and avoid any activities that could cause trauma for at least 1 month after surgery, which is the critical period for tendon remodeling. Patients with little finger injuries as well as concurrent FDS and FDP ruptures require special attention and careful monitoring.

Anterior Cruciate Ligament Reconstruction: 3-Incision Technique With Allograft Quad Tendon ACL Reconstruction

Background: Anterior cruciate ligament (ACL) ruptures are becoming more common in younger and older athletes. Approximately 250,000 ACL injuries occur each year, requiring the need for an effective and reproducible surgical technique. Indications: The 3-incision outside-in technique utilizes the donor quadriceps tendon, an extraordinarily strong graft, without damage from autogenous harvesting of patellar tendon or hamstrings. While some data suggest higher re-rupture risk with donor tissue, this is counterbalanced by avoiding secondary surgical site damage. Technique Description: The ruptured ACL is removed and the intercondylar notch is cleaned to visualize the anatomical ACL insertion site. Using the 3-tunnel technique a gaff is passed through the intercondylar notch, through a puncture hole (incision 1) and a rear entry guide hooked to its tip. The guide point is pulled into the knee and placed in posterior aspect of the anatomic footprint of the native ACL. Through incision 2, a guide pin is drilled to this point and overdrilled with a 10-mm drill. The edges of the hole in the intercodylar notch are smoothed with a currette. The tibial footprint is cleared, a tibial aiming guide placed. Through incision 3, a guide pin is placed and over drilled with a 10-mm drill followed by a Gore-Tex reamer to ensure no impingement would inhibit graft passage. The proximal bone of a quadriceps tendon graft is sized through a 10-mm sizer and compacted. Two holes are drilled to hold sutures for the proximal aspect of the femoral graft. The quadriceps tendon graft is sized to fit through a 9-mm tunnel and the free end whipped with a stitch before being passed from outside-in through the smoothed tunnels. The femoral bone block is tapped to have a press fit initially and then is fixed with a Milagro screw. The knee is cycled ten times to remove slack and the interference fit guide pin is placed on the anterior aspect of the graft, and fixed with the knee at 15° to 30° of flexion. Stability is tested with confirmation of no impingement, and then an extra-articular reconstruction with a semitendinosus allograft is performed. The extra articular reconstruction is placed at the point between Gerdy's tubercle and the fibular head, passed under the skin and the iliotibial band, and then inserted just anterior and superior to the ACL femoral drill hole. Results: Patient outcomes in our initial experience are comparable to our autogenous bone-tendon-bone (BTB) procedures without anterior knee pain. Return to sport is similar with autogenous procedures, with a delay of 6 to 12 months. In addition, there is a possibility for acceleration of healing with the addition of platelet-rich plasma and hyaluronic acid between 1 and 3 months postsurgery. We have insufficient data so far to determine if the re-rupture rate will decline compared with reported outcomes. Conclusion: The 3-incision technique with allograft quadriceps tendon for ACL reconstruction is a reproducible surgical technique that avoids harvest from the patient's own body. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Proximal Hamstring Repair With All-Suture Anchors and an Accelerated Rehabilitation and Bracing Protocol Demonstrates Good Outcomes at 1-Year Follow-Up

