Disappointment and frustration, but long-term satisfaction: patient experiences undergoing treatment for a chronic Achilles tendon rupture-a qualitative study.

BACKGROUND: Delayed treatment of Achilles tendon ruptures is generally due to either misdiagnosis or patient delay. When the treatment is delayed more than 4 weeks, the rupture is defined as "chronic", and almost always requires more invasive surgery and longer rehabilitation time compared with acute Achilles tendon ruptures. There is insufficient knowledge of patient experiences of sustaining and recovering from a chronic Achilles tendon rupture. METHODS: To evaluate patients' experiences of suffering a chronic Achilles tendon rupture, semi-structured group interviews were conducted 4-6 years after surgical treatment using a semi-structured interview guide. The data were analyzed using qualitative content analysis described by Graneheim and Lundman. RESULTS: The experiences of ten patients (65 ± 14 years, 7 males and 3 females) were summarized into four main categories: (1) "The injury", where the patients described immediate functional impairments, following either traumatic or non-traumatic injury mechanisms that were misinterpreted by themselves or the health-care system; (2) "The diagnosis", where the patients expressed relief in receiving the diagnosis, but also disappointment and/or frustration related to the prior misdiagnosis and delay; (3) "The treatment", where the patients expressed high expectations, consistent satisfaction with the surgical treatment, and addressed the importance of the physical therapist having the right expertise; and (4) "The outcomes", where the patients expressed an overall satisfaction with the long-term outcome and no obvious limitations in physical activity, although some fear of re-injury emerged. CONCLUSIONS: An Achilles tendon rupture can occur during both major and minor trauma and be misinterpreted by both the assessing health-care professional as well as the patient themselves. Surgical treatment and postoperative rehabilitation for chronic Achilles tendon rupture results in overall patient satisfaction in terms of the long-term outcomes. We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history.

Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the "GAIT" Study Group.

Surgical repair of acute mid-substance Achilles tendon ruptures is performed in active patients, but the postoperative rehabilitation program is often based on the experience of the surgeon or therapist, rather than on evidence-based protocols. The aim of the study is to establish an evidence-based protocol for rehabilitation. This study is a consensus statement. The "GAIT" study group (German, American, and Italian Tendon), an informal collection of 4 experienced foot and ankle surgeons, met to address the question of what items they felt were important relative to rehabilitate a surgically repaired Achilles tendon acute rupture. Thirty-three statements were formulated. A value of 100% agreement by all the members was set to produce a proposed consensus statement. A value of 80% consensus was set to produce "strong recommendation." A systematic review of the literature was also performed. The GAIT group reach 100% agreement on the average postoperative non-weightbearing for 2.3 weeks, the foot in plantarflexion for the first 4 weeks, avoiding ROM exercises beyond neutral, and both stretching and eccentric exercise, not started before 12 weeks. Concentric bilateral heel raises should be performed after 6 weeks, and the average return to initiate sports, was 24.4 weeks. The use of a 1/8th-1/4th inch heel cushions in daily shoes after 8 weeks, the use of an antigravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended. Given lack of established verified protocols, the recommendations by our experienced panel should be considered. These proposed consensus statements could be used as a basis for larger controlled trials, and develop best practices.

Immediate Weightbearing and Ankle Motion Exercise After Acute Achilles Tendon Rupture Repair.

