Conservative treatment outcome for Achilles tendon re-rupture occurring in the subacute phase after primary repair.

INTRODUCTION: Until now, a treatment protocol for Achilles tendon re-rupture (ATRR) occurring in the postoperative period 5-12 weeks following primary Achilles tendon repair has not been established. We refer to this time frame as the subacute postoperative phase, and the objective of this study was to assess the efficacy of conservative treatment for subacute ATRR in this phase. MATERIALS AND METHODS: We conducted a retrospective review of 390 cases (385 patients) who had undergone primary Achilles tendon repair using the 4-strand Krachow method between January 2010 and August 2021. All patients were subjected to more than 12 months of follow-up and were categorized into two groups based on the presence of subacute ATRR: Group 1 comprised 370 cases without ATRR, while Group 2 comprised 20 cases with ATRR. Following confirmation of ATRR, we immediately applied a below-knee cast in an ankle plantar flexed position (25°-30°), followed by bracing according to the same rehabilitation plan used for the primary repair. After administering conservative treatment to the patients with ATRR, we compared several outcome parameters between the two groups, including isokinetic plantar flexion power measured using a dynamometer, time required for a single heel raise (t-SHR), time needed for ten repetitive SHRs (t-SHR10), Achilles Tendon Total Rupture Score (ATRS), and Foot and Ankle Ability Measure (FAAM) scores. The baseline timepoints for Groups 1 and 2 were the dates of the primary repair and the re-injury event. RESULTS: After primary Achilles tendon repair, subacute ATRR occurred in 5.1% of patients. There were no significant differences between the groups in terms of t-SHR and t-SHR10 (P = 0.281, 0.486). Similarly, the isokinetic dynamometer measurements revealed no significant differences in peak torque for plantar flexion at angular velocities of 30°/s and 120°/s, both in absolute values and as a percentage of the contralateral side, between the groups (P > 0.05 for each). However, ATRSs were significantly lower in Group 2 compared to Group 1 before 6 months (P < 0.05), as were FAAM-Activities of Daily Living scores at 6 months (P < 0.05). After 12 months, there were no significant differences in these scores between the two groups (both P > 0.05). CONCLUSION: Conservative treatment for subacute ATRR following primary Achilles tendon repair yields clinical outcomes comparable to those without ATRR. Therefore, we recommend that surgeons consider relying on the patient's natural healing capabilities rather than opting for aggressive surgical interventions, as expediting such operations may be unnecessary for subacute injuries.

Return to Play and Functional Outcomes Following Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-Analysis.

Return to play (RTP) and functional outcomes are critical to treatment success for acute Achilles tendon rupture (AATR). This systematic review and meta-analysis explored treatment superiority essential in optimal treatment selection concerning individual patients and their expectations regarding RTP and functional outcomes. This study was in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. The included studies were assessed regarding the level and quality of evidence. Fixed-effects models were employed for I2 < 25% and random-effects models for I2 ≥ 25%. The RTP rate meta-analysis of surgical vs conservative treatment revealed no significant difference. This was similar to the subgroup analysis of open repair and conservative treatment. The RTP rate and Achilles Tendon Total Rupture Score (ATRS) meta-analysis of open repair + earlier rehabilitation (ER) vs + later rehabilitation (LR) also revealed no significant differences. The mean time to RTP meta-analysis of open repair + ER vs + LR showed that open repair + ER was significantly favored (-4.19 weeks; p = .002). The ATRS meta-analysis of conservative treatment with ER vs with LR revealed no significant difference. This meta-analysis has revealed that the RTP rates following treatment of AATR are high. Therefore, the decision for surgical vs conservative treatment or open repair + ER vs + LR for AATR should not be selected based on the expectation of RTP. However, open repair + ER can be advocated over + LR for reduced mean time to RTP.

Outcomes of early versus late functional weight-bearing after the acute Achilles tendon rupture repair with minimally invasive surgery: a randomized controlled trial.

