Achilles tendon

Endoscopically Assisted Reconstruction of the Achilles Tendon Using Semitendinosus Graft (2025)

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Type of publication:

Journal article

Author(s):

*Carmont, Michael R; *Saha, Arunansu; *Rhind, John-Henry; Nilsson, Niklas; Karlsson, Jon; Nilsson-Helander, Katarina.

Citation:

Video Journal of Sports Medicine. 1(5):26350254211021859, 2021 Sep-Oct.

Abstract:

Background: Chronic ruptures of the Achilles tendon may lead to symptomatic weakness, despite rehabilitation. Open reconstruction yields good outcome but has a high complication rate, notably wound problems. Endoscopically assisted free semitendinosus transfer restores ankle and preserves first metatarsophalangeal joint (MTPJ) function.

Indications: The main indication for the procedure is symptomatic chronic rupture of the Achilles tendon with a palpable tendon gap.

Technique Description: The procedure can be split into 4 stages: graft harvest, calcaneum and tunnel preparation, proximal graft attachment, and finally graft passage and screw insertion.

Discussion/Conclusion: Following reconstruction, patients use a cast in full plantar flexion for 2 weeks, then a graduated walker for full weight-bearing.

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Validation of a Composite Outcome Score for Assessing Return to Sports After Achilles Tendon Repair (2025)

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Type of publication:

Journal article

Author(s):

Lopes, Ronny; Freiha, Kinan; *Carmont, Michael R; Valentin, Eugenie; Alvino, Kylian; Mousa, Mohamed; Rauline, Gauthier; Fourchet, Francois; Picot, Brice; Hardy, Alexandre.

Citation:

American Journal of Sports Medicine. 2025 Apr 22.[epub ahead of print]

Abstract:

BACKGROUND: The Ankle-GO is a composite outcome score based on 4 functional tests and 2 patient-reported outcome measures. It was initially described and validated for its ability to predict return to sports (RTS) at the same level of play after lateral ankle sprains.

PURPOSE/HYPOTHESIS: The main aim of this study was to assess the psychometric properties of the Ankle-GO in patients after Achilles tendon repair. The second objective was to evaluate its ability to predict RTS at the same level of play. It was hypothesized that this composite outcome score is a valid and reliable tool that is able to discriminate and predict the level of RTS at 9 months after Achilles tendon repair.

STUDY DESIGN: Case-control study; Level of evidence, 3.

METHODS: This was a prospective multicenter study. Patients who were active in sports and underwent primary acute Achilles tendon repair between April 2021 and December 2022 were included. A control group comprising 30 participants with no history of lower limb injuries was also evaluated. After standard rehabilitation for the first 2 months, the Ankle-GO was administered at 6 and 9 months after repair by the same experienced physical therapist. During testing, the patients were asked whether they were able to practice their main sport again and, if so, whether at the same or a lower level of play. A comparison between control participants and patients at 9 months after surgery was performed.

RESULTS: A total of 50 patients (24 women and 26 men), with a mean age of 38.3 +/- 10.1 years, were included. No patients were lost to follow-up at 9 months. The Ankle-GO score at 6 months was 10.7 +/- 4.8. At 9 months, the score had risen by 4.8 points. All participants scored above the minimum threshold. The minimum score achieved was 3 points (n = 5 [10%]). Only 1 patient (2%) obtained the maximum score (25 points). There was a significant difference in the Ankle-GO score between patients at 6 and 9 months and between control participants and patients at 9 months after Achilles tendon repair. Of the 50 patients included in the study, 14 (28%) returned to their preinjury level of sport at 9 months. The ability of the Ankle-GO score at 6 months to predict RTS at the preinjury level at 9 months was good (area under the curve = 0.71 [95% CI, 0.56-0.85]; P < .01). A Youden index of 0.42 was observed for a cut-off score of 8 points, which corresponds to a sensitivity of 81.8% and a specificity of 41.2%.

CONCLUSION: The Ankle-GO is a valid tool to evaluate and discriminate patients during the RTS continuum after Achilles tendon repair and to predict RTS at the same level at 9 months after surgery. This composite outcome score assesses ankle function and the patient's psychological readiness to avoid premature RTS and worsening of the injury. Further studies are needed to assess its value in identifying and predicting patients at risk of a recurrence.

Fear of reinjury after acute Achilles tendon rupture is related to poorer recovery and lower physical activity postinjury (2024)

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Type of publication:

Journal article

Author(s):

Larsson, Elin; LeGreves, Agnes; Brorsson, Annelie; Eliasson, Pernilla; Johansson, Christer; *Carmont, Michael R; Nilsson Helander, Katarina.

Citation:

Journal of Experimental Orthopaedics. 11(4):e70077, 2024 Oct.

Abstract:

Purpose: The aim of this study was to investigate how fear of reinjury to the Achilles tendon affects return to previous levels of physical activity and self-reported Achilles tendon Total Rupture Score (ATRS) outcomes.

Methods: Data were collected from a large cohort of patients treated for an acute Achilles tendon rupture at Sahlgrenska University Hospital Molndal between 2015 and 2020. The ATRS and additional questions concerning fear of reinjury, treatment modality, satisfaction of treatment and recovery were analyzed 1-6 years postinjury. Analysis was performed to determine the impact of fear of reinjury on patient-reported recovery and physical activity.

Results: Of a total of 856 eligible patients, 550 (64%) answered the self-reported questionnaire and participated in the follow-up. Of the participants, 425 (77%) were men and 125 (23%) were women. ATRS, recovery in percentage, satisfaction of treatment, recovery on a 5-point scale and physical activity level post- versus preinjury were significantly related to fear of reinjury (p < 0.001). Of the nonsurgically treated patients, 59% reported fear of reinjury compared to 48% of the surgically treated patients (p = 0.024) Patients that reported fear of reinjury had a 15-point lower median ATRS score than those who did not (p < 0.001).

Conclusion: More than half of patients who have suffered an Achilles tendon rupture are afraid of reinjuring their tendon. Patients who reported fear of reinjury exhibited a significantly lower ATRS score. This indicates the importance of addressing psychological aspects in the treatment after this injury.

Level of Evidence: Level II.

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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 (2024)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R; Nilsson-Helander, Katarina; Carling, Malin.

Citation:
BMC Musculoskeletal Disorders. 25(1):610, 2024 Aug 01.

Abstract:
PURPOSE: Achilles 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. METHODS: Following 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. RESULTS: At 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. CONCLUSIONS: To 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.

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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 (2024)

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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. 9(2):148-152, 2024 Apr.

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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