iTRAQ-based proteomics reveals potential markers and treatment pathways for acute Achilles tendon rupture.

BACKGROUND: Due to its limited blood supply and irregular mechanical loading, the Achilles tendon is the most frequently ruptured tendon. Despite the rising incidence of acute Achilles tendon rupture (AATR), the optimal treatment remains controversial. Missed diagnoses and delayed treatments lead to poor outcomes and limited treatment options. This study aimed to identify potential biomarkers for diagnosing and developing therapies for AATR. METHODS: We employed the coupled isobaric tag for relative and absolute quantitation-liquid chromatography-electrospray ionization-tandem mass spectrometry approach to investigate protein expression in tissues from AATR patients. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were conducted to identify differentially expressed proteins (DEPs) between AATR patients and healthy individuals. A protein-protein interaction (PPI) network of DEPs was constructed using the Search Tool for the Retrieval of Interacting Genes. The screened hub genes were selectively verified by immunohistochemical staining. RESULTS: We identified 410 DEPs between AATR patients and controls. The DEPs were significantly enriched in GO terms such as the extracellular region, extracellular region part, and defense response, as well as KEGG pathways, including complement and coagulation cascades, focal adhesion, and regulation of actin cytoskeleton. The main hub nodes in the PPI network comprised fibronectin 1 (FN1), major histocompatibility complex, class I, B (HLA-B), filamin A (FLNA), heat shock 27-kDa protein 1 (HSPB1), heat shock protein family A member 5 (HSPA5), apolipoprotein A4 (APOA4), and myosin IC (MYO1C). Although APOA4 and collagens I, II, and III were detectable in healthy tendons, immunohistochemical staining confirmed higher expression of these proteins in the acutely ruptured Achilles tendon. CONCLUSIONS: Our findings lay a foundation for further molecular studies of AATR. Inflammation and age-related degeneration may contribute to the pathogenesis of AATR. Moreover, the identified DEPs could be potential biomarkers for AATR diagnosis and treatment.

The Treatment of Complex Motorcycle Spoke Injuries in Children.

Motorcycle spoke injuries involving the soft tissue, Achilles tendon, and calcaneal defects are rare in children. Currently, calcaneal defects are very challenging to treat. Multiple methods have been used in clinical practice; however, an effective treatment has yet to be established, especially when Achilles tendon and soft-tissue defects are also present. It is important to address this condition, because the calcaneus plays a key role in standing and gait. Unsatisfactory treatment of calcaneal defects may significantly decrease patients' quality of life (eg, by limiting mobility). In this article, we report the effective treatment of calcaneal defects in four children using distraction osteogenesis with an external fixator framework designed by the authors. From May 2014 to May 2015, four children (age range, 6-11 years) with defects of the Achilles tendon, soft tissue, and calcaneus resulting from a motorcycle accident were treated at our hospital. The Achilles tendon and soft-tissue defects were treated with second-stage reconstruction. In the third-stage surgery, osteotomy of the residual calcaneus was performed. A customized external fixator was used to lengthen the calcaneus at a rate of 1.5 mm/day in the posterior direction and reposition it by 40° in the inferior direction. In all four children, the calcaneus was lengthened by 5 cm. Distraction osteogenesis through external fixation is effective for restoring the length, width, and height of the calcaneus in children.

A novel minimally invasive surgery combined with early exercise therapy promoting tendon regeneration in the treatment of spontaneous Achilles tendon rupture.