To evaluate patient-reported outcomes and risk for rerupture after surgical treatment of proximal hamstring tendon ruptures using all-suture anchors and a unique postoperative bracing strategy. A retrospective review of a prospectively collected database was conducted of patients undergoing proximal hamstring repair or reconstruction from 2020 to 2022 at a tertiary, academic institution. Patients were included if they reached minimum 1-year follow-up and completed postoperative patient-reported outcomes. The surgical protocol for proximal hamstring repairs included all-suture anchors placed either in an open or endoscopic fashion in the ischial tuberosity. After surgery, all patients underwent an accelerated rehabilitation protocol, including 6 weeks touchdown weight-bearing in a hinged knee brace locked in extension for ambulation, allowing passive knee flexion to 90° while seated. Descriptive statistics were used to analyze the data. Twenty-one patients were included (mean age 50.4 ± 9.5 years, body mass index 24.4 ± 3.5, 66.7% female). Lower Extremity Functional Scale score achieved postoperatively was 74.2 ± 7.5 (out of 80). Patients had minimal pain (mean visual analog scale pain score of 0.9 ± 1.2). 61.9% of patients were able to return to the same level of activity after based on Tegner score by 1 year. Postoperative Single Assessment Numeric Evaluation activity of daily living was 94.3 ± 8.3, and Single Assessment Numeric Evaluation Sports was 82.3 ± 19.0. Mean Short Form Survey (SF-12) postoperative scores were 51.6 ± 6.8 for SF-12 Physical Component Score and 53.9 ± 9.7 for Mental Component Score. 95.2% (20 of 21) patients were satisfied with their outcome. There were no reruptures, infections, or reoperations. One patient of 21 (4.8%) incurred a postoperative deep venous thrombosis, which was treated with therapeutic anticoagulation for 3 months. All-suture anchors for proximal hamstring repair with a unique accelerated postoperative rehabilitation and bracing protocol result in good outcomes and patient satisfaction with minimal risk of complications. Level IV, case series, therapeutic.

Impact of Lateral Extra-Articular Procedure Augmentation on Rerupture Risk and Tegner Activity Scale Outcomes in Adolescent Anterior Cruciate Ligament: A Matched Comparative Study With a Minimum 2-Year Follow-up

Background: Despite the well-established role of lateral extra-articular procedures (LEAPs) in reducing failure rates after anterior cruciate ligament (ACL) reconstruction (ACLR) in the adult population, similar in-depth research for the adolescent and pediatric population remains lacking. Purpose: To examine the effect of the LEAP augmentation on the rerupture rate after ACLR in patients aged <18 years. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective analysis of prospectively collected data from October 2012 to June 2020, involving adolescents <18 years old undergoing primary ACLR with a minimum follow-up of 2 years. Two groups, matched for age, sex, Tegner activity scale, and presence of meniscal injury, were established: ACLR alone and ACLR+LEAP augmentation. The primary outcome measure was the rate of rerupture after ACLR. The secondary outcome measures were the rate of non–graft rupture related reoperation after ACLR; rate of return to sport (RTS) rate, timing, and level compared with preinjury status; and functional scores including the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (Pain, Symptoms, Activities of Daily Living, Sport and Recreation, and Quality of Life), Tegner activity scale score, ACL Return to Sport after Injury (ACL-RSI) score, and Lysholm score. Results: After accounting for follow-up losses, we analyzed 132 patients who underwent ACLR alone and 121 patients who underwent ACLR+LEAP from the initial 147 per group. The mean age of the patients in both groups was 16.1 years (SD, 1.1 and 1.0 years, respectively), with similar patient and injury characteristics across both groups (P > .05). Both groups also showed comparable preoperative functional scores. A significantly lower preoperative ACL-RSI score was observed in the ACLR-alone group compared with the ACLR+LEAP group (P = .0044). Graft rupture was significantly less common in the ACLR+LEAP group (2.5%) than in the ACLR-alone group (13.6%) (P = .002). The attributable risk reduction for ACLR+LEAP was 11.1%, and the calculated number needed to treat was 9. Kaplan-Meier analysis showed significantly better rerupture-free survival at 5 years for the ACLR+LEAP group (P = .001). Cox regression confirmed a 6-fold increased rerupture risk in the ACLR-alone group (P = .004). At the final follow-up, despite similar IKDC, KOOS, Lysholm, and ACL-RSI values across both groups, the ACLR+LEAP group had a significantly higher Tegner score (7.2 vs 6.3; P = .0042). No significant differences were observed in RTS rates or sport level compared with preinjury states between the groups. Conclusion: ACLR+LEAP augmentation significantly reduced rerupture risk and facilitated higher postoperative activity levels in adolescents. Registration: NCT02511158 (ClinicalTrials.gov identifier).

