Long-term follow-up after acute achilles tendon rupture — Does treatment strategy influence functional outcomes?

BackgroundPatients struggle to fully recover after an Achilles tendon rupture. Although several studies has investigated surgical and non-surgical treatment, the best treatment is still uncertain. The aim of this study was to investigate long-term patient-reported outcomes and objective measures 4 years after acute Achilles tendon rupture and compare whether outcomes differed between patients treated on basis of the previous regimen preferring surgical treatment and the new regimen preferring functional rehabilitation.MethodsAchilles tendon Total Rupture Score (ATRS), number of re-ruptures and the objective measures; Achilles tendon resting angle, calf circumference, heel-rise height, and muscle endurance were measured at a 4-year follow-up. Patients were recruited from Aalborg University Hospital.ResultsSeventy-six patients were included (29% female). The mean ATRS was 71.4 (95% CI: 65.8 to 77.1) at 4 years follow-up. No difference in ATRS was observed between Previous regimen and New regimen at any timepoint (time x group interaction, (p = 0.851). The injured side was still significantly impaired compared with the non-injured side in terms of all objective measures. Impairments in objective measures were not dependent on the preferred treatment strategy.ConclusionsPatient reported impairments and objective functional deficits persist 4 years after an acute Achilles tendon rupture. No differences in patient reported outcome or objective measures at the 4 years follow-up was observed between the old treatment regimen preferring surgery compared with the new treatment regimen preferring functional rehabilitation.     

How early must an acute Achilles tendon rupture be repaired?

An acute Achilles tendon rupture is the most common tendon rupture of the lower extremities, yet the optimal timing for an early surgical repair is unclear. To identify the optimal time for an early surgical repair with favorable results, we evaluated the isokinetic muscle strength and clinical outcomes of early surgical repairs of acute Achilles tendon ruptures performed at different time points after injury. Between January 2011 and July 2015, a total of 65 patients underwent an acute Achilles tendon rupture repair within 1 week after injury. To compare the outcomes at different time points post-injury, we divided patients into 3 groups: group 1, surgical treatment at ≤24 h; group 2, surgery at ≥24 h and ≤48 h; and group 3, surgery at ≥48 hours and ≤1 week. The isokinetic muscle strength in both ankles were measured using a Cybex dynamometer, and the Achilles tendon total rupture score, the modified Tegner scoring system, the visual analog scale was used to assess clinical outcomes. Kruskal-Wallis and Fisher’s exact tests were used to compare multiple results in the 3 groups. No significant differences were found among the groups in terms of ankle isokinetic muscle strength or clinical outcome scores (P > 0.05). The complication rate was low in all groups. There were no significant differences in isokinetic muscle strength or clinical outcomes following acute Achilles tendon rupture repairs performed within 1 week after injury.     

Chronic Achilles tendon rupture reconstructed using hamstring tendon autograft

BackgroundChronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and augmentation methods are challenging when the defect exceeds 5–6 cm, especially if the distal stump is grossly tendinopathic.MethodsWe describe our method of Achilles tendon reconstruction with ipsilateral semitendinosis autograft and interference screw fixation in a patient with chronic rupture, a 9 cm defect and gross distal tendinopathy.ResultsPatient reported outcome measures consistently demonstrated improved health status at 12 months post surgery: MOXFQ-Index 38–25, EQ5D-5L 18–9, EQ VAS 70–90 and VISA-A 1–64. The patient was back to full daily function, could single leg heel raise and was gradually returning to sport. No complications or adverse events were recorded.ConclusionReconstruction of chronic tears of the Achilles tendon with large defects and gross tendinopathy using an ipsilateral semitendinosis autograft and interference screw fixation can achieve satisfactory improvements in patient reported outcomes up to 1 year post-surgery.     

Carotid Artery Pseudoaneurysm Treated with an ePTFE-prosthesis

We report a case with a pseudoaneurysm of the common carotid artery treated by carotid aneurysmectomy.A 34-year-old male was admitted with a swelling on the left side of his neck. A duplex ultrasound showed a 2.5×1.5×1.5 cm pseudoaneurysm of the left common carotid artery, 1 cm caudal to the bifurcation. Twelve hours later the pseudoaneurysm had increased and an acute aneurysmectomy was performed. An 8 mm externally supported expanded polytetrafluoroethylene (ePTFE) graft was interpositioned. The patient was discharged 1 week after the surgery and 6 months after the operation he had recovered completely from a paresis of the left vocal cord. The reason for the pseudoaneurysm formation remains unclear as no bacterial, iatrogenic or traumatically aetiology was found.     