INTRODUCTION: Optimal postoperative rehabilitation regimen for acute Achilles tendon rupture (AATR) remains unclear. It is important to evaluate whether early functional weight-bearing rehabilitation program after minimally invasive repair results in an earlier return to pre-injury activity but increases the risk of re-rupture. MATERIALS AND METHODS: This was a prospective randomized controlled trial involving 68 AATR patients undergoing minimally invasive surgery. 34 patients were enrolled in early weight­bearing mobilization accelerated rehabilitation group (AR group); 34 patients were enrolled in the traditional rehabilitation (TR) group. Outcomes measures included American Orthopaedic Foot and Ankle Society Score (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS) score before surgery and 3, 6, and 12 months after surgery, incidence rate of Achilles tendon re-rupture and total complications, length of hospital stay, time return to work and sports. RESULTS: There was no significant difference in preoperative basic data between the two groups. However, AOFAS score and ATRS score were better in AR group than TR group at 3 months postoperatively (92.4 ± 3.5 vs 88.3 ± 4.5, P < 0.01; 91.1 ± 4.4 vs 88.9 ± 3.4, P = 0.03, respectively), the mean length of hospital stay (4.7 ± 1.5 vs 7.6 ± 2.0 days, P < 0.01) and time return to work (4.5 ± 1.0 vs 7.5 ± 1.6 weeks, P < 0.01) were shorter in AR group than in TR group. No statistical significance was calculated in patient-reported outcomes during the rest of the follow-up time and complications. CONCLUSION: Early accelerated rehabilitation with weight-bearing in patients with AATR after minimally invasive surgery results in better early functional outcomes and shows similar security and feasibility. REGISTRATION NO: ChiCTR2100043398.

A retrospective analysis of controlled active motion (CAM) versus modified Kleinert/Duran (modKD) rehabilitation protocol in flexor tendon repair (zones I and II) in a single center.

INTRODUCTION: The aim of this study was to analyze primary flexor tendon repair results in zones I and II, comparing the rupture rate and clinical outcomes of the controlled active motion (CAM) protocol with the modified Kleinert/Duran (mKD) protocol. MATERIALS AND METHODS: Patients who underwent surgery with traumatic flexor tendon lacerations in zones I and II were divided in three groups according to the type of rehabilitation protocol and period of management: group 1 included patients who underwent CAM rehabilitation protocol with six-strand Lim and Tsai suture after May 2014. Group 2 and 3 included patients treated by six-strand Lim Tsai suture followed by a modified Kleinert/Duran (modK/D) protocol with additional place and hold exercises between 2003 and 2005 (group 2) and between 2011 and 2013 (group 3). RESULTS: Rupture rate was 4.7% at 12 weeks in group 1 (3/63 flexor tendon repairs) compared to 2% (1/51 flexor tendon repairs) in group 2 and 8% in group 3 (7/86 flexor tendon repairs). The grip strength at 12 weeks was significantly better in group 2 compared to the group 1 (35 kg/25 kg, p = 0.006). The TAM in group 1 [113° (30-175°)] was significantly worse (p < 0.001) than the TAM in group 2 [141° (90-195°)] but with similar extension deficits in both groups. The assessment of range of motion by the original Strickland classification system resulted in 20% excellent and 15% good outcomes in the CAM group 1 compared with 42% and 36% in the modK/D group 2. Subanalysis demonstrated improvement of good/excellent results according to Strickland from 45% at 3 months to 63.6% after 6-month follow-up in the CAM group. CONCLUSION: The gut feeling that lead to change in our rehabilitation protocol could be explained by the heterogenous bias. A precise outcome analysis of group 1 could underline that in patients with complex hand trauma, nerve reconstruction, oedema or early extension deficit, an even more intensive and individual rehabilitation has to be performed to achieve better TAM at 6 or 12 weeks. Our study explicitly demonstrated a significant better outcome in the modK/D group compared to CAM group. This monocenter study is limited by its retrospective nature and the low number of patients.

Relative motion flexion following zone I-III flexor tendon repair: Concepts, evidence and practice.

STUDY DESIGN: Narrative review and case series. INTRODUCTION: The relative motion approach has been applied to rehabilitation following flexor tendon repair. Positioning the affected finger(s) in relatively more metacarpophalangeal joint flexion is hypothesized to reduce the tension through the repaired flexor digitorum profundus by the quadriga effect. It is also hypothesized that altered patterns of co-contraction and co-inhibition may further reduce flexor digitorum profundus tension, and confer protection to flexor digitorum superficialis. METHODS: We reviewed the existing literature to explore the rationale for using relative motion flexion orthoses as an early active mobilization strategy for patients after zone I-III flexor tendon repairs. We used this approach within our own clinic for the rehabilitation of a series of patients presenting with zone I-II flexor tendon repair. We collected routine clinical and patient reported outcome data. RESULTS: We report published outcomes of the clinical use of relative motion flexion orthoses with early active motion, implemented as the primary rehabilitation approach after zone I-III flexor digitorum repairs. We also report novel outcome data from 18 patients. DISCUSSION: We discuss our own experience of using relative motion flexion as a rehabilitation strategy following flexor tendon repair. We explore orthosis fabrication, rehabilitation exercises and functional hand use. CONCLUSIONS: There is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. We highlight key areas for future research and describe a current pragmatic randomized controlled trial.