IMMUNOMODULATORY POTENTIAL OF MAGNETICALLY ASSISTED CELL SHEET UNDER HYPOXIC ENVIRONMENTS UPON MAGNETIC STIMULATION

Common tendon injuries impair healing, leading to debilitation and an increased re-rupture risk. The impact of oxygen-sensing pathways on repair mechanisms, vital in regulating inflammation and fibrosis, remains unclear despite their relevance in tendon pathologies. Recent studies show that pulsed electromagnetic field (PEMF) reduce inflammation in human tendon cells (hTDCs) and in hypoxia-induced inflammation. We investigated the hypoxia's impact (1% and 2% oxygen tension) using magnetic cell sheet constructs (IL-1β-magCSs) primed with IL-1β. IL-1β-magCSs were exposed to low OT (1h, 4h,6h) in a hypoxic chamber. To confirm the role of PEMF (5Hz, 4mT, 50% duty cycle) on hypoxia modulation, IL-1β-magCSs, previously exposed to OT, were 1h-stimulated with PEMF. Our results show a significant increase in HIF- 1a and HIF-2a expression on IL-1β-magCSs after exposure to 2%-OT at all time points, compared to 1%- OT and normoxia. TNFa, IL-6, and IL-8 expression increased after 6 hours of 1%-OT exposure. PEMF stimulation of hypoxic IL-1β-magCSs led to decreased pro-inflammatory genes and increased anti-inflammatory (IL-4,IL-10) expression compared to unstimulated magCSs. IFN-g, TNF-α, and IL-6 release increased after 6 hours, regardless of %-OT, while IL-10 levels tended to rise after PEMF stimulation at 2%-OT. Also, NFkB expression was increased on IL-1β-magCSs exposed to 4 h and 6 h of 2%-OT, suggesting a link between NFkB and the production of pro-inflammatory factors. Moreover, PEMF stimulation showed a significantly decreased NFkB level in IL-1β-magCSs.Overall, low OT enhances expression of hypoxia-associated genes and inflammatory markers in IL-1β-magCSs with the involvement of NFkB. PEMF modulates the response of magCSs, previously conditioned to hypoxia and to inflammatory triggers, favouring expression of anti-inflammatory genes and proteins, supporting PEMF impact in pro-regenerative tendon strategies.Acknowledgements: ERC CoG MagTendon(No.772817), FCT under the Scientific Employment Stimulus-2020.01157.CEECIND. Thanks to Hospital da Prelada for providing tendon tissue samples (Portugal), and TERMRES Hub (Norte-01-0145-FEDER-022190).

Current treatment concepts for Achilles tendon rupture.

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

The effects of zinc sulfate mineral supplementation on Achilles tendon healing in rats.

The Achilles tendon is the most commonly injured and ruptured tendon in the body and typically occurs during participation in sports or recreational activities in men between 30 and 50 years of age. Treatment options for Achilles tendon rupture include conservative and surgical approaches. Conservative treatment is associated with a higher risk of rerupture, while surgical treatment carries a risk of wound site complications. Generally, both methods result in a prolonged tendon healing time. Studies are ongoing to identify biomolecules that aid tendon repair. The main objective of our study is to investigate the effects of zinc sulfate (ZnSO4) mineral supplementation on Achilles tendon healing in rats. Forty-eight female Sprague-Dawley rats were divided into four equal groups (C-15, C-30, ZnSO4-15, and ZnSO4-30) after standard Achilles tendon repair surgery. The ZnSO4-15 and ZnSO4-30 groups received an oral zinc sulfate monohydrate solution (50 mg/kg/day) for 15 and 30 days, respectively. The C-15 and C-30 groups were given 1 mL of distilled water per day orally during the experimental periods. Rats were sacrificed on the 15th and 30th day depending on their groups, and the healing of the operated tendons was evaluated using Movin and Bonar histopathologic scoring. For biomechanical analyses, the operated and intact Achilles tendons of all groups were removed, and tensile tests were performed to determine the tensile strength and toughness values for each tendon. Movin and Bonar scores were significantly lower in the ZnSO4-15 group than in the C-15 group and in the ZnSO4-30 group than in the C-30 group (p<0.05). Although we did not find the biomechanical results statistically significant, the intact tendons of the ZnSO4-15 group exhibited higher toughness than those of the C-15 group, and the tensile strength and toughness values of the operated and intact tendons of the ZnSO4-30 group were also higher than those of the C-30 group. Zinc sulfate monohydrate mineral supplementation had histopathologically positive effects on the proliferation and remodeling stages of Achilles tendon healing and may biomechanically benefit both operated and intact tendons.