Combined flexor hallucis longus tendon transfer and gastrocnemius recession for reconstruction of gapped chronic achilles tendon ruptures

ObjectiveThe aim of this study was to assess the functional outcomes after a combined FHL transfer and a gastrocnemius recession for treatment of chronic ruptures of Achilles tendon with a gap and to investigate the patient's satisfaction about the great toe function after transfer.Material and methods19 patients with chronic rupture of the Achilles tendon with a gap were treated with a flexor halluces longus tendon transfer combined with a gastrocnemius recession, Clinical diagnosis depends on the presence of gap in the tendon on examination, inability of tip toe walking on the affected side and positive calf-squeeze test, MRI was used to confirm the clinical diagnosis. American Orthopedic Foot & Ankle Society hind foot score was used for assessment of the results.ResultsThe AOFAS score improved significantly from a mean of 65 preoperatively to 94 at the last follow up (p < 0.001), there was no significant difference in the final outcome between patients with FHL tendon weaved through the stump of the Achilles tendon and those with trans osseous tunnels, the mean AOFAS score at the last follow up was 94.2, 93.8 respectively, no patient complained of big toe dysfunction.ConclusionManagement of chronic rupture of the Achilles tendon with a gap with flexor halluces longus tendon transfer combined with a gastrocnemius recession is a safe and reliable method with a significantly improved functional outcome, muscle advancement through gastrocnemius recession decreases the length of the gap without affecting the muscle function, flexor halluces longus tendon transfer doesn't harm the big toe function.     

Quadriceps tendon rupture in maintenance haemodialysis patients: Results of surgical treatment and analysis of risk factors

BackgroundReports of spontaneous quadriceps ruptures in end-stage renal disease (ESRD) patients are scarce, and the assessment of risk factors for tendon rupture is poorly addressed in the majority of the studies. The purpose of the present study is to report a series of patients on haemodialysis with spontaneous quadriceps tendon ruptures operated at our institution. The results of the surgical treatment are described and the potential risk factors associated with the rupture are analyzed.MethodsOur study consisted of retrospective analysis of patient's charts. Clinical and laboratory findings of the operated group were compared to the ones of a control group of haemodialysis patients matched by age, gender, and time on haemodialysis, but without tendon rupture.ResultsBetween 1998 and 2010, six ESRD patients with 11 spontaneous ruptures of the quadriceps tendon were treated at our institution. On postoperative evaluation all patients were able to walk without crutches after six months of follow-up, and there were no new ruptures. Positive serology for Hepatitis C was present in two cases (33%) but in none of the controls (p = 0.034). Mean serum levels of intact parathormone (iPTH) and alkaline phosphatase were both higher in cases (p = 0.013 and p = 0.034, respectively). In contrast, mean serum levels of albumin, ferritin and haemoglobin were all lower in cases (p = 0.008, p = 0.043 and p = 0.016, respectively).ConclusionReconstructive surgery is a good way to restore knee function in ESRD patients with quadriceps tendon ruptures. Our cases exhibited higher levels of iPTH and alkaline phosphatase than control patients, reinforcing the role of secondary hyperparathyroidism in tendon weakening. They also had a higher frequency of hepatitis C and lower levels of albumin and haemoglobin compared to controls, possibly implicating chronic inflammation as a potential risk factor for tendon rupture.     

A left thoracic approach in a prone position for thoracoscopic thoracic duct ligation in a patient with post-esophagectomy chylothorax: A case report

IntroductionWe debate whether or not to approach from right thorax for the left chylothorax after esophagectomy.Presentation of caseA 50 s-year-old female underwent right-sided thoracoscopic esophagectomy with three-field lymphadenectomy for esophageal carcinoma (type 0-IIa, 3.4 × 2.2 cm, T1bN0M0, Stage IA), followed by reconstruction with esophagogastric anastomosis through the posterior mediastinum. The thoracic duct was excised and ligated. The left thoracic drainage increased to 2115 mL/day on the fifth postoperative day. Thoracic duct injury was diagnosed, and surgery was performed on sixth postoperative day. With the patient in a prone position, the thoracic duct was ligated successfully under thoracoscopy in the left thorax. The leakage point was found in the crushed duct by 8.8-mm titanium clips. Then, we performed mass ligation of the thoracic duct with 11-mm titanium clips below the leakage point after careful dissection. The surgery took 58 min, with an estimated total blood loss of 0 g.DiscussionAlthough thoracic duct is anatomically located on the right side of the descending aorta, we employed a left-sided thoracoscopic approach due to the chylous leakage in the left thorax. With the patient in the prone position, surgeons can easily convert from a left thoracic approach to a right thoracic approach immediately without postural change if the thoracic duct cannot be found in the left thoracic cavity.ConclusionThis technique is useful and should be considered for patients with left chylothorax.     

