E. J. M. M. Verleisdonk

Acute Achilles Tendon Rupture: Minimally Invasive Surgery versus Nonoperative Treatment with Immediate Full Weightbearing—A Randomized Controlled Trial

Background Surgical repair of acute Achilles tendon ruptures is considered superior to nonoperative treatment, but complications other than rerupture range up to 34%. Nonoperative treatment by functional bracing seems a promising alternative. Hypothesis Nonoperative treatment of acute Achilles tendon rupture with functional bracing reduces the number of complications compared with surgical treatment with a minimally invasive technique. Study Design Randomized controlled clinical trial; Level of evidence, 2. Method Using concealed random allocation, 83 patients with acute Achilles tendon rupture were assigned to nonoperative treatment by functional bracing or minimally invasive surgical treatment followed by tape bandage. Patients were allowed full weightbearing, and follow-up was 1 year. Results Complications risk other than rerupture by intention-to-treat basis was 9 in 42 patients (21 %) for surgical treatment and 15 in 41 patients (36%) for nonoperative treatment (risk ratio, 0.59; 95% confidence interval, 0.29-1.19). Reruptures risk was 5 in 41 patients after nonoperative treatment and 3 in 42 patients for surgical treatment (risk ratio, 0.59; 95% confidence interval, 0.15-2.29). The mean time to work was 59 days (SD, 82) after surgical treatment and 108 days (SD, 115) after nonoperative treatment (difference, 49 days; 95% confidence interval, 4-94; P < .05). The difference between treatments for return to sports (risk ratio, 0.55; 95% confidence interval, 0.23-1.29), pain, and treatment satisfaction did not reach statistical significance. Conclusion There appears to be a clinically important difference in the risk of complications between minimally invasive surgical treatment and nonoperative treatment for acute Achilles tendon ruptures, but this was not statistically significant.

The diagnostic value of MRI scans for the diagnosis of chronic exertional compartment syndrome of the lower leg

Abstract Objective. A prospective descriptive study to determine the value of magnetic resonance imaging (MRI) as an aid in diagnosing (chronic) exertional compartment syndrome. Design and patients. MRI was performed in 21 patients (41 anterior compartments) with chronic compartment syndrome at rest and following physical exercise. Median (T2-weighted) signal intensity on the MRI scan was determined in the anterior and the (superficial) posterior compartment of the lower leg before and after exercise. Postexercise increases in the signal intensity in these two compartments were compared. After fasciotomy, a second MRI scan was performed in 13 patients (25 anterior compartments) on the basis of the same protocol. MR studies were performed in 12 normal controls (24 anterior muscle compartments) on the basis of the same protocol. Results. T2-weighted signal intensity increased by 27.5% (range 13.6–38.6%) following exercise in the anterior compartment of patients with a chronic compartment syndrome. In the posterior compartment this increase amounted to 4.25% (range 0–10.2%). Following fasciotomy, the increase in the anterior compartment was 4.1% (range 1.0–5.2%), while the increase in the posterior compartment amounted to 5.6% (range 0–11.0%), In normal controls, the increase in the anterior compartment was 7.6% (range 0–9.1%), while in the posterior compartment it was 4.0% (range 0–7.2%). Conclusions. In patients with a chronic compartment syndrome, the affected (anterior) compartment shows a statistically significant increase in (T2-weighted) signal intensity during exercise compared with both the (superficial) posterior compartment and the anterior compartment of normal controls. This effect disappeared after fasciotomy. In view of the substantial increase in T2-weighted signal intensity, MRI can be used in diagnosing chronic compartment syndrome.

Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial

BackgroundWe present the design of an open randomized multi-centre study on surgical versus conservative treatment of acute Achilles tendon ruptures. The study is designed to evaluate the effectiveness of conservative treatment in reducing complications when treating acute Achilles tendon rupture.Methods/DesignAt least 72 patients with acute Achilles tendon rupture will be randomized to minimally invasive surgical repair followed by functional rehabilitation using tape bandage or conservative treatment followed by functional rehabilitation with use of a functional bracing system. Both treatment arms use a 7 weeks post-rupture rehabilitation protocol. Four hospitals in the Netherlands will participate. Primary end-point will be reduction in complications other than re-rupture. Secondary end-point will be re-rupturing, time off work, sporting activity post rupture, functional outcome by Leppilahti score and patient satisfaction. Patient follow-up will be 12 month.DiscussionBy making this design study we wish to contribute to more profound research on AT rupture treatment and prevent publication bias for this open-labelled randomized trial.Trial registrationISRCTN50141196

Effect of Complications After Minimally Invasive Surgical Repair of Acute Achilles Tendon Ruptures: Report on 211 Cases

Background: Complications of acute Achilles tendon rupture treatment are considered to negatively influence outcome, but the relevance of these effects is largely unknown. Purpose: The Achilles Tendon Total Rupture Score (ATRS) was used to determine level of disability in patients with minimally invasive surgical Achilles tendon rupture repair with a complicated postoperative course. Study Design: Case series; Level of evidence, 4. Methods: The charts of 340 consecutive patients treated for an acute Achilles tendon rupture by minimally invasive surgical repair were reviewed. Complications were categorized as rerupture, severe wound infection, sural nerve injury, and other. Level of disability was evaluated by the 10-item ATRS with a sum score of minimum 0 to maximum 100 points. Results: A total of 211 patients returned a completed questionnaire: mean follow-up was 6.2 years (range, 3-10 years). Mean ATRS for all 211 patients was 84 (95% confidence interval: 82, 87). The mean ATRS for the 135 (64%) uncomplicated cases was 89 of 100 points, 71 points for the 17 (8%) patients with a rerupture (95% confidence interval: 63, 79; P < .0001), 79 points for the 41 patients (19%) with a sural nerve injury (95% confidence interval: 74, 85; P = .0008), and 75 points for the 17 patients (8%) with another complication (95% confidence interval: 67, 83; P = .001). Of these other complications, 13 patients (6%) suffered a wound-healing complication considered minor. Their average ATRS score was 80 points (95% confidence interval: 71, 88.7; P = .0445). One patient suffered a severe wound infection as well, scoring 28 of 100 points. Rerupture significantly increased the risk of quitting or changing sport participation on the long term. Conclusion: Long-term outcome after minimally invasive Achilles tendon rupture repair is excellent. Rerupture and severe wound infection are the most important complications with lasting negative effect on outcome. It justifies the use of rerupture as a relevant outcome measure in treatment evaluation.

Long-term Results of a Randomized Double-blinded Prospective Trial of a Lightweight (Ultrapro) Versus a Heavyweight Mesh (Prolene) in Laparoscopic Total Extraperitoneal Inguinal Hernia Repair (TULP-trial).

Objective:The aim of the randomized clinical trial was to compare the 2 years of clinical outcomes of a lightweight (Ultrapro) vs a heavyweight (Prolene) mesh for laparoscopic total extraperitoneal (TEP) inguinal hernia repair. Background:Lightweight meshes reduce postoperative pain and stiffness in open anterior inguinal hernia repair. The discussion about a similar benefit for laparoscopic repair is ongoing, but concerns exist about higher recurrence rates. Methods:Between March 2010 and October 2012, male patients who presented with a primary, reducible unilateral inguinal hernia who underwent day-case TEP repair were eligible. Outcome parameters included chronic pain, recurrence, foreign body feeling, and quality of life scores. Results:During the study period, 950 patients were included. One year postoperatively the presence of relevant pain (Numeric Rating Score 4–10) was significantly higher in the lightweight mesh group (2.9%) compared with the heavyweight mesh group (0.7%) (P = 0.01), and after 2 years this difference remained significant (P = 0.03). There were 4 (0.8%) recurrent hernias in the heavyweight mesh group and 13 (2.7%) in the lightweight group (P = 0.03). No differences in foreign body feeling or quality of life scores were detected. Conclusions:In TEP hernia surgery, there was no benefit of lightweight over heavyweight meshes observed 2 years postoperatively.