Implementing an internal audit to change practice: Current evidence and review of patient outcomes enabled transition to the relative motion extension approach in the postoperative management of zones IV-VI extensor tendon repairs.

BACKGROUND: Evidence supports use of the relative motion extension (RME) approach following extensor tendon repairs in zones V-VI yielding good or excellent outcomes. PURPOSE: To demonstrate how a 3-year internal audit and regular review of emerging evidence guided our change in practice from our longstanding use of the Norwich Regimen to the RME approach using implementation research methods. We compared the outcomes of both approaches prior to the formal adoption of the RME approach. STUDY DESIGN: Prospective clinical audit. METHODS: A prospective audit of all consecutive adult finger extensor tendon repairs in zones IV-VII rehabilitated in our tertiary public health hand centre was undertaken between November 2014 and December 2017. Each audit year, outcomes were reviewed regarding the Norwich regimen and the RME early active motion approaches. As new evidence emerged, adjustments were made to our audit protocol for the RME approach. Discharge measurements of the range of motion of the affected and contralateral fingers and complications were recorded. RESULTS: During the 3-year audit, data was available on 79 patients (56 RME group including 59 fingers with 71 tendon repairs; 23 Norwich group including 28 fingers with 34 tendon repairs) with simple (n = 68) and complex (n = 11) finger extensor tendon zones IV-VI repairs (no zone VII presented during this time). Over time, the practice pattern shifted from the Norwich Regimen approach to the RME approach (and with the use of the RME plus [n = 33] and RME only [n = 23] approaches utilized). All approaches yielded similar good to excellent outcomes per total active motion and Miller's classification, with no tendon ruptures or need for secondary surgery. CONCLUSIONS: An internal audit of practice provided the necessary information regarding implementation to support a shift in hand therapy practice and to gain therapist or surgeon confidence in adopting the RME approach as another option for the rehabilitation of zone IV-VI finger extensor tendon repairs.

Relative motion orthoses for early active motion after finger extensor and flexor tendon repairs: A systematic review.

BACKGROUND: The relative motion (RM) orthosis was introduced over 40 years ago for extensor tendon rehabilitation and more recently applied to flexor tendon repairs. PURPOSE: We systematically reviewed the evidence for RM orthoses following surgical repair of finger extensor and flexor tendon injuries including indications for use, configuration and schedule of orthosis wear, and clinical outcomes. STUDY DESIGN: Systematic review. METHODS: A PRISMA-compliant systematic review searched eight databases and five trial registries, from database inception to January 7, 2022. The protocol was registered prospectively (CRD42020211579). We identified studies describing patients undergoing rehabilitation using RM orthoses after surgical repair of acute tendon injuries of the finger and hand. RESULTS: For extensor tendon repairs, ten studies, one trial registry and five conference abstracts met inclusion criteria, reporting outcomes of 521 patients with injuries in zones IV-VII. Miller's criteria were predominantly used to report range of motion; with 89.6% and 86.9% reporting good or excellent outcomes for extension lag and flexion deficit, respectively. For flexor tendon repairs, one retrospective case series was included reporting outcomes in eight patients following zones I-II repairs. Mean total active motion was 86%. No tendon ruptures were reported due to the orthosis not protecting the repair for either the RME or RMF approaches. DISCUSSION: Variation was seen in use of RME plus or only, use of night orthoses and orthotic wear schedules, which may be the result of evolution of the RM approach. Since Hirth et al's 2016 scoping review, there are five additional studies, including two RCTs reporting the use of the RM orthosis in extensor tendon rehabilitation. CONCLUSIONS: There is now good evidence that the RM approach is safe in zones V-VI extensor tendon repairs. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs. Further high-quality clinical studies are needed to demonstrate its safety and efficacy.

Safety and efficacy of ultrasonography of tension after zone II flexor tendon repair: A randomized controlled trial.