The incidence of Achilles tendon rupture is increasing. Postoperative rehabilitation after repairing acute Achilles tendon rupture is very important because the choice of treatment during the rehabilitation period can influence the results. Moreover, the method of functional rehabilitation varies and is developing steadily. Recent studies recommend a functional rehabilitation protocol, and this approach is accepted widely. This study aimed to introduce our most accelerated functional rehabilitation protocol following surgery for acute Achilles tendon rupture and to review the results retrospectively. From July 2014 to July 2016, 67 patients underwent surgery for acute Achilles tendon rupture by one surgeon. Age, sex, body mass index, injury mechanism, rehabilitation method and progress, time to return to previous physical activity, and complications were evaluated. The mean time to be able to squat fully was 10 ± 4.7 (4-20) weeks. Full squatting was possible in 92.8% (52 patients). The mean time to perform a single-limb heel rise and repetitive single-limb heel rise was 12.6 ± 3.9 (6-24) and 23.3 ± 7.7 (8-40) weeks, respectively. The mean time to return to sports was 20.6 ± 5.2 (12-32) weeks. The major complication rate was 3.5% (one re-rupture and one tendon elongation). The mean pre- and postoperative Achilles Tendon Total Rupture Score was 29.5 ± 3.7 (20-38) and 79.3 ± 18.5 (20-98) points, respectively. The increase was significant (p < .01). In conclusion, immediate full weightbearing and ankle motion exercise after repair of acute Achilles tendon rupture can provide a good rehabilitation option with a low re-rupture rate and satisfactory functional results.

Meniscal Ramp Lesions and Root Tears: A Review of the Current Literature.

The importance of the menisci in providing joint stability and their role in load transmission within the knee are well understood. A growing body of literature has emerged on 2 distinct injury patterns to these crucial anatomic structures, ramp lesions and root tears. Ramp lesions may be characterized as tears at the posterior meniscocapsular junction, while root tears involve bony or soft tissue avulsion of the meniscal insertions at the anterior or posterior intercondylar regions. In this 2-part review, we present an overview of the current available literature on ramp lesions and meniscal root tears, summarizing the unique anatomic considerations, etiology, biomechanics, management decisions, clinical outcomes pertinent to these very distinct injuries.

Rehabilitation and Return to Play Following Meniscus Repair.

Injuries to the meniscus, particularly tears, can have significant negative impacts on pain, function, and quality of life. Preservation of the meniscus is favorable, especially in the athletic and active populations. While first line treatment is often nonoperative in nature, recalcitrant, and more complex tears, typically require surgery. Meniscus repair rates have increased significantly during the last 2 decades as surgical techniques and postoperative outcomes have improved. Longer postoperative timeframes are to be expected when compared with menisectomy, however, accelerated programs have demonstrated favorable outcomes. Rehabilitation and return to play guidelines should reflect the intricacies of the tear type and repair procedure. Close communication with the surgeon is a vital component to optimize patient outcomes. Further, the patient's goals and expected level of return to function, or sport, must be taken into account for a rehabilitation program to be fully successful.

Influence of Achilles tendon rupture site on surgical repair outcomes.

PURPOSE: This study aims to measure the distance between the common site of Achilles tendon rupture and calcaneal insertion through ultrasound and to compare the outcomes between proximal and distal rupture groups. METHODS: We investigated the electronic medical records of 117 patients and preoperative ultrasound describing the rupture site. Among 88 patients, we compared the patient-reported outcome and re-rupture rate of proximal and distal rupture groups. RESULTS: The mean rupture site of the 117 included subjects was 4.5 ± 1.3 cm. The rupture site had a weak negative correlation with body mass index (ρ = -0.230, P = 0.013). Furthermore, 77% of the patients with distal rupture reported good outcome (Achilles Tendon Rupture Score > 80) compared to 56% of the patients with proximal rupture (P = 0.041). CONCLUSION: Patients with proximal rupture had less satisfactory postoperative outcomes than those with distal rupture.

Rupture, reconstruction, and rehabilitation: A multi-disciplinary review of mechanisms for central nervous system adaptations following anterior cruciate ligament injury.

BACKGROUND: Despite surgical reconstruction and extensive rehabilitation, persistent quadriceps inhibition, gait asymmetry, and functional impairment remain prevalent in patients after anterior cruciate ligament (ACL) injury. A combination of reports have suggested underlying central nervous system adaptations in those after injury govern long-term neuromuscular impairments. The classic assumption has been to attribute neurophysiologic deficits to components of injury, but other factors across the continuum of care (e.g. surgery, perioperative analgesia, and rehabilitative strategies) have been largely overlooked. OBJECTIVE: This review provides a multidisciplinary perspective to 1) provide a narrative review of studies reporting neuroplasticity following ACL injury in order to inform clinicians of the current state of literature and 2) provide a mechanistic framework of neurophysiologic deficits with potential clinical implications across all phases of injury and recovery (injury, surgery, and rehabilitation) RESULTS: Studies using a variety of neurophysiologic modalities have demonstrated peripheral and central nervous system adaptations in those with prior ACL injury. Longitudinal investigations suggest neurophysiologic changes at spinal-reflexive and corticospinal pathways follow a unique timecourse across injury, surgery, and rehabilitation. CONCLUSION: Clinicians should consider the unique injury, surgery, anesthesia, and rehabilitation on central nervous system adaptations. Therapeutic strategies across the continuum of care may be beneficial to mitigate maladaptive neuroplasticity in those after ACL injury.