OBJECTIVE: Acute closed spontaneous Achilles tendon rupture often occurs in elderly individuals and is usually accompanied with many complications. Conventional surgical approaches to remove the tendon lesions and enthesophytes are highly traumatic and cause complications. In this study, a previously established minimally invasive surgical approach was modified and combined with a Kazakh exercise therapy to reduce trauma, improve wound healing, and promote tendon regeneration in the management of acute closed spontaneous Achilles tendon rupture. METHODS: Fifty-two patients with acute closed spontaneous Achilles tendon rupture were randomly classified into 2 groups. Group A included 23 patients that were treated with the novel approach. Group B included 29 patients that were treated with a continuous medial oblique surgical approach. Follow-up examinations were performed at post-operative weeks 12 and 24, and year 2. Outcomes were assessed by Achilles tendon rupture score (ATRS), a heel-rise endurance test, and ultrasonographic and multislice spiral computerized tomography. RESULTS: Mean ATRS in Group A was 68.6 and 86.0 at post-operative week 12 and 24, respectively, significantly higher than that in Group B (55.9 and 72.0, respectively). Recovery of patients in Group A was significantly better compared to Group B (p < 0.01), allowing them to participate in early rehabilitating kinesiotherapy. Patients in Group A rarely experienced complications after surgery, such as infection and Achilles tendon exposure, while in Group B, the wound healing was slower, the inside flaps were prone to necrosis and infection, and Achilles tendon exposure occurred in 10% of patients. CONCLUSIONS: The novel minimally invasive surgery is more advantageous in the treatment of acute closed spontaneous Achilles tendon rupture over previous approaches by promoting wound healing and tendon regeneration.

Active exercise promotes Achilles tendon healing and is accompanied by the upregulation of collapsin response mediator protein­2 in rats.

Collapsin response mediator protein-2 (CRMP-2) is involved in neurite elongation and regeneration; however, its role in wound healing remains to be elucidated. The present study aimed to investigate the effects of active mobilization treatment on Achilles tendon healing and to determine the role of CRMP­2 in the healing process. Sprague Dawley rats were subjected to Achilles tendon injury, which was verified by hematoxylin and eosin staining and scanning electronic microscopy. Immobilization induced the disruption of collagen fibril arrangement and promoted collagen fibril damage. The average collagen fibril perimeter in the active mobilization group was significantly increased compared with in the immobilization group (125.6±0.8 nm vs. 119.9±1.7 nm; P<0.05). In addition, immunohistological analysis revealed that CRMP­2 expression was significantly upregulated, particularly in the ruptured site of Achilles tendon tissues derived from animals in the mobilization group compared with the immobilization group (0.32±0.00 vs. 0.08±0.00; P<0.05). The increased CRMP­2 levels were also confirmed by western blotting (active mobilization group, 0.71±0.03; immobilization group, 0.49±0.01 nm; P<0.05). These results indicated that active mobilization may promote Achilles tendon healing via upregulation of CRMP­2 protein expression.

Percutaneous Yurt-bone suture versus minimally invasive surgery for acute Achilles tendon rupture / 中华创伤骨科杂志

Objective To compare the clinical outcomes of percutaneous Yurt-bone suture versus minimally invasive surgery in the treatment of acute Achilles tendon rupture.Methods Between September 2011 and December 2015,31 patients with acute Achilles tendon rupture were treated at our department.Of them,14 received percutaneous Yurt-bone suture and 17 minimally invasive surgery.The 2 groups were compared in terms of hospital stay,intraoperative bleeding volume,surgery time,decrease in leg circumference,delayed healing of the incision,single heel rise test,rerupture rate,sural nerve lesion and Achilles tendon total rupture scores (ATRS) at the final follow-up.Results The average follow-up period was 17.6 months (range,from 9 to 27 months) for all the patients in the 2 groups.The percutaneous Yurt-bone suture group had significantly less intraoperative bleeding volume (8.5 ± 3.6 mL),shorter surgery time (41.4 ± 5.3 min) and shorter hospital stay (4.2 ± 0.8 days),than the minimally invasive surgery group (43.5 ± 7.6 mL,75.5 ±7.8 min and 5.8 ± 1.3 days,respectively) (P ＜ 0.05).There were no statistically significant differences between the 2 groups regarding decrease in leg circumference (1.9 ± 0.2 cm versus 2.0 ±0.2 cm),delayed healing of the incision(0 versus 2 cases),positive single heel rise test (both one case),sural nerve lesion(one versus 0) or ATRS score (91.2 ± 3.7 versus 90.4 ± 3.3) (P ＞ 0.05).No re-rupture was observed in either group.Conclusion In the treatment of acute Achilles tendon rupture,compared with minimally invasive surgery,percutaneous Yurt-bone suture has advantages of shorter hospital stay,shorter surgery time,less intraoperative bleeding but a similar rate of complications.