BACKGROUND: Primary flexor tendon repairs of lacerations in zone II of the hand are fraught with problems. Traditionally, exercise (active and passive), orthoses, and physical agents are common interventions for the rehabilitation of patients experiencing these issues. One area of focus in this field is how to safely utilize tension to lengthen gliding distance following zone II injury. Finding effective solutions in this area is a key priority for improving patient outcomes and quality of life. PURPOSE: To identify the optimal immobilization position that meets safety standards for tension and is the most efficient, and consequently, to validate our clinical effectiveness. STUDY DESIGN: A cross-sectional study was adopted for the first part of the research (Research 1). A prospective, parallel, 2-group, randomized trial was conducted with concealed allocation and single blinding in the second part of the research (Research 2). METHODS: A total of 60 healthy adults were recruited to select the best-fit protective immobilization position in Research 1, which was confirmed by tendon tension (via Young's modulus) and excursion (via gliding distance). We then randomly assigned 45 patients after zone II flexor tendon repair into two groups in Research 2 to compare functional outcomes. The control group underwent the conventional modified Duran protocol with early passive motion, while the experimental group received the protocol (optimized by Research 1) with early active motion. Ultrasonography was used to measure the tension and excursion of the flexor tendons. The outcomes measured at 16 weeks post-repair included total active motion, strength, the Disabilities of the Arm, Shoulder and Hand, and Strickland scores. RESULTS: Three participants were unable to participate in Research 2 due to medical issues and poor attendance. The investigation found that the safe tendon threshold was 345.09 ± 87.74 kPa for partial active digital motion among the 60 participants. The optimal immobilization position requires the wrist to be neutral with a flexion angle of 30° at the metacarpophalangeal joint. The grip strengths (p = 0.012), ratio of grip strength (p = 0.015), the Disabilities of the Arm, Shoulder and Hand (p = 0.036), and total active motion (p = 0.023) differed significantly between the two groups. CONCLUSIONS: Protective immobilization of the wrist in a neutral flexion position and with the metacarpophalangeal joint flexed at 30° can secure the repaired flexor tendon safely and efficiently. The effects of an early active motion protocol may improve the grip strength and upper limb mobility of individuals after zone II flexor tendon repair. CLINICAL TRIAL REGISTRATION: ChiCTR2000030592.

A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures.

BACKGROUND: Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context. METHODS: A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review. RESULTS: Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study. CONCLUSION: Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context. LEVEL OF EVIDENCE: Level IV; Systematic Review.

The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors.

PURPOSE: The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture. METHODS: A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years. RESULTS: Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050). CONCLUSION: The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture. LEVEL OF EVIDENCE: III.

Effect of a Text Message-Based Support Program on Outcomes of Patients After Flexor Tendon Injury Repair.

PURPOSE: Although the effectiveness of using text messages in home-based rehabilitation programs has been investigated, its ability to engage patients in home rehabilitation exercises and, as a result, improve hand outcomes, specifically in patients with flexor tendon injuries, has not been evaluated. The aim of this study was to determine whether the addition of a text message-based intervention to usual care is effective in improving hand outcomes in patients with flexor tendon injuries after repair. METHODS: In this 2-arm parallel randomized controlled trial, 40 patients were randomly assigned to either the intervention group (usual care plus the support program) or the control group (usual care only). Intervention included an automated package of instructional text messages containing links to a secure website for instructional rehabilitation videos delivered over 12 weeks. The Quick Disabilities of the Arm, Shoulder, and Hand and visual analog scale for pain scores were assessed at 6 and 12 weeks. Physician-reported grip strength and total active motion were assessed after 12 weeks. RESULTS: The study was completed by 90% (36 of 40) of the patients who were enrolled. There were statistically significant differences between the 2 groups with respect to Quick Disabilities of the Arm, Shoulder, and Hand and visual analog scale scores at the 6-week and 12-week assessments. In addition, there were statistically significant differences between the 2 groups with respect to total active motion and grip strength at 12 weeks. Finally, a high level of satisfaction with the intervention was reported. CONCLUSIONS: The text message-based program was associated with improved outcomes over the first 12 weeks after flexor tendon repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Factors affecting orthosis adherence after acute traumatic hand tendon repairs: A prospective cohort study.