Transfer of either index finger extensor tendon to the extensor pollicis longus tendon

BACKGROUND:

Extensor pollicis longus (EPL) tendon ruptures have been treated succesfully with the transfer of the extensor indicis proprius (EIP) tendon. Situations exist in which, due to intraoperative observations, another tendon transfer may be considered preferable to the standard EIP transfer method.

OBJECTIVES:

To determine whether transfer of the extensor digitorum communis II (EDC II) tendon from the index finger to the EPL tendon, leaving the EIP tendon to the index finger intact, would serve as an equally efficient transfer and not adversely affect the function of the hand.

METHODS:

Two patients who had the EDC II tendon transferred to the ruptured EPL tendon, and two patients who had the EIP tendon transferred, were retrospectively reviewed. In each transfer type, one patient had suffered an EPL tendon rupture after a Colles’ fracture, and the other had rheumatoid arthritis. The rupture occurred on the non-dominant side in one patient in each transfer type. Each patient was examined and subjected to range of motion and power testing at least one year following surgery.

RESULTS:

All four patients showed a minimal extension lag with the lift off test, but there was no noticeable difference in range of motion, pinch grip and hand grip strength between the transfer types. Both EDC II transfer patients demonstrated an 8° to 15° loss of thumb interphalangeal joint flexion compared with the unoperated side; EIP transfer patients demonstrated less than a 5° loss. Three patients demonstrated a minor extension lag in the index finger and middle finger. Extension power of the thumb and index finger in all patients varied with wrist flexion and extension and ranged from 50% to 150% of the unoperated side.

CONCLUSIONS:

These case reports suggest that either index finger tendon may be successfully transferred in EPL tendon ruptures.     

Outcome after operative treatment for chronic versus acute Achilles tendon rupture — A comparative analysis

Background

This study compared outcomes after treatment of acute Achilles tendon (AT) rupture via percutaneous suturing, with those after chronic AT rupture treated via open reconstruction.

A survey of extensor pollicis longus tendon injury at the time of distal radius fractures

BackgroundThe purpose of this study is to investigate the presence or absence, incidence, and degree of extensor pollicis longus (EPL) tendon injury by visual confirmation of the EPL at the time of osteosynthesis for distal radius fractures.MethodsThe subjects were 25 patients (5 males and 20 females; mean age: 56 years) with distal radius fracture that had a dorsal roof fragment. During osteosynthesis using a volar locking plate, the third compartment was exposed in order to determine the EPL injury. The survey items in this study were: incidences of the forms of EPL injury (1: absent, 2: tendon floor fibrillation, and 3: laceration), and the presence or absence of periosteal rupture on the EPL tendon floor. In addition, on the final follow-up, the presence or absence of EPL rupture, the range of wrist motion, grip strength, Visual Analog Scale (VAS) score, Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the Mayo wrist score were investigated.ResultsDuring the operation, EPL injury was classified as: 1) absent (12%), 2) tendon floor fibrillation (52%), or 3) laceration (36%). In the EPL tendon floor, periosteal rupture was observed in all patients. The mean postoperative follow-up period was 8 months (6–12 months) and no EPL rupture was observed in any patient. The wrist range of motion was 71° for flexion, 75° for extension, 84° for pronation, and 85° for supination, and the grip (% compared with the unaffected side) was 79%. The VAS, Q-DASH and Mayo scores were 1, 10 and 93 respectively.ConclusionThis study showed a high incidence of EPL tendon injury at the time of distal radius fractures (88%). To improve the ambient environment of the damaged tendon may be useful in terms of the prevention of tendon injury.     