Duration of immobilisation after Achilles tendon rupture repair by open surgery: a retrospective cohort study.

BACKGROUND: The best treatment for acute Achilles tendon ruptures remains controversial. No cohort studies have compared different immobilisation durations after open surgery. This retrospective cohort study aimed to determine the optimal duration of immobilisation after this surgery. METHODS: A total of 266 patients with acute Achilles tendon rupture were divided into 4 groups (A, B, C, and D) according to immobilisation duration of 0, 2, 4, and 6 weeks, respectively. All patients underwent the same suture technique with a similar rehabilitation protocol and were examined clinically at 2, 4, 6, 8, 10, 12, 14, 16, 24, and 48 weeks, with a final follow-up at a mean of 22.3 months postoperatively. The primary outcome was the time of return to light sports activity (LSA). Secondary outcomes included range of motion (ROM) and single-legged heel rise height (SHRH). Data on operation time, complications, visual analogue pain scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and Achilles tendon Total Rupture score (ATRS) were also collected. Demographic baseline data were analysed using one-way analysis of variance; outcome parameters were analysed using Kruskal-Wallis H test, and complications were analysed using Fisher's exact test. Statistical significance was considered at P ≤ 0.05. RESULTS: VAS scores decreased significantly, reaching 0 in all groups after 12 weeks. The AOFAS and ATRS scores were significantly different between the groups from weeks 2 to 12 (P<0.001) and weeks 2 to 16 (P<0.001), respectively. All the mean scores showed better results in group B than in the other groups. In terms of recovery time of ROM, SHRH, and LSA, groups A and B were significantly faster than groups C and D (P<0.001). There were 13 (13/266, 4.9%) complications: 5 superficial infections, 3 deep venous thrombosis, and 5 trauma-related re-ruptures. On the last follow-up, all complications had recovered. There were no significant differences in complications between the groups. CONCLUSIONS: Immobilisation for 2 weeks after this open surgery is the best choice for early rehabilitation and weight-bearing while minimising pain and other complications.

Rehabilitation following surgery for flexor tendon injuries of the hand.

