Eva Faxén

The Achilles Tendon Total Rupture Score (ATRS) Development and Validation

Background There is a need for a patient-relevant instrument to evaluate outcome after treatment in patients with a total Achilles tendon rupture. Purpose To develop and validate a new patient-reported instrument for measuring outcome after treatment for total Achilles tendon rupture. Study Design Cohort study (diagnosis); Level of evidence, 1. Methods Development of this instrument consisted of item generation and test construction, item reduction, validation, evaluation of structure and internal consistency, test-retest, and test for responsiveness. The final version, the Achilles tendon Total Rupture Score (ATRS), was tested for validity, structure, and internal consistency (Cronbachs alpha) on 82 patients and 52 healthy persons. A correlation analysis was performed of the ATRS with the 2 validated foot/ankle/Achilles tendon scores, the Foot and Ankle Outcome Score (FAOS) and the Swedish version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-S). Structure was evaluated with factor analysis. Test-retest reliability was evaluated on 43 patients. The ATRS responsiveness was tested on 43 patients by calculating the effect size. Results The total score for the patients ranged from 17 to 100 with a mean (median) of 77 (85) and a standard deviation (interquartile range) of 21.4 (23). A significantly (P < .0001) higher total score was found for the healthy subjects, ranging from 94 to 100 with a mean (median) of 99.8 (100) and a standard deviation (interquartile range) of 1.1 (0). The ATRS correlated significantly (P < .01) with all subscales of the FAOS (r = 0.60-0.84) and the VISA-A-S (r = 0.78). The factor analysis gave 1 factor of importance. The internal consistency was 0.96 as measured with Cronbachs alpha. The test-retest produced an intraclass correlation coefficient of 0.98. The tests for responsiveness showed an effect size between 0.87 and 2.21. Conclusion The ATRS is a patient-reported instrument with high reliability, validity, and sensitivity for measuring outcome after treatment in patients with a total Achilles tendon rupture. Clinical Relevance The ATRS is a self-administered instrument with high clinical utility, and we suggest the score for measuring the outcome, related to symptoms and physical activity, after treatment in patients with a total Achilles tendon rupture.

Acute Achilles Tendon Rupture A Randomized, Controlled Study Comparing Surgical and Nonsurgical Treatments Using Validated Outcome Measures

Background There is no consensus regarding the optimal treatment for patients with acute Achilles tendon rupture. Few randomized controlled studies have compared outcomes after surgical or nonsurgical treatment with both groups receiving early mobilization. Purpose This study was undertaken to compare outcomes of patients with acute Achilles tendon rupture treated with or without surgery using early mobilization and identical rehabilitation protocols. Study Design Randomized, controlled trial; Level of evidence, 1. Methods Ninety-seven patients (79 men, 18 women; mean age, 41 years) with acute Achilles tendon rupture were treated and followed for 1 year. The primary end point was rerupturing. Patients were evaluated using the Achilles tendon Total Rupture Score (ATRS), functional tests, and clinical examination at 6 and 12 months after injury. Results There were 6 (12%) reruptures in the nonsurgical group and 2 (4%) in the surgical group (P = .377). The mean 6- and 12-month ATRS were 72 and 88 points in the surgical group and 71 and 86 points in the nonsurgical group, respectively. Improvements in ATRS between 6 and 12 months were significant for both groups, with no significant between-group differences. At the 6-month evaluation, the surgical group had better results compared with the nonsurgically treated group in some of the muscle function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work test in favor of the surgical group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower than that of the uninjured leg in both groups. Conclusion The results of this study did not demonstrate any statistically significant difference between surgical and nonsurgical treatment. Furthermore, the study suggests that early mobilization is beneficial for patients with acute Achilles tendon rupture whether they are treated surgically or nonsurgically. The preferred treatment strategy for patients with acute Achilles tendon rupture remains a subject of debate. Although the study met the sample size dictated by the authors’ a priori power calculation, the difference in the rerupture rate might be considered clinically important by some.

