Achilles tendon

Musculotendinous ruptures of the achilles tendon had greater heel-rise height index compared with mid-substance rupture with non-operative management: A retrospective cohort study (2023)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R; Gunnarsson, Baldvin; Brorsson, Annelie; Nilsson-Helander, Katarina.

Citation:
Journal of Isakos. 2023 Dec 27.

Abstract:
INTRODUCTION: Achilles tendon ruptures (ATRs) may occur at varying locations with ruptures at the mid-substance (MS) of the tendon most common, followed tears at the musculotendinous (MT) junction. There is scant literature about the outcome of MT ATR. This study compared the outcome of patients with a MT ATR with patients following a MS ATR. METHODS: The diagnostic features and clinical outcome of 37 patients with a MT ATR were compared with a cohort of 19 patients with a MS ATR. Patients in both groups were managed non-operatively and received the same rehabilitation protocol with weight-bearing rehabilitation in protective functional brace. RESULTS: From February 2009 to August 2023, 556 patients presented with an ATR. Of these, 37 (6.7 %) patients were diagnosed with a MT tear. At final follow-up, at 12 months following injury, the MT group reported an Achilles tendon total rupture score (ATRS) of mean (standard deviation (SD)) of 83.6 (3.5) (95 % confidence interval (CI) 81.8, 85.4) and median (inter-quartile range (IQR)) ATRS of 86 points (78-95.5) and the MS group mean (SD) of 80.3 (8.5) (95%CI) 76.1, 80.5) and median (IQR) of 87 points (59-95) (p = 0.673). Functional evaluation, however, revealed statistically significant differences in mean (SD) heel-rise height index MT group 79 % (25) (95%CI 65.9, 92.1) and MS group 59 % (13) (95%CI 51.9, 67.1) (p = 0.019). In the MT rupture group, there were considerably less complications than the MS rupture group. CONCLUSIONS: When managed non-operatively, with only a 6 weeks period of brace protection, patients have little limitation although have some residual reduction of single heel-rise at the one-year following MT ATR. LEVEL OF EVIDENCE: IV.

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Endoscopically assisted reconstruction of chronic Achilles tendon ruptures and re-ruptures using a semitendinosus autograft is a viable alternative to pre-existing techniques (2022)

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Type of publication:
Journal article

Author(s):
Nilsson N; Gunnarsson B; *Carmont MR; Brorsson A; Karlsson J; Nilsson Helander K

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy : official journal of the ESSKA, 2022 Apr 09 [epub ahead of print]

Abstract:
Purpose: Achilles tendon ruptures are termed chronic after a delay in treatment for more than 4 weeks. The literature advocates surgical treatment with reconstruction to regain ankle push-off strength. The preferred technique is, however, still unknown and is often individualized. This study aims to present the technique and clinical outcome of an endoscopically assisted free semitendinosus reconstruction of chronic Achilles tendon rupture and Achilles tendon re-ruptures with delayed representation. It is hypothesized that the presented technique is a viable and safe alternative for distal Achilles tendon ruptures and ruptures with large tendon gaps.
Method: Twenty-two patients (13 males and 9 females) with a median (range) age of 64 (34-73) treated surgically with endoscopically assisted Achilles tendon reconstruction using a semitendinosus autograft were included. The patients were evaluated at 12 months post-operatively for Achilles tendon Total Rupture Score (ATRS), calf circumference, Achilles Tendon Resting Angle (ATRA), heel-rise height and repetitions together with tendon length determined by ultrasonography, concentric heel-rise power and heel-rise work.
Results: The patients reported a median (range) ATRS of 76 (45-99) out of 100. The median (range) ATRA on the injured side was 60° (49°-75°) compared with 49.5° (40-61°), p < 0.001, on the non-injured side. Eighteen out of 22 patients were able to perform a single-leg heel-rise on the non-injured side. Sixteen patients out of those 18 (89%) were also able to perform a single heel-rise on the injured side. They did, however, perform significantly lower number of repetitions compared with the non-injured side with a median (range) heel-rise repetitions of 11 (2-22) compared with 26 (2-27), (p < 0.001), and a median (range) heel-rise height of 5.5 cm (1.0-11.0 cm) compared with 9.0 cm (5.0-11.5 cm), (p < 0.001). The median calf circumference was 1.5 cm smaller on the injured side, 37.5 cm compared with 39 cm, when medians were compared. The median (range) tendon length of the injured side was 24.8 cm (20-28.2 cm) compared with 22 cm (18.4-24.2 cm), (p < 0.001), on the non-injured side.
Conclusion: The study shows that endoscopically assisted reconstruction using a semitendinosus graft to treat chronic Achilles tendon ruptures and re-ruptures with delayed representation produces a satisfactory outcome. The technique can restore heel-rise height in patients with more distal ruptures or large tendon defects and is therefore a viable technique for Achilles tendon reconstruction.
Level of Evidence: IV.