BACKGROUND: Various rehabilitation treatments may be offered following surgery for flexor tendon injuries of the hand. Rehabilitation often includes a combination of an exercise regimen and an orthosis, plus other rehabilitation treatments, usually delivered together. The effectiveness of these interventions remains unclear. OBJECTIVES: To assess the effects (benefits and harms) of different rehabilitation interventions after surgery for flexor tendon injuries of the hand. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, MEDLINE, Embase, two additional databases and two international trials registries, unrestricted by language. The last date of searches was 11 August 2020. We checked the reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs that compared any postoperative rehabilitation intervention with no intervention, control, placebo, or another postoperative rehabilitation intervention in individuals who have had surgery for flexor tendon injuries of the hand. Trials comparing different mobilisation regimens either with another mobilisation regimen or with a control were the main comparisons of interest. Our main outcomes of interest were patient-reported function, active range of motion of the fingers, and number of participants experiencing an adverse event. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the quality of the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology. MAIN RESULTS: We included 16 RCTs and one quasi-RCT, with a total of 1108 participants, mainly adults. Overall, the participants were aged between 7 and 72 years, and 74% were male. Studies mainly focused on flexor tendon injuries in zone II. The 17 studies were heterogeneous with respect to the types of rehabilitation treatments provided, intensity, duration of treatment and the treatment setting. Each trial tested one of 14 comparisons, eight of which were of different exercise regimens. The other trials examined the timing of return to unrestricted functional activities after surgery (one study); the use of external devices applied to the participant to facilitate mobilisation, such as an exoskeleton (one study) or continuous passive motion device (one study); modalities such as laser therapy (two studies) or ultrasound therapy (one study); and a motor imagery treatment (one study). No trials tested different types of orthoses; different orthosis wearing regimens, including duration; different timings for commencing mobilisation; different types of scar management; or different timings for commencing strengthening. Trials were generally at high risk of bias for one or more domains, including lack of blinding, incomplete outcome data and selective outcome reporting. Data pooling was limited to tendon rupture data in a three trial comparison. We rated the evidence available for all reported outcomes of all comparisons as very low-certainty evidence, which means that we have very little confidence in the estimates of effect. We present the findings from three exercise regimen comparisons, as these are commonly used in clinical current practice. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol) was compared in one trial of 53 participants with mainly zone II flexor tendon repairs. There is very low-certainty evidence of no clinically important difference between the two groups in patient-rated function or active finger range of motion at 6 or 12 months follow-up. There is very low-certainty evidence of little between-group difference in adverse events: there were 15 overall. All three tendon ruptures underwent secondary surgery. An active exercise regimen versus an immobilisation regimen for three weeks was compared in one trial reporting data for 84 participants with zone II flexor tendon repairs. The trial did not report on self-rated function, on range of movement during three to six months or numbers of participants experiencing adverse events. The very low-certainty evidence for poor (under one-quarter that of normal) range of finger movement at one to three years follow-up means we are uncertain of the finding of zero cases in the active group versus seven cases in the immobilisation regimen. The same uncertainty applies to the finding of little difference between the two groups in adverse events (5 tendon ruptures in the active group versus 10 probable scar adhesion in the immobilisation group) indicated for surgery. Place and hold exercise regimen performed within an orthosis versus a controlled passive regimen using rubber band traction was compared in three heterogeneous trials, which reported data for a maximum of 194 participants, with mainly zone II flexor tendon repairs. The trials did not report on range of movement during three to six months, or numbers of participants experiencing adverse events. There was very low-certainty evidence of no difference in self-rated function using the Disability of the Arm, Shoulder and Hand (DASH) functional assessment between the two groups at six months (one trial) or at 12 months (one trial). There is very low-certainty evidence from one trial of greater active finger range of motion at 12 months after place and hold. Secondary surgery data were not available; however, all seven recorded tendon ruptures would have required surgery. All the evidence for the other five exercise comparisons as well as those of the other six comparisons made by the included studies was incomplete and, where available, of very low-certainty. AUTHORS' CONCLUSIONS: There is a lack of evidence from RCTs on most of the rehabilitation interventions used following surgery for flexor tendon injuries of the hand. The limited and very low-certainty evidence for all 14 comparisons examined in the 17 included studies means that we have very little confidence in the estimates of effect for all outcomes for which data were available for these comparisons. The dearth of evidence identified in this review points to the urgent need for sufficiently powered RCTs that examine key questions relating to the rehabilitation of these injuries. A consensus approach identifying these and establishing minimum study conduct and reporting criteria will be valuable. Our suggestions for future research are detailed in the review.

The heel-rise work test overestimates the performed work with 21-25% after an Achilles tendon rupture.