Biodegradable and Metallic Interference Screws in Anterior Cruciate Ligament Reconstruction Surgery Using Hamstring Tendon Grafts Prospective Randomized Study of Radiographic Results and Clinical Outcome

Background The use of biodegradable screws in anterior cruciate ligament reconstruction has grown in popularity. Purpose To compare the clinical and radiographic results in arthroscopically assisted anterior cruciate ligament reconstruction using 4-strand hamstring tendon grafts and either metallic (metal group) or biodegradable (PLLA group) interference screw fixation. Study Design Randomized controlled trial; Level of evidence, 1. Methods A randomized series of 77 patients, all with a unilateral anterior cruciate ligament rupture, was included in the study. The preoperative assessments in both groups were similar in gender, Tegner activity level, Lysholm score, KT-1000 arthrometer measurements, and single-legged hop test results. In both groups, interference screw fixation of the graft was used at both ends, and 68 of 77 (88%) patients returned for a radiographic examination at 6 and 24 months, respectively. Results At follow-up, no significant differences were found between the 2 groups in KT-1000 arthrometer laxity measurements, Tegner activity level, or Lysholm score. The PLLA group had a significantly better outcome in the single-legged hop test and the final International Knee Documentation Committee classification (P=. 007 and P=. 03,respectively). At 6 and 24 months after the index operation, the PLLA group displayed significantly larger drill holes on the radiographs than did the metal group on both the tibial (8.1 vs 6.6 mm at 6 months [P=.0007]; 6.0 vs 3.2 mm at 24 months [.0001]) and femoral sides (7.8 vs 5.6 mm at 6 months [P <.0001]; 6.3 vs 1.9 mm at 24 months [P <.0001]). Conclusion There were significantly larger radiographically visible drill holes on both the tibial and femoral sides in the PLLA group compared with the metal group at 6 and 24 months. Clinical examination at 2 years revealed no major differences between the groups. The larger drill holes in the PLLA group did not correlate with inferior clinical results.

Is a knee brace advantageous after anterior cruciate ligament surgery? A prospective, randomised study with a two-year follow-up.

The aim of this study was to evaluate the use of a knee brace after arthroscopic anterior cruciate ligament reconstruction using central third patellar tendon autografts. Fifty patients were randomly allocated to two groups. The patients in Group A wore a brace for three weeks post‐operatively, while the patients in Group B were rehabilitated without the use of a brace. Pre‐operatively, the groups were comparable in terms of age, sex, activity level, knee laxity and muscle strength. The follow‐up examination was performed by one independent observer. All the patients were followed up for a minimum of two years. At the follow‐up, there were no significant differences between the study groups in terms of the Tegner activity level, Lysholm score, IKDC evaluation system, one‐leg‐hop quotient, KT‐1000 measurements and isokinetic torque. Using the visual analogue scale, the patients in Group A evaluated their pain during the first two post‐operative weeks as 1.0 (0–7), compared with 2.3 (0–9) in Group B (P=0.04). Furthermore, the patients in Group A had a tendency towards fewer problems with swelling, haemathrosis and wound leakage during the early post‐operative period (P=0.08). We conclude that the patients who were rehabilitated with the use of a brace had less pain and a tendency towards fewer complications during the early post‐operative period than the patients who were rehabilitated without the use of a brace. However, there were no differences in terms of function or knee laxity at the two‐year follow‐up.

Closing patellar tendon defects after anterior cruciate ligament reconstruction: absence of any benefit

Abstract The most common graft in anterior cruciate ligament (ACL) surgery involves using the central one-third of the patellar tendon. Knowledge concerning the postoperative disability after harvesting the patellar tendon is, however, limited. The aim of this study was to evaluate the impact patellar tendon suture and bone grafting of the patellar bone defect might have in terms of functional outcome and patellofemoral pain after harvesting the bone-tendon-bone graft, compared with leaving the harvested site non-sutured and non-grafted. Sixty patients, scheduled for arthroscopically assisted ACL reconstruction, were randomly allocated to two groups. In group I, suture of the patellar tendon and bone grafting of the patellar defect were performed. In group II, the tendon gap and the patellar defect were left open. Preoperatively, there was no significant difference between the groups when comparing objective knee stability, as measured with a KT-1000 laxity meter, Lysholm score, Tegner activity level, IKDC score, or patellofemoral pain score. Both groups had a significantly improved Lysholm score at the 2-year follow-up, without any difference between them. Tegners activity level was significantly lower at follow-up, compared with the pre-injury level in both groups. The patellofemoral pain score improved significantly after the reconstruction, without any difference between the groups. Ultrasonography did not reveal any difference between the groups in terms of healing of the tendon gap. This study revealed no differences in donor site morbidity, functional outcome, patellofemoral pain score or knee joint stability between the two treatment groups. The conclusion is that suture of the patellar tendon and bone grafting of the patellar defect do not improve the functional results or reduce donor site morbidity after arthroscopically assisted ACL.

A prospective four- to seven-year follow-up after arthroscopic anterior cruciate ligament reconstruction.