Finite element analysis of the knee joint: a computational tool to analyze the combined behavior after treatment of torn ligaments and menisci in the human knee joint.

Finite element analysis (FEA) is a fundamental tool that can be used in the orthopaedic world to simulate and analyze the behaviour of different surgical procedures. It is important to be aware that removing more than 20% of the meniscus could increase the shear stress in the cartilage and enlarge the risk of knee joint degeneration. In this fact, the maximal shear stress value in the medial cartilage increased up to 225% from 0.15MPa to 0.5MPa after medial meniscectomy. Also, meniscal root repair can improve meniscal biomechanics and potentially reduce the risk of osteoarthritis, even in cases of a loose repair. FEA has been used to better understand the biomechanical role of cruciate ligaments in the knee joint. ACLr with bone-patellar tendon-bone graft at 60N of pretension and double-bundle PCLr were closer to that of a native knee in terms of biomechanics. The addition of a lateral extra-articular augmentation technique can reduce 50% of tibial translation and internal rotation, protecting the graft and minimizing the risk of re-rupture. Interestingly, anatomic and non-anatomic medial patellofemoral ligament reconstruction increased the pressure applied to the patellofemoral joint by increasing patellar contact pressure to 0.14MPaat 30° of knee flexion using the semitendinosus as a graft. After all the advances in medical imaging technologies, future studies should take into consideration patient-specific data on both anatomy and mechanics, in order to better personalize the experimental model.

Anterior Cruciate Ligament Reconstruction using Bone-Tendon-Bone Allograft: Surgical Technique Using Augmentation with Bio-Composite Scaffold

Anterior cruciate ligament (ACL) rupture rates remain high; the incidence of isolated ACL ruptures is 68.6 per 100,000. This Technical Note introduces a technique for ACL reconstruction (ACLR) using a bone-tendon-bone (BTB) allograft augmented with BioBrace, a biocomposite scaffold. The BioBrace scaffold is sutured onto the BTB allograft to reinforce the ligament and accelerate healing. Graft preparation with BioBrace, ACLR, and graft passage is described. This technique aims to reduce re-rupture risk, enhance graft healing, and improve patient-reported outcomes. BioBrace offers advantages over other augmentation approaches and synthetic materials, providing improved remodeling, biologic integration, and increased mechanical strength. Feasibility and efficacy have been demonstrated in animal models and human applications. This technique presents a promising approach to enhance ACLR outcomes.

Acute Achilles tendon rupture: modern management

Achilles tendon rupture is a common injury and its incidence is increasing. There is a large body of literature on the subject and much of it debates the influence of management on re-rupture rates. Operative treatment was thought to be superior in reducing the risk of re-rupture. However, it must be balanced against the risks, in particularly wound infection and breakdown, and sural nerve injury. Minimally invasive surgery aimed to reduce wound complications but has frequently been associated with a higher risk of sural nerve damage and irritation. The introduction of functional rehabilitation, which includes early weight bearing and range of motion within an orthosis, has been pivotal in improving outcomes particularly in non-operatively managed patients. More recent evidence suggests that re-rupture rates are now similar between operatively and non-operatively managed patients when incorporating a functional rehabilitation protocol. The publication of the Achilles Tendon Rupture Score, which has been validated specifically for this injury, has been helpful in providing a more detailed picture of post-injury symptoms and function. The studies which have included this as an outcome measure have also shown comparable results between operatively and non-operatively treated patients.

