Accelerated rehabilitation following Achilles tendon repair after acute rupture – Development of an evidence-based treatment protocol

The acute rupture of the Achilles tendon is a protracted injury. Surgery is only the beginning of a long rehabilitation period. Therefore, the rehabilitation protocol is an integral aspect to restore the pre-injury activity level. Despite several trials available comparing different treatment regimes, there is still no consensus regarding the optimal protocol. Consequently, the aim of our study was to systematically search the evidence available and define a precise rehabilitation programme after operative repair of acute Achilles tendon rupture based on the trials with the highest level of evidence.We performed a systematic literature search in Medline, Embase and Cochrane library. We identified twelve randomized controlled trials comparing different treatment regimes after operative repair of the Achilles tendon.Five trials compared full to non weight bearing, all applying immobilization in equinus. Immediate full weight bearing led to significant higher patient satisfaction, earlier ambulation and return to pre-injury activity. Four trials compared early ankle mobilization to immobilization. All trials found mobilization to be superior as it shortens time to return to work and sports significantly. Three trials compared the combination of full weight bearing and early ankle mobilization to immobilization. This combination was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced atrophy and tendon elongation. No study found an increased rerupture rate for the more progressive treatment.In conclusion, the rehabilitation protocol after Achilles tendon repair should allow immediate full weight bearing. After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied.     

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.

Chronic rupture of Achilles tendon: is the percutaneous suture technique effective?

Background We report the long-term results of the surgical treatment of chronic rupture of the Achilles tendon using percutaneous suturing under local anesthesia. Patients and methods We operated on 22 patients with median age of 50 years (29–72) with chronic rupture of Achilles tendon between 1991 and 2005. The median time from injury to surgery was 7.1 weeks (4–40). We used percutaneous surgical technique similar to a technique described by Ma and Griffith (1977, Clin Orthop Relat Res 128:247–255) and Kosanović (1994, Arch Orthop Trauma Surgery 113:177–179). Eighteen (82%) patients attended the clinical review at a mean of 67 months (14–176). During follow up, patients were asked about pain, stiffness, weakness of the calf, footwear restrictions, occupation and level of activity before and after injury (Tegner score), influence of injury on ADL activities and satisfaction with treatment. The passive and active range of movement of the ankle and the power of isometric plantar flexion were measured, and the endurance test was performed. Functional assessment was performed using a Leppilahti clinical scoring scale and a modified Merkel score Results Complete healing of the tendon was achieved in 21 patients (95%). In 17 patients (77%) the postoperative course was complications free. There were no reruptures during the observation period. All were able to stand on the tiptoe of the injured leg. The operated leg had a mean of 87.5% of the isometric power compared with the uninjured leg (p = NS). On an average they could stand on toes and raise the heel 13 times on side with the ruptured tendon. The Leppilahti scoring scale revealed a result that was excellent for 11 patients (62%), good for 2 (11%), fair for 5 (28%) and no one had poor result. The average score was 83.3 (60–100). Eighty-three percent of patients stated that the result of surgery was very good and 11% rated it as good. Fourteen patients (78%) returned to same level of activity at median 7 months after surgery. Conclusions Our series is one of the largest to be reported for the treatment of chronic rupture. Our technique offers a considerable advantage; it is minimal invasive, easy to perform with no associated harvesting morbidity and increased patient acceptance. We recommend this technique for the treatment of chronic rupture of Achilles tendon.     

Is open acute Achilles tendon rupture repair still justified? A single center experience and critical appraisal of the literature

IntroductionAcute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures.MethodsBetween June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved.ResultsWe recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5–39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21–63) and 28 (IQR 15–28). Nevertheless, a difference of 10 points is considered clinically relevant.ConclusionThe overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed.     

How early is early laparoscopic treatment of acute cholecystitis?

BACKGROUND: Despite the well-accepted success of laparoscopic cholecystectomy in elective treatment of symptomatic cholelithiasis, the efficacy and timing of this technique has been subject to some debate in the setting of acute cholecystitis. This study was undertaken to evaluate our institution's experience with early cholecystectomy as a safe, effective treatment of acute cholecystitis. METHODS: Charts of all patients who had undergone laparoscopic cholecystectomy for the diagnosis of acute cholecystitis were reviewed. Patients were divided into two groups based on the length of time from onset of symptoms to surgical intervention: less than 48 hours in the early group (n = 14) and more than 48 hours in the late group (n = 31). RESULTS: Comparing the two groups, the conversion rate to an open procedure was significantly less (0 versus 29%, P <0.04) in the early treated patients. Furthermore, the operative time (73 versus 96 minutes, P <0.004), postoperative hospitalization (1.2 versus 3.9 days, P <0.001), and total hospital stay (2.1 versus 5.4 days, P <0.004) were significantly reduced in patients undergoing early laparoscopic cholecystectomy. CONCLUSIONS: Laparoscopic cholecystectomy performed by experienced surgeons is a safe, effective technique for treatment of acute cholecystitis. Patients treated within 48 hours of onset of symptoms experience a lower conversion rate to an open procedure, shorter operative time and reduced hospitalization.     