PURPOSE: The purpose of this study was to evaluate concurrent validity of the heel-rise work test performed with use of the heel as a surrogate for the center of body mass. METHODS: The study was a validity study performed on a prospective cohort of consecutive patients. Forty-five patients were included in the study. The heel-rise work test estimates the total work performed by repeated heel-rises until fatigue. In this study, the heel-rise work was assessed by the linear encoder and a motion capture system simultaneously for validation. The linear encoder was attached to the patient's heel and reflective marker was attached to the pelvis and heel. Student's paired t-test, linear regression analysis and Bland Altman plots were used to estimate the measurement error of the linear encoder. RESULTS: The heel-rise work test overestimated the total work with 21.0% on the injured leg and 24.7% on the non-injured leg. Student's paired t-test showed no difference in measurement error between the limbs (n.s.). The linear regression analysis showed no difference in limb symmetry index between the two methods of heel-rise work estimation (a (slope) = 1.00, R = 0.94, p < 0.0001). CONCLUSION: The heel-rise work test performed using the heel as a surrogate for center of body mass overestimates the total work with 21.0-24.7% compared to a gold standard but was able to precisely detect the relative difference between the limbs. The heel marker can be considered a valid measurement device for assessing relative differences between the limbs. CLINICAL RELEVANCE: Clinical testing of injuries to the lower body using the heel-rise work test is valid when using the relative difference between the limbs. LEVEL OF EVIDENCE: I.

Multiple comparisons of the efficacy and safety for six treatments in Acute Achilles Tendon Rupture patients: A systematic review and network meta-analysis.

BACKGROUND: The choice of the best therapeutic regimen for Acute Achilles Tendon Rupture (AATR) remains controversial. Our study aims to evaluate the efficacy and safety of therapeutic regimens in AATR patients using a network meta-analysis of data from clinical randomized controlled trials. MATERIAL/METHODS: The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA). RESULTS: 38 randomized controlled trials involving 2480 participants were included. The studies were published between 1981 and 2019. A total of 6 therapeutic regimens -open repair (OR), minimally invasive repair (MIR) and nonoperative treatment (non) combined with traditional standard rehabilitation (TSR) and accelerated functional rehabilitation (AFR) - were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the re-rupture rate, the therapeutic regimens were ranked as follows: OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR. In terms of the wound-related complication, the therapeutic regimens were ranked as follows: MIR&AFR, nonoperative treatment &AFR, MIR&TSR, nonoperative treatment &TSR, OR&AFR and OR&TSR. In terms of the sural nerve injury, the therapeutic regimens were ranked as follows: non, OR and MIR. In terms of the deep venous thrombosis, the therapeutic regimens were ranked as follows: MIR&AFR, OR&AFR, nonoperative treatment &AFR, OR&TSR, MIR&TSR and nonoperative treatment &TSR. In terms of the returning back to sport, the therapeutic regimens were ranked as follows: MIR&TSR, OR&AFR, OR&TSR, nonoperative treatment &AFR, nonoperative treatment &TSR and MIR&AFR. CONCLUSIONS: MIR can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications. AFR is superior to TSR without increasing the risk of rerupture. MIR&AFR is the best therapeutic regime for AATR. More RCTs focused on AATR are needed to further indicate this conclusion.

Optimization of the knot configuration for early accelerated rehabilitation after Achilles tendon rupture.

Background Panda Rope Bridge Technique (PRBT) was an new minimally invasive technique consisted of two bridge anchors (proximal anchors at calcaneus and distal anchors at myotendinous junction) and strong ropes (threads of the suture anchors) stretched between them, which was suitable for early accelerated rehabilitation of Achilles tendon rupture. However, the optimal knot configuration with PRBT was unknow. The purpose of this study was identify minimum number of half hitches necessary to maintain knot security for PRBT. Methods Using an Instron device we tested the effect of different knot configuration in two kinds of suture threads (Ethibond™ #5 and Ultrabraid™ #2). According to the result of it, we put the optimal knot configuration into Part 1 with PRBT test model and Part 2 with modified PRBT test model, to evaluate whether the optimal knot configuration could complete the cyclic loading test simulated early rehabilitation. Findings In the first part of the study, the optimal knot configuration of Ethibond™ #5 suture thread was the combination of three half hitches and one double throw half knot, and the optimal knot configuration of Ultrabraid™ #2 suture thread was the combination of five half hitches and one double throw half knot. In the second part of the study, only Ultrabraid™ #2 suture thread with optimal knot configuration had finished all test in Part 1. Interpretation The Ultrabraid™ #2 suture thread with optimal knot configuration was suitable for PRBT with early accelerated rehabilitation after Achilles tendon repair.

The effects of rehabilitation on the outcomes of surgically treated acute and chronic thumb metacarpophalangeal ulnar collateral ligament ruptures.