INTRODUCTION: Custom-made orthoses are used to prevent contractures and reinjury of tissues such as tendon rupture after traumatic tendon repairs. Despite their wide usage in hand rehabilitation, orthosis adherence is usually an overlooked problem. PURPOSE OF THE STUDY: This study aims to evaluate the possible factors affecting the orthosis adherence in patients with acute traumatic tendon repairs. STUDY DESIGN: This is a prospective cohort study. METHODS: Two hundred twelve patients with acute traumatic hand tendon repair were included in this prospective cohort study. Patients were evaluated on the third day postoperatively and at three weeks. All patients were told to wear their orthosis 24 h a day for three weeks and allowed to take it off to wash the hand carefully once a day. Adherence was measured as fully adherent, partially adherent, and nonadherent. Factors that may affect orthosis adherence were evaluated according to the five dimensions of the multidimensional adherence model including socioeconomic, condition-related, treatment-related, patient-related, and health-care system-related factors. The Modified Hand Injury Severity Scale was used to assess the severity of the injury. Depression and anxiety symptoms were evaluated with the Beck Depression Inventory and Beck Anxiety Inventory. A multivariate logistic regression model was constructed for orthosis adherence. RESULTS: One hundred thirty-three patients were analyzed. Forty-four (33.1%) patients were fully adherent with the prescribed orthosis, whereas 67 (50.4%) were partially adherent and 22 (16.5%) were nonadherent. Higher depression symptoms caused orthosis nonadherence [odds ratio = 1.2 (95% confidence interval = 1.1-1.3), P = .001] and partial adherence [odds ratio = 1.1 (95% confidence interval = 1.0-1.2), P = .01]. CONCLUSIONS: Among our patients with acute traumatic tendon repair, only one-third of the patients were fully adherent with the orthosis wear program. Depression in the very acute period of injury impaired orthosis adherence.

Patient outcomes and costs after isolated flexor tendon repairs of the hand.

BACKGROUND: Acute flexor tendon injuries are challenging injuries for patients, surgeons, and therapists alike. There is ongoing debate about the optimal timing and amount of therapy after these injuries. PURPOSE: We sought to investigate the relationship between hand therapy utilization and reoperation rates after flexor tendon repair and quantify reoperation rates and costs associated with flexor tendon repair. We hypothesize there will be an inverse relationship between the number of hand therapy visits and later reoperation rates and a positive correlation between reoperation rates and total cost of care. STUDY DESIGN: A retrospective cohort study of patients undergoing primary flexor tendon repair was pursued. METHODS: A commercially available database was utilized to access insurance claims data for 20.9 million patients in the US from 2007 to 2015. Patients undergoing primary flexor tendon repair were included and followed for one year. Patients with fractures, vascular injuries, or digit replantation were excluded. We studied post-operative rehabilitation utilization, reoperation rates, and costs. Chi-Square tests and multivariable logistic regressions were used to assess the relationship between therapy utilization and reoperation rates and costs. RESULTS: The one-year reoperation rate was 11.4 percent at a median time of 100.0 days amongst 1,129 patients undergoing primary tendon repair. In multivariable analysis, age between 30 and 59, male sex, and utilization of over 21 therapy sessions were associated with increased odds of reoperation. Mean insurance reimbursement one year following primary flexor repair was $14,533 per patient but $27,870 if patients went on to reoperation. CONCLUSION: Continued therapy utilization after primary flexor tendon repair is an independent predictor of reoperation need. These findings may help surgeons counsel patients who require a large number of visits after flexor tendon repair on when to revisit surgical options.

Ultrasonographic assessment in vivo of the excursion and tension of flexor digitorum profundus tendon on different rehabilitation protocols after tendon repair.

STUDY DESIGN: Interpretive description study. PURPOSE: In management of patients with flexion tendon injuries, passive, control active and active motion protocols were proposed after repair to minimize tendon adhesion. The purpose of this study was to compare the excursion distance and the tension of Flexor Digitorum Profundus (FDP) during simulated active and passive motion using ultrasonography techniques using normal subjects. METHODS: Ultrasonographic assessment of FDP tendon of the middle finger was performed at the wrist level on 20 healthy college students using 3 types of treatment protocols: modified Kleinert protocol, modified Duran protocol, and active finger flexion protocol. The excursion distance was measured following the musculotendinous junction of FDP using the B mode ultrasound system. The elasticity of FDP tendon was measured using the shear wave elastography technique. The excursion distance and the elasticity value were compared among 3 protocols using one-way ANOVA analysis. RESULTS: Twelve male and 8 female students with mean age of 22.6 ± 1.8 years were invited to join the study. The excursion distance of FDP was 21.82 ± 3.77 mm using the active finger flexion protocol, 8.59 ± 2.59 mm using the modified Duran protocol, and 12.26 ± 2.71 mm using the modified Kleinert protocol. The elasticity was significantly higher in extension position when compared to passive flexion positions, but found lower than active flexion position. DISCUSSION: The active finger protocol was found to require strongest tension of the tendon and with longest excursion. There was similar tension generated using both passive motion protocols. The modified Duran protocol appeared to create less excursion upon movements than the modified Kleinert approach using the objective ultrasonic evaluation. It is suggested that if the surgical repair was strong and without any complications, the active flexion protocol might work best to regain tension excursion. However, if there are complex problems involved, then the Kleinert approach or Duran approach would be chosen.