Reliability of Achilles Tendon Resting Angle and Calf Circumference measurement techniques

BackgroundThe resting angle of the ankle joint may be altered following apparently successful management of Achilles tendon rupture. The reliability of the Achilles Tendon Resting Angle and Calf Circumference measurements was determined.MethodsThree test–retest measurements for reliability assessment were performed on 16 healthy subjects: 10 males and 6 females.ResultsThe mean left Achilles Tendon Resting Angle was mean 50.1° (range [26–61]), ICC 0.92 (CI [0.83–0.97]), SEM 2.4°. The mean right Achilles tendon resting angle was mean 49.9° (range [26–60]), ICC 0.91 (CI [0.80–0.96]), SEM 2.6°. The mean left calf circumference was mean 38.5 cm (range [33.3–44.2]), ICC 0.97 (CI [0.94–0.98]), SEM 0.6 cm, and the mean right calf circumference was mean 38.4 cm (range [33.3–43.6]), ICC 0.97 (CI [0.94–0.99]), SEM 0.5 cm.ConclusionsThe Achilles Tendon Resting Angle and Calf Circumference at 15 cm from the antero-medial joint line had excellent test–retest reliability. These are simple, quick and inexpensive measurements, which have the potential to correlate with tendon elongation and functional outcome. The Achilles tendon resting angle may be used as a guide to tendon length during intra-operative repair and rehabilitation     

Flexor hallucis longus tendon transfer for chronic Achilles tendon rupture. A retrospective study

BackgroundThe transfer of Flexor Hallucis Longus Tendon (FHL) is an established method for the treatment of chronic Achilles tendon ruptures. An extensive examination of power, strength, endurance and complications related to this procedure is presented.Methods21 patients treated with open FHL transfer for chronic Achilles tendon rupture were studied retrospectively. Medical records were reviewed. The patients were examined with a test battery for triceps surae strength, functional tests and PROMs.ResultsThe median maximal concentric strength was equal,1300 vs 1336 W, comparing affected with unaffected side. The endurance tests showed a larger difference, 219 J vs. 2398 J, respectively. The median AOFAS score was 87. 11 of 21 patients sustained one or more complications; the most common were infection, disturbed wound healing, and clawing of small toes.ConclusionsPatients achieve almost normal maximal strength after open FHL transfer, but endurance is notably lower. The complication rate was high.     

Six years of follow-up after bilateral hand replantation

Replantation is the gold standard surgical treatment of amputations of the upper limb; however, this demanding procedure is not always preformed in bilateral limb amputation. The objective of this study was to analyze, six years after surgery, the sensorimotor recovery of both replanted hands. A 21-year-old patient with bilateral hand amputation was benefited from limb replantation. Surgery included debridement of the amputated hands and recipient's stumps, bone fixation, arterial and venous anastomoses, nerve sutures, tendon sutures and skin closure. Rehabilitation program included physiotherapy, electrostimulation and occupational therapy. Sensory and motor evaluation was performed 6 years after replantation. At 6 years, the patient presented a good/satisfactory recovery of range of motion and strength, better at right hand. The patient was able to perform right thumb opposition. Static two-point discrimination was 20 mm, sensitivity to pain and thermal stimuli and ability to sweat were present on both hands. Reinnervation was confirmed by electromyography. Functional recovery was higher at the right hand when compared to the left hand. He was highly satisfied with the result of surgery for right hand and fairly satisfied with the result for left hand. He was able to return to a secretary work 16 months after the accident. A proper functional result can be accomplished with bilateral hand replantation.     

The influence of an orthopaedic walker boot on forefoot force

BackgroundIn the treatment of an Achilles tendon rupture the patients are commonly equipped with an orthopaedic walker boot with wedges. To what extent this influences the tensile force placed on the Achilles tendon is unclear.PurposeTo assess the forefoot force and describe changes in muscle activity of the medial gastrocnemius, soleus and tibialis anterior when using one or three wedges during ambulation in a weightbearing orthopaedic walker boot.MethodsThe force on the forefoot was measured with a force sensor insole and muscle activity of the medial gastrocnemius, soleus and tibialis anterior were measured using surface electromyography in 10 healthy participants. Three different types of ambulation were performed (walking without crutches (unass.), walking with crutches (+crutch) and walking with crutches and verbal instructions to place body weight on heel (heel + crutch) with one and three heel wedges respectively.FindingsThe total peak force displayed an interaction where forefoot force decreased when wearing three wedges only for the +crutch ambulation type (80 N, p = 0.001) although there was a trend to decrease with three wedges also for the heel + crutch ambulation type (48 N, p = 0.05). The relative peak force on the forefoot showed a main effect with a significant decrease when using three wedges compared to one wedge across all three ambulation types (19.1%, p = 0.009).InterpretationThe force on the forefoot and hereby the Achilles tendon significantly decreased when using three wedges compared to one wedge. These findings have important implications for the rehabilitation post Achilles tendon rupture.     