The aim of this study was to compare the outcome of patients who received rehabilitation to those who did not receive it after surgical treatment of acute and chronic tears of the ulnar collateral ligament (UCL) of the thumb. Forty-two patients with an acute UCL injury repaired with two soft mini-anchors to bone insertion sites, and 40 patients with a chronic UCL injury reconstructed with autografts were involved in this study. The patients were divided two subgroups depending on rehabilitation. Patient characteristics were not significantly different between the two groups and subgroups. Range of motion, grip strength and pinch strength were evaluated. There was no significant change in terms of grip and pinch strength in patients with acute UCL injury who received rehabilitation after surgical treatment. However, significantly better results were achieved in flexion, extension, ulnar and radial deviation. There was no significant change in pinch strength in patients with chronic UCL reconstructions, but significantly better results were achieved in grip strength, flexion, extension, ulnar and radial deviation. A rigid MCP splint in patients with acute and chronic UCL tears is effective in preventing early ligament insufficiency.

Treatment of Acute Achilles Tendon Rupture.

There is no clear consensus on the optimal treatment of acute Achilles tendon rupture. Recently, studies have demonstrated the critical role of functional rehabilitation in the treatment of ruptured Achilles tendons. Hence, conservative treatment is preferred by a growing number of surgeons seeking to treat the condition without the risk of complications from surgery. However, operative treatment is still considered as a more reliable treatment option for acute Achilles tendon rupture. In this review article, we provide an overview of recent treatment strategies for acute rupture of the Achilles tendon.

Heterotopic Ossification After an Achilles Tendon Rupture Cannot Be Prevented by Early Functional Rehabilitation: A Cohort Study.

BACKGROUND: Tendon loading might play a role in the development of heterotopic ossification after Achilles tendon ruptures. Early heavy loading on a healing tendon in animals has been shown to prolong the proinflammatory response, and inflammatory cells are thought to drive heterotopic ossification formation. Taken together, this suggests that early rehabilitation might influence heterotopic ossification development. QUESTIONS/PURPOSES: The purposes of this study were to investigate (1) whether the presence of heterotopic ossification after Achilles tendon ruptures influences clinical outcome and (2) whether early mobilization or weightbearing prevents the development of heterotopic ossification. METHODS: This was a retrospective analysis of 69 patients from a previous clinical trial. All patients were treated surgically, but with three different early rehabilitation protocols after surgery: late weightbearing and ankle immobilization, late weightbearing and ankle mobilization, and early weightbearing and ankle mobilization. Plain radiographs taken 2, 6, 12, 26, and 52 weeks postoperatively were analyzed for heterotopic ossification, which was detected in 19% of patients (13 of 69) at 52 weeks. Heterotopic ossification was measured, scored, and correlated to clinical outcomes; heel-raise index (HRI), ankle joint ROM, tendon strain, Achilles tendon rupture score (ATRS), and Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire scores at 26 and 52 weeks postoperatively. RESULTS: Heterotopic ossification had no adverse effects on patient-reported outcomes (ATRS or VISA-A), tendon strain, or ROM. In fact, patients with heterotopic ossification tended to have a better HRI at 52 weeks compared with patients without (mean difference 14% [95% CI -0.2 to 27]; p = 0.053). Neither the occurrence (heterotopic ossification/no heterotopic ossification) nor the heterotopic ossification severity (ossification score) differed between the three rehabilitation groups. Seventeen percent of the patients (four of 24) with early functional rehabilitation (early weightbearing and ankle joint mobilization exercise) had heterotopic ossification (score, 2-3) while late weightbearing and immobilization resulted in heterotopic ossification in 13% of the patients (score, 3-4). CONCLUSIONS: Heterotopic ossification occurs relatively frequently after Achilles tendon ruptures but appears to have no adverse effects on functional outcomes. Furthermore, heterotopic ossification develops during the first 6 weeks after rupture, and weightbearing or ankle-joint mobilization does not prevent this from occurring. LEVEL OF EVIDENCE: Level III, prognostic study.