Augmentation of the Anterior Cruciate Ligament Using the Peroneus Longus: Description of the Surgical Technique

Background: The quadruple graft from the hamstring tendons has become a widely used option in the reconstruction of the anterior cruciate ligament (ACL), however, this graft may not have the desirable diameter for the reconstruction, increasing the risk of re-rupture. In this context, the peroneus longus tendon graft appears as an option to complement other grafts, transforming a thin quadruple graft into a sextuple graft. Indications: The sextuple graft technique for ACL reconstruction is used in patients who have a quadruple graft with a diameter of less than 8 mm, and due to its length, it is not possible to make a quintuple graft, for example. Technique Description: Initially, the hamstring tendons are removed with the aid of a tenotome. After that, the anterior half of the peroneus longus tendon is identified and removed. On the back table, the definitive graft is prepared so that we have a sextuple graft with a diameter greater than 8 mm. Finally, the ACL reconstruction is performed anatomically using an adjustable loop device in the femur and an interference screw in the tibia. Results: In our experience with patients who have a hamstring graft diameter of less than 8 mm, we obtained an average increase of 1.8 mm in graft diameter when augmentation was performed with the anterior half of the peroneus longus. Discussion: Grafts less than 8 mm in diameter are at increased risk of rupturing and failure of surgical treatment of the ACL injury. The surgeon must be prepared to make a quintuple or sextuple graft, but in some patients, the tendons are short or there is no availability of a tissue bank, making this practice impossible. The use of the anterior half of the peroneus longus to perform graft augmentation is safe, causing almost no morbidity to the donor area and is easily accessible during the procedure, making it an excellent option for increasing the diameter of thin grafts. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Effect of the Copenhagen Achilles Rupture Treatment Algorithm (CARTA) on Calf Muscle Volume and Tendon Elongation After Acute Achilles Tendon Rupture: A Predefined Secondary Analysis of the First 60 Patients in a Randomized Controlled Trial.

Surgical treatment of acute Achilles tendon rupture (ATR) lowers the risk of rerupture and may reduce calf atrophy and elongation of the Achilles tendon. The Copenhagen Achilles Rupture Treatment Algorithm (CARTA) was developed to provide individualized treatment selection based on ultrasonographic evaluation of the rupture. In a randomized setup, the present study aimed to investigate whether treatment selection using the CARTA could reduce atrophy and tendon elongation compared with (1) patients treated surgically and (2) patients treated nonsurgically. Randomized controlled trial; Level of evidence, 2. A total of 60 patients with an acute ATR were randomly assigned to receive treatment based on the CARTA (intervention), surgical treatment (control), or nonsurgical treatment (control) in a 1 to 1 to 1 ratio. After 1 year, magnetic resonance imaging of both calves was performed, and muscle volume and Achilles tendon length were measured. Results were presented as the ratio between the affected and the unaffected limbs (ie, limb symmetry index; %). A total of 156 patients were assessed for eligibility, 60 patients were randomized, and 54 patients provided data for the study-19 patients received treatment based on the CARTA (intervention group), 17 patients received nonsurgical treatment (control), and 18 patients received surgical treatment (control). No statistically significant differences were found between the intervention group and the 2 control groups regarding muscle volume and tendon length. No statistically significant differences were found between patients treated surgically and patients treated nonsurgically. Comparison between the affected and the unaffected limb showed statistically significant muscle atrophy (24%-30%) and tendon elongation (soleus, 59%-76%; gastrocnemius, 8%-14%) in the affected limb in all 3 groups. Individualized treatment of acute ATR using an ultrasonographic selection algorithm did not reduce calf muscle atrophy or tendon elongation when compared with surgical and nonsurgical treatment. Surgical treatment did not reduce calf muscle atrophy or tendon elongation compared with nonsurgical treatment.