The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture (2022)

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Type of publication:Journal article

Author(s):*Carmont, Michael R; Knutsson, Sara Brandt; Brorsson, Annelie; Karlsson, Jón; Nilsson-Helander, Katarina

Citation:Knee Surgery, Sports Traumatology, Arthroscopy : official journal of the ESSKA; Mar 2022; vol. 30 (no. 3); p. 1109-1117

Abstract:PURPOSE Operative repair of Achilles tendon rupture may lead to complications, which influence outcome adversely. The aim of this study was to determine the incidence, impact and response to treatment of post-operative adhesions. METHODS From February 2009 to 2021, 248 patients operated on with percutaneous or minimally invasive surgical repair have been prospectively evaluated using the Achilles tendon Total Rupture Score (ATRS) and Heel-Rise Height Index (HRHI), following acute Achilles tendon rupture. RESULTS Fourteen (5.6%) patients were identified as having adhesions. Four patients reported superficial adhesions and ten patients reported a deeper tightness of the tendon. At a mean (SD) of 10.5 (2.3) months following repair, the overall ATRS was at a median (IQR) 65 (44.5-78) points and (HRHI) was mean (SD) 81.5 (13.5)%. Of those deemed to have deep adhesions the antero-posterior diameter of the tendon was at mean (SD) 15.6 (4.6) mm. Open release of superficial adhesions resulted in improved ATRS in all patients. Endoscopic debridement anterior to the Achilles tendon led to alleviation of symptoms of tightness and discomfort from deep adhesions and improved outcome in terms of the ATRS score. At a mean (SD) of 15.9 (3.3)-month follow-up from initial rupture and repair, the patients reported at median (IQR) ATRS scores of 85 (64.8-92.8) points, Tegner level 5 (3-9) and mean (SD) HRHI 86.2 (9.5)%. Patients significantly improved both ATRS and HRHI following release at median (IQR) of 16.5 (- 1.8-29.3) points (p = 0.041) and mean (SD) 5.6 (8.3)% (p = 0.043). CONCLUSIONS The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. The occurrence of superficial adhesions was associated with a lower outcome scores as well as symptoms of anterior tendon tightness and stiffness were associated with a lower score in most patients. Surgical release of adhesions led to a significant improvement in outcome.

MRI of the Achilles tendon - a comprehensive pictorial review. Part two (2021)

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Type of publication:
Journal article

Author(s):
Szaro P.; Nilsson-Helander K.; *Carmont M.

Citation:
European Journal of Radiology Open; Jan 2021; vol. 8

Abstract:
The most common disorder affecting the Achilles tendon is midportion tendinopathy. A focal fluid signal indicates microtears, which may progress to partial and complete rupture. Assessment of Achilles tendon healing should be based on tendon morphology and tension rather than structural signal. After nonoperative management or surgical repair of the Achilles tendon, areas of fluid signal is pathologic because it indicates re-rupture. A higher signal in the postoperative Achilles tendon is a common finding and is present for a prolonged period following surgical intervention and needs to be interpreted alongside the clinical appearance.

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MRI of the Achilles tendon-A comprehensive pictorial review. Part one (2021)

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Type of publication:
Journal article

Author(s):
Szaro P.; Nilsson-Helander K.; *Carmont M.

Citation:
European Journal of Radiology Open; Jan 2021; vol. 8

Abstract:
The normal Achilles tendon is composed of twisted subtendons separated by thin high signal septae, which are a potential pitfall on MRI because they mimic a tendon tear. Tendinopathy and full thickness tears may be assessed effectively both on MRI and ultrasound. MRI is superior to ultrasound in detection of partial tears and for postoperative assessment. The use of fat suppression sequences allows the ability to detect focal lesions. Sagittal and coronal sections are useful for assessing the distance between stumps of a ruptured tendon. Sequences with contrast are indicated in postoperative investigations and suspicion of infection, arthritis or tumor. MRI may reveal inflammatory changes with minor symptoms long before the clinical manifestations of seronegative spondyloarthropathy. The most common non-traumatic focal lesion of the Achilles tendon is Achilles tendon xanthoma, which is manifested by intermediate or slightly higher signal on T1- and T2-weighted images compared to that in the normal Achilles tendon. Other tumors of the Achilles tendon are very rare, whereas the involvement of the tendon from tumor in adjacent structures is more frequent. The novel MRI sequences may help to detect disorders of the Achilles tendon more specifically before clinical manifestation. Regeneration or remodeling of the Achilles tendon can be non-invasively detected and monitored in diffusion tensor imaging. Assessment of healing is possible using T2-mapping while evaluating the tendon vascularization in intravoxel incoherent motion MRI.