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.

A Comprehensive Evaluation of Minimally Invasive Achilles Tendon Reconstruction with Hamstring Graft Indicates Satisfactory Long-Term Outcomes.

Background and objectives: The Achilles tendon, the largest tendon in the body, is vulnerable to injury because of its limited blood supply and the combination of forces to which it is subjected. Given the relevance of the Achilles tendon in the proper function of the foot and ankle, the primary goal of the present study was to use a holistic approach for a comprehensive evaluation of Achilles tendon reconstruction results on multiple levels. Materials and Methods: The study was designed in the following way: 30 patients with partial or total Achilles tendon tears were subjected to the minimally invasive Achilles tendon reconstruction. Patients were then subjected to the clinical, functional and isokinetic tests 12 and 24 months after the treatment. The clinical evaluation included calf circumference measurements and subjective patient-reported tests: ATRS, EQ-5D-5L and VAS scales. The functional evaluation was based on three tests: the weight-bearing lunge test, the heel rise test and single leg hop. Isometric and isokinetic evaluation was performed using a Biodex 3 dynamometer. Results: The calf circumference of the operated limbs was significantly lower than the non-operated limb 12 months after the surgical procedure, however this improved at the second evaluation. All subjective outcomes improved significantly 24 months after the surgery. Significantly better results in the function of the operated limbs were also obtained 24 months after the surgery. However, most of the muscle strength parameters of the operated limbs were already comparable to non-operated ones 12 months after the surgery and were comparable between two evaluation times. Conclusions: The overall results of this extensive evaluation are highly satisfactory and patients returned to their normal physical activity. From a medical point of view, it is assumed that the healing process is completed 12 months after the surgery, however, importantly, our results indicate that we should consider the healing process and the rehabilitation process separately.

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.

A smartphone application to facilitate adherence to home-based exercise after flexor tendon repair: A randomised controlled trial.

OBJECTIVE: Evaluate the effect of a smartphone application on exercise adherence, range of motion and self-efficacy compared to standard rehabilitation after repair of the flexor digitorum profundus tendon. DESIGN: Prospective multi-centre randomised controlled trial. SETTING: Four hand surgery departments in Sweden. SUBJECTS: A total of 101 patients (35 women) (mean age 37.5 ± 12.8) were randomised to control (n = 49) or intervention group (n = 52). INTERVENTION: A smartphone application to facilitate rehabilitation. MAIN OUTCOME MEASURES: Adherence assessed with the Sport Injury Rehabilitation Adherence Scale at two and six weeks (primary outcome). Secondary outcomes were self-reported adherence in three domains assessed at two and six weeks, self-efficacy assessed with Athlete Injury Self-Efficacy Questionnaire at baseline, two and six weeks. Range of motion and perceived satisfaction with rehabilitation and information were assessed at 12 weeks. RESULTS: Twenty-five patients were lost to follow-up. There was no significant between group difference in Sport Injury Rehabilitation Adherence Scale at two or six weeks, mean scores (confidence interval, CI 95%) 12.5 (CI 11.8-13.3), 11.8 (CI 11.0-12.8) for the intervention group, and 13.3 (CI 12.6-14.0), 12.8 (CI 12.0-13.7) for the control group. Self-reported adherence for exercise frequency at six weeks was significantly better for the intervention group, 93.2 (CI 86.9-99.5) compared to the controls 82.9 (CI 76.9-88.8) (P = 0.02). There were no differences in range of motion, self-efficacy or satisfaction. CONCLUSION: The smartphone application used in this study did not improve adherence, self-efficacy or range of motion compared to standard rehabilitation for flexor tendon injuries. Further research regarding smartphone applications is needed. LEVEL OF EVIDENCE: I. Randomised controlled trial.

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.