Understanding limitations in sport 1 year after an Achilles tendon rupture: a multicentre analysis of 285 patients.

PURPOSE: The purpose of this study was to determine patient-related and treatment-related predictors of superior and inferior function in sport and recreational activities 1 year after an Achilles tendon rupture. METHODS: This study is based on a multicentre cohort from 4 previous randomised controlled trials. All the patients who had responded to the Foot and Ankle Outcome Score (FAOS) at the 1-year follow-up were included. All the patients had a clinically verified Achilles tendon rupture and patients who underwent surgery were treated within 96 h of the time of rupture. Patients were excluded in the event of a previous Achilles tendon rupture or the presence of other lifestyle diseases. The primary outcomes of the study were reported in the 20th and 80th percentiles of the FAOS subscale, function in sports and recreational activities. RESULTS: A total of 285 (84% men) patients with an average age of 40.0 (SD 8.4) years were included. Smoking increased the odds of superior self-reported FAOS sport and recreation [OR 4.59 (95% CI 1.58-13.32), p = 0.005] compared with non-smoking, while being female [OR 0.38 (95% CI 0.16-0.93), p = 0.035] and every increment of one unit in BMI [OR 0.89 (95% CI 0.81-0.99), p = 0.029] reduced the odds. No variable was statistically significant when attempting to predict which patients report inferior FAOS sport and recreation. The recovery of symmetry in heel-rise tests had no effect on 1-year FAOS sport and recreation. Patient-reported outcomes had a good-to-excellent explanatory capacity of superior and inferior 1-year function in sport and recreational activities (AUC = 0.87-0.93). CONCLUSION: BMI is a modifiable risk factor, which, when lowered, may be associated with less impairment in sports 1 year after an Achilles tendon rupture. Females appear to perceive more limitations than males. Unexpectedly, smokers experience less limitations in foot and ankle function. Patients who report no functional limitation in sport are characterised by an overall perception of adequate foot, ankle and Achilles function, despite not having recovered symmetry in the heel-rise test. LEVEL OF EVIDENCE: I.

Achilles tendon rupture repair: Biomechanical comparison of the locking block modified Krackow technique and the Giftbox technique.

BACKGROUND: Open Giftbox repair of the Achilles tendon has good biomechanical advantages, but it is not minimally invasive. We designed a peritendon fixation technique, the "Locking Block Modified Krackow" (LBMK) technique, to meet minimally invasive needs. This study used a simulated protocol of early rehabilitation to compare the biomechanics of LBMK with those of the Giftbox technique. METHODS: Twenty fresh bovine Achilles tendon specimens were randomly assigned to either the LBMK group or the Giftbox group. The LBMK technique and the Giftbox technique were used as the main suture configurations, and transverse sutures were used as secondary suture configurations in both groups. Each repaired specimen was subjected to two cyclic loading protocols (20-100 N, 20-190 N). The gapping between the tendon ends was measured after each stage of loading. Finally, all specimens underwent a load-to-failure test at a stretching rate of 25 mm/s. RESULTS: After the first loading stage, the mean tendon gapping was 0.76±0.44 mm in the LBMK group and 0.86 ± 0.47 mm in the Giftbox group (p = 0.620). After the second loading test, the average gapping measures of the LBMK and Giftbox groups were 3.8 ±â€¯1.9 mm and 4.2 ±â€¯2.2 mm, respectively (p = 0.466). Finally, the catastrophic load to failure was 732.8 ±â€¯138 N in the LBMK group and 645.5 ±â€¯121 N in the Giftbox group. The difference was statistically significant (p = 0.023). CONCLUSION: Both the LBMK and Giftbox techniques meet the requirements of early rehabilitation, but the suture strength in the LBMK group was significantly higher than that in the Giftbox group.

ACL rupture in the immediate build-up to the Olympic Games: return to elite alpine ski competition 5 months after injury and ACL repair.