Early Ankle Mobilization Promotes Healing in a Rabbit Model of Achilles Tendon Rupture.

The use of early mobilization of the ankle joint without orthosis in the treatment of Achilles tendon rupture has been advocated as the optimal management. The goal of this study was to compare outcomes in a postoperative rabbit model of Achilles tendon rupture between early mobilization and immobilized animals using a differential proteomics approach. In total, 135 rabbits were randomized into the control group (n=15), the postoperative cast immobilization (PCI) group (n=60), and the early mobilization (EM) group (n=60). A rupture of the Achilles tendon was created in each animal model and repaired microsurgically, and tendon samples were removed at 3, 7, 14, and 21 days postoperatively. Proteins were separated using 2-dimensional polyacrylamide gel electrophoresis and identified using peptide mass fingerprinting, tandem mass spectrometry, NCBI database searches, and bioinformatics analyses. A series of differentially expressed proteins were identified between groups, some of which may play an important role in Achilles tendon healing. Notable candidate proteins that were upregulated in the EM group were identified, such as CRMP-2, galactokinase 1, tropomyosin-4, and transthyretin. The healing of ruptured Achilles tendons appears to be affected at the level of protein expression with the use of early mobilization. The classic postoperative treatment of Achilles tendon rupture with an orthosis ignored the self-protecting instinct of humans. With a novel operative technique, the repaired tendon can persist the load that comes from traction in knee and ankle joint functional movement. In addition, kinesitherapy provided an excellent experimental outcome via a mechanobiological mechanism.

Clinical outcome of exercise therapy and early post-operative rehabilitation for treatment of neglected Achilles tendon rupture: a randomized study.

PURPOSE: Treatment of neglected Achilles tendon rupture is very challenging. This randomized study aimed to compare the clinical outcome of early post-operative rehabilitation (EPR) with post-operative cast immobilization (PCI). METHODS: Fifty-seven patients with neglected Achilles tendon rupture were randomized to receive EPR (n = 26) or PCI (n = 31) management following surgery. Clinical outcome was monitored by follow-up at weeks 8, 12, 18 and 26 and year 2. The significance of intergroup differences from the Leppilahti scoring system (LSS), ultrasonography, multislice spiral computerized tomography (MSCT) and electromyography was assessed. RESULTS: Ultrasonography and MSCT revealed no occurrence of tendon elongation or adhesion. Four patients could perform sustained single-leg heel-raise exercise for 60 s at post-operative day 40. The PCI group also showed increased post-operative LSS score, but recovery was slower. Post-operative complications, such as ankle joint ankylosis and osteoporosis, only occurred in the PCI group. CONCLUSIONS: Compared with cast immobilization, early post-operative rehabilitation results in better clinical outcome and faster overall tendon regeneration of neglected Achilles tendon rupture. LEVEL OF EVIDENCE: II.

Outcome of a one-stage tensile stress surgical technique and early postoperative rehabilitation in the treatment of neglected achilles tendon rupture.

The present study evaluated the effect of single-stage internal traction combined with early postoperative active rehabilitation and the yurt bone suture method, a new surgical technique, on the clinical outcomes after surgical repair of Achilles tendon. A total of 51 patients with neglected Achilles tendon rupture who underwent the yurt bone suture treatment also participated in an accelerated postoperative rehabilitation program. The clinical outcome was evaluated for 18 weeks using the Leppilahti scoring system, bilateral ultrasound examination, and computed tomography examination. The ultrasound and computed tomography examinations revealed that Achilles tendon elongation and adhesion occurred in none of the patients. All the patients could perform the single leg heel raise exercise for a mean of 30 ± 7.6 seconds at 12 weeks postoperatively. In addition, the patients could participate in sport exercises and heavy physical activities by around 13 weeks postoperatively. The mean Leppilahti score was 85.8 ± 3.7 at 8 weeks postoperatively, and it had increased to 96.1 ± 3.2 and 100.0 ± 0.0 at 12 and 18 weeks, respectively, after the operation. The 1-stage internal traction technique, combined with early postoperative active rehabilitation and the yurt bone surgical technique, resulted in good clinical outcomes for the treatment of neglected Achilles tendon rupture.