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No difference in Achilles Tendon Resting Angle, Patient-reported outcome or Heel-rise height Index between Non- and Early-weightbearing the First Year after an Achilles Tendon Rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont M; Brorsson, A.; Karlsson, J.; Nilsson-Helander, K.

Citation:
Muscles, Ligaments & Tendons Journal (MLTJ); Oct 2020; vol. 10 (no. 4); p. 651-658

Abstract:
Background. Patient-reported outcome scores and comparable re-rupture rates in randomized controlled trials have not shown a definitive benefit for operative treatment after acute Achilles tendon rupture. This, together with the increasing rupture rates in the older age group has led to non-operative treatment being increasingly used. Objective. This study aimed to determine the variation in Achilles Tendon Resting Angle (ATRA) together with patient reported and functional outcome, with non-operative management of the ruptured Achilles tendon using two different regimes, which have been shown to offer low re-rupture rates. Methods. This is a non-randomised cohort comparison of Achilles tendon rupture patients managed with Non-Weight-Bearing (NWB) for 6 weeks vs. Early Weight-Bearing (EWB). The NWB-group received a cast in plantar flexion for 2 weeks followed by 6 weeks in a controlled ankle motion boot with incremental diminishing plantar flexion. The EWB-group received an initial anterior protective plaster slab in plantar flexion followed by 6 weeks of weight-bearing on the meta-tarsal heads, with an anterior shell restricting dorsiflexion. Results. At 12 months after the injury there were no differences in any of the variables between the two treatment groups. The NWB-group compared to the EWB-group reported at mean (SD) for ATRA -9.8° (4.6°) versus -11.4° (5°), p=0.32, for Achilles tendon Total Rupture Score (ATRS) 87 (10) versus 79 (19), p=0.43 and for Heel-Rise Height Index (HRHI) 71% (19%) versus 59% (13%), p=0.13. Conclusions. The two methods of non-operative treatment studied lead to increased relative ATRA following injury, however, patients report only minor limitation in terms of outcome. Patients had almost a third less heel-rise height compared with the non-injured ankle.

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The reliability, reproducibility and utilization of the radiographic Achilles Tendon Loading Angle in the management of Achilles Tendon rupture (2021)

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Type of publication:
Journal article

Author(s):
*Carmont M.R.; *Littlehales J.; Brorsson A.; Karlsson J.; Nilsson-Helander K.; Barfod K.W.; Ginder L.

Citation:
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons; Oct 2021; vol. 27 (no. 7); p. 760-766

Abstract:
Background: During 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. Method(s): A 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. Result(s): The 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). Conclusion(s): The 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.

No difference in strength and clinical outcome between early and late repair after Achilles tendon rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R; Zellers, Jennifer A; Brorsson, Annelie; Silbernagel, Karin Grävare; Karlsson, Jón; Nilsson-Helander, Katarina

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA; May 2020; vol. 28 (no. 5); p. 1587-1594

Abstract:
PURPOSE This retrospective study aimed to determine the patient-reported and functional outcome of patients with delayed presentation, who had received no treatment until 14 days following injury of Achilles tendon rupture repaired with minimally invasive surgery and were compared with a group of sex- and age-matched patients presenting acutely. Based on the outcomes following delayed presentation reported in the literature, it was hypothesized that outcomes would be inferior for self-reported outcome, tendon elongation, heel-rise performance, ability to return to play, and complication rates than for acutely managed patients.
METHODS Repair was performed through an incision large enough to permit mobilisation of the tendon ends, core suture repair consisting of a modified Bunnell suture proximally and a Kessler suture distally and circumferential running suture augmentation.
RESULTS Nine patients presented 21.8 (14.9) days (range 14-42 days) after rupture. The rate of delayed presentation was estimated to be 1 in 10. At 12 months following repair, patients with delayed treatment had median (range) ATRS score of 90 (69-99) compared with 94 (75-100) in patients treated acutely presenting 0.66 (1.7) (0-5) days. There were no significant differences between groups: ATRA [mean (SD) delayed: – 6.9° (5.5), acute: – 6° (4.7)], heel-rise height index [delayed: 79% (20), acute: 74% (14)], or heel-rise repetition index [delayed: 77% (20), acute: 71% (20)]. In the delayed presentation group, two patients had wound infection and one iatrogenic sural nerve injury.
CONCLUSIONS Patients presenting more than 2 weeks after Achilles tendon rupture may be successfully treated with minimally invasive repair. LEVEL OF EVIDENCE III.

