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.

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.

Active Achilles tendon kinesitherapy accelerates Achilles tendon repair by promoting neurite regeneration.

Active Achilles tendon kinesitherapy facilitates the functional recovery of a ruptured Achilles tendon. However, protein expression during the healing process remains a controversial issue. New Zealand rabbits, aged 14 weeks, underwent tenotomy followed immediately by Achilles tendon microsurgery to repair the Achilles tendon rupture. The tendon was then immobilized or subjected to postoperative early motion treatment (kinesitherapy). Mass spectrography results showed that after 14 days of motion treatment, 18 protein spots were differentially expressed, among which, 12 were up-regulated, consisting of gelsolin isoform b and neurite growth-related protein collapsing response mediator protein 2. Western blot analysis showed that gelsolin isoform b was up-regulated at days 7-21 of motion treatment. These findings suggest that active Achilles tendon kinesitherapy promotes the neurite regeneration of a ruptured Achilles tendon and gelsolin isoform b can be used as a biomarker for Achilles tendon healing after kinesitherapy.

Proteomic analysis of differential protein expression of achilles tendon in a rabbit model by two-dimensional polyacrylamide gel electrophoresis at 21 days postoperation.

Postoperative early kinesitherapy has been advocated as an optimal method for treating Achilles tendon rupture. However, an insight into the rationale of how early kinesitherapy contributes to healing of Achilles tendon remains to be achieved, and research in the area of proteomic analysis of Achilles tendon has so far been lacking. Forty-two rabbits were randomized into control group, immobilization group, and early motion group, and received postoperative cast immobilization and early motion treatments. Achilles tendon samples were prepared 21 days following microsurgery, and the proteins were separated with two-dimensional polyacrylamide gel electrophoresis. Differentially expressed proteins were first recognized by PDQuest software, and then identified using peptide mass fingerprinting, tandem mass spectrometry, and database searching. A total of 463 ± 12, 511 ± 39, and 513 ± 80 protein spots were successfully detected in the two-dimensional polyacrylamide gels for the Achilles tendon samples of rabbits in the control group, immobilization group, and early motion group, respectively. There were 15, 8, and 9 unique proteins in these three groups, respectively, and some differentially expressed proteins were also identified in each group. It was indicated that some of the differentially expressed proteins were involved in various metabolism pathways and may play an important role in healing of Achilles tendon rupture. Postoperative early kinesitherapy resulted in differentially expressed proteins in ruptured Achilles tendon compared with those treated with postoperative cast immobilization. These differentially expressed proteins may contribute to healing of Achilles tendon rupture through a mechanobiological mechanism due to the application of postoperative early kinesitherapy.