Surgical versus non-surgical treatment for acute Achilles’ tendon rupture. A systematic review of literature and meta-analysis

BackgroundAchilles’ tendon injury affect 31.17 per 100,000 yearly, it has a major impact on quality of life of affected patients, mostly active young individuals. Different management options exist ranging from conservative treatment, to operative repair either open or percutaneous repair. No consensus has been reached on which treatment modality is preferred for each patient. In this study we systematically reviewed the literature for available evidence regarding management of acute Achilles’ tendon rupture.MethodsThis systematic review consisted of 9 studies, including a systematic search of literature (PubMed, SCOPUS, and The Cochrane Library), selection of studies, extraction of study characteristics, assessment of methodological quality and bias and extraction of data on clinical outcomes and their comparisons between different surgical groups.ResultsA total of 9 studies were included, 822 patients were extracted from the included studies. Of the 822 patients, 415 (50.4%) had undergone surgical intervention and 407 (49.6%) had received non-surgical treatment. The minimum follow-up duration was 12 months. The left Achilles' tendon was relatively more prone to rupture. The interval from injury to treatment was within 2 to 14 days. Five 5 different surgical techniques were used; end to end, modified Kessler, augmented repair, Krackow type and interrupted circumferential stitch. Operative repair was found to significantly decrease rupture rate (Risk Ratio of 0.36, 95% CI 0.21–0.64; P = 0.0005) with higher risk of wound complications. No statistically significant difference between the two groups in functional outcome scores and range of motion.ConclusionWe concluded that surgical technique lowers the risk of rerupture rate but associated with higher complication rate which can be reduced by using the minimally invasive techniques. Multicenter randomized clinical trials are needed to obtain a high-quality level of evidence for the comparison between the different modified surgical techniques and the gap effect on making different decision of managements.     

Evolution of the Achilles tendon: The athlete's Achilles heel?

The Achilles tendon is believed to have first developed two million years ago enabling humans to run twice as fast. However if the Achilles tendon is so important in terms of evolution, then why is this tendon so prone to injury – especially for those more active like athletes. The Achilles tendon had an integral role in evolving apes from a herbivorous diet to early humans who started hunting for food over longer distances, resulting in bipedal locomotion. Evolutionary advantages of the Achilles tendon includes it being the strongest tendon in the body, having an energy-saving mechanism for fast locomotion, allows humans to jump and run, and additionally is a spring and shock absorber during gait. Considering these benefits it is therefore not surprising that studies have shown athletes have thicker Achilles tendons than subjects who are less active. However, contradictory to these findings that show the importance of the Achilles tendon for athletes, it is well known that obtaining an Achilles tendon injury for an athlete can be career-altering. A disadvantage of the Achilles tendon is that the aetiology of its pathology is complicated. Achilles tendon ruptures are believed to be caused by overloading the tensed tendon, like during sports. However studies have also shown athlete Achilles tendon ruptures to have degenerative changes in the tendon. Other flaws of the Achilles tendon are its non-uniform vascularity and incomplete repair system which may suggest the Achilles tendon is on the edge of evolution. Research has shown that there is a genetic influence on the predisposition a person has towards Achilles tendon injuries. So if this tendon is here to stay in our anatomy, and it probably is due to the slow rate of evolution in humans, research in genetic modification could be used to decrease athletes’ predisposition to Achilles tendinopathy.     

Is Achillon repair safe and reliable in delayed presentation Achilles tendon rupture? A five-year follow-up

Background

To assess the outcome of delayed repair of ruptured Achilles tendon using the Achillon mini-open technique.

Reconstruction of segmental defects of Achilles tendon: Is it a must in infected complex defects?

Loss of Achilles tendon combined with overlying soft tissue loss is a challenging problem. Multiple techniques like tendon graft with coverage by soft tissue flap or composite flaps have been used. All these options are technically demanding. Reports do exist whereby muscle flaps bridging the defect used as cover in course of time could transmit the tendon force across the defect. We are presenting a case where a free gracilis muscle flap used to cover the soft tissue defect at the Achilles tendon at 2 years follow up provided stable cover and produced active function of the Achilles tendon allowing the patient to stand tip toe. Mechanism of its action has been analysed by MRI and M-mode ultrasound. While in primary Achilles tendon injury reconstruction is still the recommended option, in complex situations mere filling of the gap with the flap without formal reconstruction of the tendon could give good functional outcome. This technique can be used in demanding situations.KEY WORDS: Achilles tendon, gracilis, muscle flap, reconstruction     

How quickly can acute symptomatic hyponatremia be corrected?