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Age and Tightness of Repair Are Predictors of Heel-Rise Height After Achilles Tendon Rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R.; Zellers, Jennifer A.; Brorsson, Annelie; Nilsson-Helander, Katarina; Karlsson, Jón; Grävare Silbernagel, Karin

Citation:
Orthopaedic Journal of Sports Medicine; Mar 2020; vol. 8 (no. 3); p. 1-8

Abstract:
Background: Achilles tendon rupture leads to weakness of ankle plantarflexion. Treatment of Achilles tendon rupture should aim to restore function while minimizing weakness and complications of management. Purpose: To determine the influence of factors (age, sex, body mass index [BMI], weight, time from injury to operative repair, and tightness of repair) in the initial surgical management of patients after an acute Achilles tendon rupture on 12-month functional outcome assessment after percutaneous and minimally invasive repair. Study Design: Cohort study; Level of evidence, 3. Methods: From May 2012 to January 2018, patients sustaining an Achilles tendon rupture receiving operative repair were prospectively evaluated. Tightness of repair was quantified using the intraoperative Achilles tendon resting angle (ATRA). Heel-rise height index (HRHI) was used as the primary 12-month outcome variable. Secondary outcome measures included Achilles tendon total rupture score (ATRS) and Tegner score. Stepwise multiple regression was used to create a model to predict 12-month HRHI. Results: A total of 122 patients met the inclusion criteria for data analysis (mean ± SD age, 44.1 ± 10.8 years; 78% male; mean ± SD BMI, 28.1 ± 4.3 kg/m2). The elapsed time to surgery was 6.5 ± 4.0 days. At 12-month follow-up, patients had an HRHI of 82% ± 16% and performed 82% ± 17% of repetitions compared with the noninjured side. Participants had a mean ATRS of 87 ± 15 and a median Tegner score of 5 (range, 1-9), with a reduction in Tegner score of 2 from preinjury levels. The relative ATRA at 12 months was –4.8° ± 3.9°. Multiple regression identified younger age (B = ±0.006; P <.001) and greater intraoperative ATRA (B = 0.005; P =.053) as predictors of more symmetrical 12-month HRHI (R 2 = 0.19; P <.001; n = 120). Conclusion: Age was found to be the strongest predictor of outcome after Achilles tendon rupture. The most important modifiable risk factor was the tightness of repair. It is recommended that repair be performed as tight as possible to optimize heel-rise height 1 year after Achilles tendon rupture and possibly to reduce tendon elongation.

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Pitfalls in the study of neovascularisation in achilles and patellar tendinopathy: a review of important factors for clinicians to consider and the need for greater standardisation (2019)

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Type of publication:
Journal article

Author(s):
Fallows, R. and *Lumsden, G.

Citation:
Physical Therapy Reviews; Dec 2019 Vol. 24(6) p.346-357

Abstract:
Background: The search for new vessels in pathological tendons is a relatively new field. In spite of a rapid growth in research and clinical experience, there is still poor agreement in the musculoskeletal community regarding the significance and measurement of so called “neovascularisation”. Any relationship between vascularity, tendon healing, degeneration and pain is not yet clear, as it has been considered as a normal physiological adaptation to loading yet also seen in chronic painful Achilles tendons. An expression of the degree of “neovascularisation” could potentially have significance if the amount of neovascularisation could be related to the degree of symptoms or dysfunction caused by the pathology in the tendon.
Objectives: This review examines the potential variables that can affect the quantification of the Doppler signal in Achilles and patellar tendinopathy under three perspectives. Firstly, the variables that arise from the actual technology that allows the capturing of the Doppler signal from intra-tendinous microvasculature flow, secondly by an awareness of known and highly likely physiological factors that may alter the rate of flow and thirdly by an exploration describing the actual methods and qualities of acquiring quantitative data of the microvascular flow with Doppler.
Methods: A literature search was conducted across AMED, CINAHL, Google Scholar, SPORTDiscus, MEDLINE and NCBI (PubMed) for studies related to the qualitative or quantitative measure of the Doppler signal in relation to a clinical outcome of Achilles or patellar tendinopathy. Parameters regarding machine settings and examination conditions were extracted to identify the utilisation of important factors and consistency with a narrative analysis.
Discussion: Many of these influential factors have never been controlled for in previous studies and the methods have been unreliable and poorly reported. There is a need for international agreement on a standardised protocol in the assessment of the microvascularity of tendons, which could then help determine if the quantification of “neovascularisation” is a reliable and clinically relevant finding.