Recovery of Calf Muscle Strength Following Acute Achilles Tendon Rupture Treatment A Comparison Between Minimally Invasive Surgery and Conservative Treatment

The aim of this study was to measure the effect of treatment of acute Achilles tendon ruptures on calf muscle strength recovery. Eighty-three patients with acute Achilles tendon rupture were randomly allocated to either minimally invasive surgery with functional after-treatment or conservative treatment by functional bracing. Calf muscle strength using isokinetic testing was evaluated at 3 months and after 6 or more months posttreatment. To exclusively investigate the effect of treatment on outcome, the authors excluded patients with major complications from the analysis. In 31 of 39 patients in the surgical treatment group and 25 of 34 patients in the conservative treatment group, isokinetic strength tests were performed. In the analysis of differences in mean peak torque, no statistically significant differences were found between surgery and conservative treatment, except for plantar flexion strength at 90 degrees per second at the second measurement, favoring conservative treatment. After 8 to 10 months follow- up, loss of plantar flexion strength was still present in the injured leg in both treatment groups. In conclusion, isokinetic muscle strength testing did not detect a statistically significant difference between minimally invasive surgical treatment with functional after-treatment and conservative treatment by functional bracing of acute Achilles tendon ruptures.

Persistent Disability Despite Sufficient Calf Muscle Strength After Rerupture of Surgically Treated Acute Achilles Tendon Ruptures

Rerupture after treatment of acute Achilles tendon rupture is considered a serious complication. Yet data on long-term outcome after rerupture are limited. This study evaluated outcome after rerupture and compares it to a reference of uncomplicated cases. Thirteen patients with a rerupture following minimally invasive surgical Achilles tendon rupture repair were evaluated using Leppilahti score and resumption of work and sport. Mean follow-up was 8.7 years. Results were compared with a reference group of 23 uncomplicated cases with a follow-up of at least 1 year. The study was designed as a follow-up study. The relative risk for a fair/poor outcome by Leppilahti score after a rerupture when compared with uncomplicated cases is 2.83 (95% confidence interval = 1.17-6.87; P = .0185). Although rerupture did not affect ultimate resumption of professional life, the relative risk for quitting sport or resuming sport at a lower level after a rerupture is 3.33 (95% confidence interval = 1.71-6.51; P = .0001). In contrast, the plantar flexion strength deficit is 5% to 10% in the rerupture group and up to 20% in the reference group. Despite sufficient recovery of calf muscle strength, rerupture after acute Achilles tendon rupture treatment results in significant long-term functional disabilities. Level of Evidence: Prognostic, Level II

The effect of ultrapro or prolene mesh on postoperative pain and well-being following endoscopic Totally Extraperitoneal (TEP) hernia repair (TULP): study protocol for a randomized controlled trial

BackgroundThe purpose of this study was to describe the rationale and design of a randomized controlled trial analyzing the effects of mesh type (Ultrapro versus Prolene mesh) on postoperative pain and well-being following an endoscopic Totally Extraperitoneal (TEP) repair for inguinal hernias (short: TULP trial).Methods and designThe TULP trial is a prospective, two arm, double blind, randomized controlled trial to assess chronic postoperative pain and quality of life following implantation of a lightweight (Ultrapro) and heavyweight (Prolene) mesh in endoscopic TEP hernia repair. The setting is a high-volume single center hospital, specializing in TEP hernia repair. All patients are operated on by one of four surgeons. Adult male patients (≥18 years of age) with primary, reducible, unilateral inguinal hernias and no contraindications for TEP repair are eligible for inclusion in the study. The primary outcome is substantial chronic postoperative pain, defined as moderate to severe pain persisting ≥ 3 months postoperatively (Numerical Rating Scale, NRS 4–10). Secondary endpoints are the individual development of pain until three years after the TEP procedure, the quality of life (QoL), recurrence rate, patient satisfaction and complications.DiscussionLarge prospective randomized controlled studies with a long follow-up evaluating the incidence of chronic postoperative pain following implantation of lightweight and heavyweight mesh in endoscopic (TEP) hernia repair are limited. By studying the presence of pain and quality of life, but also complications and recurrences in a large patient population, a complete efficiency and feasibility assessment of both mesh types in TEP hernia repair will be performed.Trial registrationThe TULP study is registered in the Dutch Trial Register (NTR2131)