The aim of this study was to evaluate the results after arthroscopic anterior cruciate ligament reconstruction using a bone‐patellar tendon‐bone graft in 99 patients, who were followed up prospectively for four to seven years. The pre‐injury Tegner activity level was 7 compared with 5 at the four‐ to seven‐year follow‐up (P<0.0001). The preoperative Lysholm score was 74.5 points. At the two‐year follow‐up, the Lysholm score was 95 points, while it was 90 points at the four‐ to seven‐year follow‐up (P<0.0001 preoperative vs two years and preoperative vs four to seven years and P<0.0005 two years vs four to seven years). Using the IKDC evaluation system, 80% of the patients were classified as normal or nearly normal and 20% as abnormal or severely abnormal at the final follow‐up. The KT‐1000 laxity measurements revealed a side‐to‐side difference of 2.9 mm preoperatively, 0.6 at two years and 1.0 mm at four to seven years. Twenty‐six patients underwent additional surgery during the follow‐up period. The results after arthroscopic reconstruction of the anterior cruciate ligament appear to be satisfactory both at the short‐ and the medium‐term follow‐ups, but there appears to be some deterioration between the two‐year and the four‐ to seven‐year follow‐up.

Biodegradable and Metallic Interference Screws in Anterior Cruciate Ligament Reconstruction Surgery Using Hamstring Tendon Grafts

Background The use of biodegradable screws in anterior cruciate ligament reconstruction has grown in popularity. Purpose To compare the clinical and radiographic results in arthroscopically assisted anterior cruciate ligament reconstruction using 4-strand hamstring tendon grafts and either metallic (metal group) or biodegradable (PLLA group) interference screw fixation. Study Design Randomized controlled trial; Level of evidence, 1. Methods A randomized series of 77 patients, all with a unilateral anterior cruciate ligament rupture, was included in the study. The preoperative assessments in both groups were similar in gender, Tegner activity level, Lysholm score, KT-1000 arthrometer measurements, and single-legged hop test results. In both groups, interference screw fixation of the graft was used at both ends, and 68 of 77 (88%) patients returned for a radiographic examination at 6 and 24 months, respectively. Results At follow-up, no significant differences were found between the 2 groups in KT-1000 arthrometer laxity measurements, Tegner activity level, or Lysholm score. The PLLA group had a significantly better outcome in the single-legged hop test and the final International Knee Documentation Committee classification (P=. 007 and P=. 03,respectively). At 6 and 24 months after the index operation, the PLLA group displayed significantly larger drill holes on the radiographs than did the metal group on both the tibial (8.1 vs 6.6 mm at 6 months [P=.0007]; 6.0 vs 3.2 mm at 24 months [.0001]) and femoral sides (7.8 vs 5.6 mm at 6 months [P <.0001]; 6.3 vs 1.9 mm at 24 months [P <.0001]). Conclusion There were significantly larger radiographically visible drill holes on both the tibial and femoral sides in the PLLA group compared with the metal group at 6 and 24 months. Clinical examination at 2 years revealed no major differences between the groups. The larger drill holes in the PLLA group did not correlate with inferior clinical results.

Biodegradable and Metallic Interference Screws in Anterior Cruciate Ligament Reconstruction

Background The use of biodegradable screws in anterior cruciate ligament reconstruction has grown in popularity. Purpose To compare the clinical and radiographic results in arthroscopically assisted anterior cruciate ligament reconstruction using 4-strand hamstring tendon grafts and either metallic (metal group) or biodegradable (PLLA group) interference screw fixation. Study Design Randomized controlled trial; Level of evidence, 1. Methods A randomized series of 77 patients, all with a unilateral anterior cruciate ligament rupture, was included in the study. The preoperative assessments in both groups were similar in gender, Tegner activity level, Lysholm score, KT-1000 arthrometer measurements, and single-legged hop test results. In both groups, interference screw fixation of the graft was used at both ends, and 68 of 77 (88%) patients returned for a radiographic examination at 6 and 24 months, respectively. Results At follow-up, no significant differences were found between the 2 groups in KT-1000 arthrometer laxity measurements, Tegner activity level, or Lysholm score. The PLLA group had a significantly better outcome in the single-legged hop test and the final International Knee Documentation Committee classification (P=. 007 and P=. 03,respectively). At 6 and 24 months after the index operation, the PLLA group displayed significantly larger drill holes on the radiographs than did the metal group on both the tibial (8.1 vs 6.6 mm at 6 months [P=.0007]; 6.0 vs 3.2 mm at 24 months [.0001]) and femoral sides (7.8 vs 5.6 mm at 6 months [P <.0001]; 6.3 vs 1.9 mm at 24 months [P <.0001]). Conclusion There were significantly larger radiographically visible drill holes on both the tibial and femoral sides in the PLLA group compared with the metal group at 6 and 24 months. Clinical examination at 2 years revealed no major differences between the groups. The larger drill holes in the PLLA group did not correlate with inferior clinical results.