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

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)

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)

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.

 

Longer duration of operative time enhances healing metabolites and improves patient outcome after Achilles tendon rupture surgery (2018)

Type of publication:
Journal article

Author(s):
Svedman S.; Aufwerber S.; Ackermann P.W.; Westin O.; Nilsson-Helander K.; *Carmont M.R.; Karlsson J.; Edman G.

Citation:
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA; Jul 2018; vol. 26 (no. 7); p. 2011-2020

Abstract:
PURPOSE: The relationship between the duration of operative time (DOT), healing response and patient outcome has not been previously investigated. An enhanced healing response related to DOT may potentiate repair processes, especially in hypovascular and sparsely metabolized musculoskeletal tissues such as tendons. This study aimed to investigate the association between DOT and the metabolic healing response, patient reported outcome and the rate of post-operative complications after acute Achilles tendon injury.METHODS: Observational cohort, cross-sectional study with observers blinded to patient grouping. A total of two-hundred and fifty-six prospectively randomized patients (210 men, 46 women; mean age 41 years) with an acute total Achilles tendon rupture all operated on with uniform anaesthetic and surgical technique were retrospectively assessed. At 2 weeks post-operatively, six metabolites were quantified using microdialysis. At 3, 6 and 12 months, patient-reported pain, walking ability and physical activity were examined using self-reported questionnaires, Achilles tendon total rupture score, foot and ankle outcome score and physical activity scale. At 12 months, functional outcome was assessed using the heel-rise test. Complications, such as deep venous thrombosis, infections and re-operations, were recorded throughout the study.RESULTS: Patients who underwent longer DOT exhibited higher levels of glutamate (p = 0.026) and glycerol (p = 0.023) at 2 weeks. At the 1-year follow-up, longer DOT was associated with significantly less loss in physical activity (p = 0.003), less pain (p = 0.009), less walking limitations (p = 0.022) and better functional outcome (p = 0.014). DOT did not significantly correlate with the rate of adverse events, such as deep venous thrombosis, infections or reruptures. Higher glutamate levels were associated with less loss in physical activity (p = 0.017). All correlations were confirmed by multiple linear regressions taking confounding factors into consideration.CONCLUSION: The results from this study suggest a previously unknown mechanism, increased metabolic response associated with longer DOT, which may improve patient outcome after Achilles tendon rupture surgery. Allowing for a higher amount of traumatized tissue, as reflected by up-regulation of glycerol in patients with longer DOT, may prove to be an important surgical tip for stimulation of repair of hypometabolic soft tissue injuries, such as Achilles tendon ruptures.II.

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Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair (2018)

Type of publication:
Journal article

Author(s):
Braunstein, Mareen; Baumbach, Sebastian F; Boecker, Wolfgang; *Carmont, Mike R; Polzer, Hans

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA; Mar 2018; vol. 26 (no. 3); p. 846-853

Abstract:
PURPOSE Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair. METHODS A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included. RESULTS One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment. CONCLUSION Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician. LEVEL OF EVIDENCE II.

Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures (2017)

Type of publication:
Journal article

Author(s):
*Carmont, Michael R; Kuiper, Jan Herman; Grävare Silbernagel, Karin; Karlsson, Jón; Nilsson-Helander, Katarina

Citation:
of experimental orthopaedics; Dec 2017; vol. 4 (no. 1); p. 26

Abstract:
BACKGROUND Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading.METHODSNineteen bovine Achilles tendons were repaired using a percutaneous/ minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with  early range of motion training and weight-bearing, before being loaded to failure.RESULTS Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. CONCLUSION The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.

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Functional outcomes of achilles tendon minimally invasive repair using 4- and 6-strand nonabsorbable suture: A cohort comparison study (2017)

Type of publication:
Journal article

Author(s):
*Carmont M.R.; Brorsson A.; Olsson N.; Nilsson-Helander K.; Karlsson J.; Zellers J.A.; Silbernagel K.G.

Citation:
Orthopaedic Journal of Sports Medicine; Jan 2017; vol. 5 (no. 8)

Abstract:
Background: The aim of management of Achilles tendon rupture is to reduce tendon lengthening and maximize function while reducing the rerupture rate and minimizing other complications. Purpose: To determine changes in Achilles tendon resting angle (ATRA), heel-rise height, patient-reported outcomes, return to play, and occurrence of complications after minimally invasive repair of Achilles tendon ruptures using nonabsorbable sutures. Study Design: Cohort study; Level of evidence, 3. Methods: Between March 2013 and August 2015, a total of 70 patients (58males, 12 females) with amean age of 42 +/- 8 years were included and evaluated at 6 weeks and 3, 6, 9, and 12 months after repair of an Achilles tendon rupture. Surgical repair was performed using either 4-strand or 6-strand nonabsorbable sutures. After surgery, patients were mobilized, fully weightbearing using a functional brace. Early active movement was permitted starting at 2 weeks. Results: There were no significant differences in the ATRA, Achilles Tendon Total Rupture Score (ATRS), and Heel-Rise Height Index (HRHI) between the 4- and 6-strand repairs. The mean (SD) relative ATRA was -13.1degree (6.6degree) (dorsiflexion) following injury; this was reduced to 7.6degree (4.8degree) (plantar flexion) directly after surgery. During initial rehabilitation at 6 weeks, the relative ATRA was 0.6degree (7.4degree) (neutral) and -7.0degree (5.3degree) (dorsiflexion) at 3 months, after which ATRA improved significantly with time to 12 months (P = .005). At 12 months, the median ATRS was 93 (range, 35-100), and the mean (SD) HRHI and Heel-Rise Repetition Index were 81% (0.22%) and 82.9% (0.17%), respectively. The relative ATRA at 3 and 12 months correlated with HRHI (r = 0.617, P < .001 and r = 0.535, P < .001, respectively). Conclusion: Increasing the number of suture strands from 4 to 6 does not alter the ATRA or HRHI after minimally invasive Achilles tendon repair. The use of a nonabsorbable suture during minimally invasive repair when used together with accelerated rehabilitation did not prevent the development of an increased relative ATRA. The ATRA at 3months after surgery correlated with heel-rise height at 12 months.

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Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures (2017)

Type of publication:
Journal article

Author(s):
*Carmont M.R.; Kuiper J.H.; Gravare Silbernagel K.; Karlsson J.; Nilsson-Helander K.

Citation:
Journal of Experimental Orthopaedics; Dec 2017; vol. 4 (no. 1)

Abstract:
Background: Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading. Methods: Nineteen bovine Achilles tendons were repaired using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weight-bearing, before being loaded to failure. Results: Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. Conclusion: The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.

Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair. (2018)

Type of publication:
Journal article

Author(s):
Braunstein M, Baumbach SF, Boecker W, *Carmont MR, Polzer H.

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy. 2018 Mar;26(3):846-853

Abstract:
Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair.
METHODS: A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included.
RESULTS: One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment.
CONCLUSION: Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician.
LEVEL OF EVIDENCE: II.