The systemic absorption of the flush liquid, including sorbitol, glycine or mannitol, can lead to complications, such as hyponatremia, volume overload and pulmonary or cerebral edema. Acute hyponatremia is defined as a reduction in the plasma sodium level in less than 48 h. Acute symptomatic hyponatremia should be corrected aggressively because it may cause irreversible neurological damage and death. Rapid correction of hyponatremia causes severe neurologic deficits, such as central pontine myelinolysis; thus, the optimal therapeutic approach has been debated. This article examined acute symptomatic hyponatremia in a patient undergoing transcervical myomectomy for a submucosal myoma. A thirty-seven-year-old patient was evaluated in obstetrics and gynecology clinic because of altered mental status and agitation. There was no history of chronic illness or drug use. It was discovered that during the operation, 12 L of the flush fluid, which contained 5 % mannitol, had been infused, but only 7 L of the flush fluid had been collected. On physical examination, the patient’s general condition was moderate, her cooperation was limited, she was agitated, and her blood pressure was 120/70 mmHg. The sodium level was 99 mEq/L. Furosemid and 3 % NaCl solution were given. Her serum sodium returned to normal by increasing 39 mEq/L within 14 h. Her recovery was uneventful, and she was discharged 24 h after her serum sodium returned to normal. In conclusion, if there is a difference between the infused and collected volumes of the mannitol irrigant, severe hyponatremia may develop due to the flush fluid used during transcervical hysteroscopy and myomectomy. In these patients, acute symptomatic hyponatremia may be corrected as rapidly as the sodium level dropped.     

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.     

Can an early peri-anastomotic LITA stenosis be reversible?

Peri-anastomotic graft stenosis is a possible complication of coronary artery bypass graft operations. Early failure of myocardial revascularization may result from graft stenosis with inherent difficulties in perioperative diagnosis and subsequent management. We report the case of a 58-year-old man who experienced early preanastomotic left internal thoracic artery bypass stenosis that progressively resolved during a 2-year period without reoperation or interventional angioplasty. Although the mechanisms underlying graft stenosis remain unclear, this case emphasizes the role of repeated coronary angiography in the choice of treatment.     

Efficacy and complications of open and minimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study—preliminary report

Purpose

Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results.

Method

We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon® device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months.

Results

No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports.

Conclusion

After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.     

How many members must an orthopaedic department have to teach effectively?

Although the subject matter contained in the curriculum of a medical school has expanded continuously, the time to present this material to the students has diminished. With the abandonment of most lectures in clinical subjects, students have been exposed to the surgical specialties by short required rotations through the services. Often these rotations are offered only as electives. However, the surgical specialties such as orthopaedic surgery have increased considerably in subject matter and scope. It no longer is possible to present the subject in a series of 10 or 12 lectures given by full-time or part-time faculty. Instead, to showcase the subject of orthopaedic surgery requires a clinical service that contains the full spectrum of the specialty from athletic injuries to scoliosis. Only in this way can the specialty attract the bright and capable students who will become the leaders of orthopaedics in the future. To field such a panoply of specialists requires a combined effort by the school, the hospital, and the private sector.     

Achilles tendon suture deteriorates tendon capillary blood flow with sustained tissue oxygen saturation – an animal study

Background  

Treatment of ruptured Achilles tendons currently constitutes of conservative early functional treatment or surgical treatment either by open or minimal invasive techniques. We hypothesize that an experimental Achilles tendon suture in an animal model significantly deteriorates Achilles tendon microcirculation immediately following suturing.     

How severe must repetitive loading be to kill chondrocytes in articular cartilage?

OBJECTIVE: Little is known about the effects of severe repetitive loading on articular cartilage chondrocytes, even though epidemiological studies associate this type of loading with osteoarthritis. We hypothesize that repetitive loading can kill cartilage chondrocytes in a dose-related manner. DESIGN: Large cartilage-on-bone specimens were cut from the patella groove of bovine knees obtained directly from a slaughterhouse. Cartilage was loaded using a flat impermeable indenter in such a manner that the loaded region was supported naturally by surrounding cartilage and subchondral bone. Specimens received 3600 cycles of compressive loading at 1 Hz, with the peak load lying in the range 1-70% of the force required to damage cartilage in a single loading cycle (35 MPa). Cell viability was assessed in thick sections of loaded and control cartilage using a paravital staining method: fluorescein diacetate stained live cells green, and propidium iodide stained dead cells red. The assay was validated on cartilage which had been subjected to repeated freeze-thaw cycles to kill the chondrocytes. RESULTS: Paravital staining revealed 100% cell death after one freeze-thaw cycle at -196 degrees C and three cycles at -20 degrees C. Baseline chondrocyte viability was 80% in unloaded cartilage, and viability decreased when applied compressive loading exceeded 6 MPa. Above this threshold, cell viability was inversely proportional to applied stress. When gross damage to the cartilage surface first became evident, above 14 MPa, 40% of cells remained viable. Load-induced chondrocyte death was greatest in the surface zone, and extended beyond the loaded area. Electron micrographs indicated that some cells were dying by apoptosis. CONCLUSIONS: Some chondrocytes are much more vulnerable to repetitive mechanical loading than others, suggesting that vigorous activity may lead to cell death in articular cartilage.