Postoperative results of distal tibialis anterior tendinosis

IntroductionAlthough distal tibialis anterior tendinopathy is a common condition, it has rarely been described in literature. It is often a condition in overweight women around 50–70 years old with pain that worsens at night. The purpose of this retrospective study is to describe the specific clinical signs and postoperative results of distal tibialis anterior tendinopathy.Material and methodsBetween 2013 and 2017 we operated 9 patients (10 ft) who failed a conservative treatment of distal tibialis anterior tendinopathy. Surgery consisted of debridement of the diseased tendon and reinsertion with a bone anchor. There was a minimum follow-up of 12 months. All patients were clinically evaluated postoperative (range 14–57 months after surgery) with the use of the American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analog Scale (VAS)ResultsThe mean AOFAS score postoperative was 99 (range 94–100). The mean VAS score postoperative was 1 (range 0–3). In all 10 cases the patient was completely satisfied with the result following surgery. There was no recurrence or rupture of tendon after debridement.ConclusionDistal tibialis anterior tendinopathy is mainly a clinical diagnosis where conservative treatment should always be the first choice. However, our results show that when conservative treatment fails, surgical treatment can lead to very good long term results with a high level of patient satisfaction.     

Résultats de la réparation primaire des plaies du nerf médian et du nerf ulnaire au poignet

IntroductionWounds on the palmar side of the wrist affecting the median or ulnar nerves are responsible for motor and sensory sequelae, severe pain and cold intolerance.Materials and methodsThirty-nine patients with 40 nerve sections were retrospectively reviewed with a mean follow up of 23 months. The median nerve alone was affected 20 times, the ulnar nerve seven times and both nerves simultaneously 13 times. In 75% of the cases, there was an associated vascular injury (radial artery and/or ulnar artery). The average number of tendons cut was 4.25.ResultsAfter repair of the median nerve, 71% of patients recovered antepulsion and opposition that was normal or possible against resistance. The strength was approximately 70% of the opposite side. The sensitive recovery was good (S3 in ≥ 50% of cases) but it was accompanied by cold intolerance one out of two patients. After repair of the ulnar nerve, 29% of the cases had an ulnar claw hand, 71% of patients recovered sensitivity greater or equal to S3 but with cold intolerance in 42% of the cases. The combined median and ulnar sections had a poorer sensory-motor prognosis. Revision surgery was necessary in 12 of these cases.ConclusionSensory recovery after an isolated ulnar nerve lesion at the wrist is better than after an isolated median nerve lesion but there is no difference in the motor recovery. Combined median and ulnar lesions have an especially bad prognosis and may require secondary palliative surgery. The existence of nerve contusion and a high number of tendon injuries were factors associated with a poorer prognosis.     

Intratendinous ganglion cyst of the extensor digitorum longus tendon: A case report

IntroductionGanglion cysts are benign lesions, common in the hand and wrist. Intratendinous ganglion, however, are rare. We present the first reported case of an intratendinous ganglion cyst in an extensor digitorum longus (EDL) tendon of the foot.Case reportA 35-year old presented with a left-sided painful dorsolateral foot swelling. Ultrasound suggested a ganglion cyst in proximity to the EDL tendon of the 5th toe. Two distinct swellings were identified on surgical exploration, including a 6 × 1 cm ganglion lying within the EDL tendon substance that had resulted in tendon splitting. The lesions were excised and EDL tendon repaired. Histological analysis confirmed that both lesions were ganglion cysts. Post-operative recovery was uneventful.DiscussionIntratendinous ganglion cysts are rare lesions that pose a unique set of diagnostic and treatment challenges. Unlike conventional ganglion, their diagnosis may not be possible until surgical exploration. They have been reported to increase the risk of spontaneous tendon rupture. As such, a lower operative threshold should be applied to prevent their progression. A high index of suspicion should be applied to any ganglion reported radiologically to be in close contact with tendons. If diagnosed upon surgical exploration, it is essential that the operating surgeon is prepared to appropriately modify the procedure to involve primary tendon repair, tendon transfer or tenodesis.