Anterior cruciate ligament (ACL) rupture in the immediate build-up to a major international competition can preclude an athletes' participation due to the prolonged period of rehabilitation that is typically required after ACL reconstruction. ACL repair is an alternative strategy that has been postulated to confer the advantage of rapid rehabilitation and earlier return to sport. A 33-year-old professional alpine skier sustained a right knee ACL rupture in September 2017. The athlete indicated that she wanted to participate in the 2018 Olympics. Arthroscopic ACL repair and reconstruction of the anterolateral ligament was undertaken. At 3 months, Lachman's test revealed a hard end point, a negative pivot shift and no side-to-side laxity difference. MRI at 6 and 12 weeks demonstrated a continuous ACL with no intraligament signal change. At 20 weeks postoperatively, she successfully participated in the slalom at the 2018 Olympic Games.

Accelerated rehabilitation results in good outcomes following acute repair of proximal hamstring ruptures.

PURPOSE: To assess outcomes of patients who underwent proximal hamstring repair utilizing an accelerated rehabilitation protocol with immediate weight bearing as tolerated and no bracing. METHODS: Retrospective chart review identified 47 proximal hamstring tendon repairs with suture anchors in 43 patients performed during 2008-2015. Rehabilitation included no immobilization or limited weightbearing. Patients were contacted by phone to assess outcomes utilizing the lower extremity functional score (LEFS), single-assessment numeric evaluation (SANE), and Marx activity scale. Overall patient-reported scores were calculated and results of acute and chronic repairs compared. RESULTS: Thirty-four patients (38 repairs, 80.8%) were available for follow-up at mean of 4.1 ± 2.0 years following repair. There were two re-tears: one complete rupture 5 weeks postoperative and one partial rupture 10 weeks postoperative in the chronic group. Patients in general reported low pain and good function with a mean LEFS score of 87 ± 21%, a mean SANE score of 88.1 ± 11.6, and a mean numeric pain score of 8.5 ± 15.3 in the last week and 12.2 ± 21.1 with activity. The acute repair group was noted to have a higher mean LEFS score (93.7 versus 79.8%, p = 0.004) and SANE score (91.3 versus 83.8, p = 0.047), and lower pain with activity (21.7 versus 4.8, p < 0.001) as compared to the chronic group. CONCLUSIONS: Repair of acute proximal hamstring ruptures results in good function and pain relief with the use of a rehabilitation protocol that does not require weight-bearing restrictions or bracing. LEVEL OF EVIDENCE: III, therapeutic.

Does elasticity of Achilles tendon change after suture applications? Evaluation of repair area by acoustic radiation force impulse elastography.

BACKGROUND: Achilles tendon injuries are one of the most common tendon injuries. Surgical treatment is preferred in young and active patients. Although there are studies which evaluate the repair area with magnetic resonance imaging and ultrasonography after surgical treatment, there are very few studies which analyzes the elasticity of the tendon by quantitative methods. ARFI (acoustic radiation force impulse) elastography is a simple and non-invasive method that can quantitatively measure the elasticity of the soft tissues. Our study aims to evaluate the elasticity in the repair area of the surgically treated Achilles tendons, compare them to the non-injured side, and evaluate the effect of the suture method to the elasticity of the repaired tendons by using ARFI elastography. METHODS: In our retrospectively designed study, 19 patients who underwent surgical treatment with Krackow and modified Kessler suture methods after the Achilles tendon rupture between 2006 and 2014 were included. Shear wave velocity (SWV) of the repaired and non-injured Achilles tendons were measured by ARFI elastography in four different positions of the ankle. RESULTS: It was determined that SWV in the surgically repaired tendons were significantly higher in each four different position of the ankle, compared to the non-injured side (p < 0.01), indicating less elasticity in the repaired tendons. There was no statistically significant difference between the SWV of Krackow and modified Kessler suture method groups at four different positions of the ankle (p > 0.05). AOFAS Ankle-Hindfoot, VISA-A, VAS, and FAOS scores were not also statistically different between these two suture methods (p > 0.05). CONCLUSIONS: In the repaired Achilles tendon, there is a decrease in the elasticity compared to the non-injured side. The functional and elastographic results of Krackow and modified Kessler suture methods are similar in long-term follow-ups of the patients.