Iikka Lantto

Epidemiology of Achilles tendon ruptures: Increasing incidence over a 33-year period

We investigated the epidemiology of total Achilles tendon ruptures and complication rates after operative and nonoperative treatments over a 33‐year period in Oulu, Finland. Patients with Achilles tendon ruptures from 1979 to 2011 in Oulu were identified from hospital patient records. Demographic data, treatment method, and complications were collected retrospectively from medical records. Overall and sex‐ and age‐specific incidence rates were calculated with 95% confidence intervals (CIs). The overall incidence per 100 000 person‐years increased from 2.1 (95% CI 0.3–7.7) in 1979 to 21.5 (95% CI 14.6–30.6) in 2011. The incidence increased in all age groups. The mean annual increase in incidence was 2.4% (95% CI 1.3–4.7) higher for non‐sports‐related ruptures than for sports‐related ruptures (P = 0.036). The incidence of sports‐related ruptures increased during the second 11‐year period whereas the incidence of non‐sports‐related ruptures increased steadily over the entire study period. Infection was four times more common after operative treatment compared with nonoperative treatment, re‐rupture rates were similar. The incidence of Achilles tendon ruptures increased in all age groups over a 33‐year period. Increases were mainly due to sports‐related injuries in the second 11‐year period and non‐sports‐related injuries in the last 11‐year period.

A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures

Background: The optimal treatment of acute Achilles tendon ruptures for active patients is under debate. Purpose: To compare clinical outcomes and calf muscle strength recovery after the nonsurgical treatment and open surgical repair of acute Achilles tendon ruptures with identical accelerated rehabilitation programs. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: From 2009 to 2013, a total of 60 patients with an acute Achilles tendon rupture were randomized to surgery or nonsurgical treatment. Nonsurgical treatment included first a week of cast immobilization, followed by a functional orthosis for 6 weeks, allowing full weightbearing after week 1 and active plantar flexion after week 5. Surgery was simple end-to-end open repair, and postoperative treatment was identical to nonsurgical treatment. Outcome measures included the Leppilahti Achilles tendon performance score, isokinetic calf muscle strength, and RAND 36-Item Health Survey at 18-month follow-up. Results: At 18-month follow-up, the mean Leppilahti score was 79.5 and 75.7 for the surgically and nonsurgically treated groups, respectively (mean difference, 3.8; 95% CI, –1.9 to 9.5; P = .19). Angle-specific peak torque results of affected legs showed that surgery resulted in faster and better recovery of calf muscle strength over the entire range of motion of the ankle joint: at 6 months, the difference varied from 16% to 24% (P = .016), favoring the surgically treated group, whereas at 18 months, surgically treated patients had 10% to 18% greater strength results (P = .037). At 18 months, a 14% difference in the peak torque of the affected leg favored the surgical group versus the nonsurgical group (mean peak torque, 110.3 vs 96.5 N·m, respectively; mean difference, 13.6 N·m; 95% CI, 2.0-25.1 N·m; P = .022). The RAND 36-Item Health Survey indicated better results in the domains of physical functioning (P = .006) and bodily pain (P = .037) for surgically treated patients. Conclusion: Surgical and nonsurgical treatments of acute Achilles tendon ruptures have similar results in terms of the Achilles tendon performance score, but surgery restores calf muscle strength earlier over the entire range of motion of the ankle joint, with a 10% to 18% strength difference favoring surgery at 18 months. Surgery may also result in better health-related quality of life in the domains of physical functioning and bodily pain compared with nonsurgical treatment. Registration: NCT02012803 (ClinicalTrials.gov)

Early Functional Treatment Versus Cast Immobilization in Tension After Achilles Rupture Repair Results of a Prospective Randomized Trial With 10 or More Years of Follow-up

Background: There are no long-term prospective controlled trials comparing postoperative regimens after Achilles tendon rupture repair. Purpose: To compare ≥10-year outcomes of 2 postoperative regimens after Achilles tendon rupture repair: early weightbearing with early mobilization versus early weightbearing with early immobilization in tension. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 50 patients with acute Achilles tendon ruptures were randomized postoperatively to receive either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks (group 1) or Achilles tendon immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks (group 2). Patients were assessed at 3, 6, and 14 months and 11 years postoperatively. Results: There were 37 patients (74%) evaluated at a mean (±SD) of 11.0 ± 0.9 years. The mean Leppilahti score was 92.9 ± 5.6 in group 1 and 93.6 ± 7.2 in group 2 (P = .68). The mean isokinetic plantar flexion peak torque deficits or average work deficits in plantar flexion showed no differences between the groups with any angular velocity. Isokinetic strength changed minimally between 1 and 11 years compared with the unaffected ankle, but a mean deficit of 5% in peak torque and mean deficit of 8% in average work were still present after 11 years. On the contrary, isometric plantar flexion strength recovered significantly, with only a 2.4% difference at 11-year follow-up. Conclusion: After the 11-year follow-up, early mobilization and immobilization in tension after Achilles rupture repair resulted in similar clinical outcomes and isokinetic strengths. Regardless of patient satisfaction with the operative treatment, calf muscle strength did not recover normally even at 11-year follow-up.

Augmented Compared with Nonaugmented Surgical Repair After Total Achilles Rupture: Results of a Prospective Randomized Trial with Thirteen or More Years of Follow-up.

BACKGROUND This prospective randomized trial with a mean fourteen-year follow-up compared simple end-to-end repair with fascial flap-augmented repair for acute Achilles tendon ruptures. METHODS From 1998 to 2001, sixty patients with acute Achilles tendon rupture were randomized to receive simple end-to-end repair or augmented repair; both groups were treated with postoperative bracing allowing free active plantar flexion. After a follow-up of thirteen years or more, fifty-five patients (twenty-eight in the nonaugmented-repair group and twenty-seven in the augmented-repair group) were reexamined. Outcome measures included the Leppilahti Achilles tendon score, isokinetic plantar flexion strength (peak torque and the work-displacement deficit at 10° intervals over the ankle range of motion), tendon elongation, and the RAND 36-item health survey. RESULTS After a mean of fourteen years of follow-up, the mean Leppilahti score was 87.1 points for the nonaugmented repairs and 91.5 points for the augmented repairs, with a mean difference of 4.3 points (95% confidence interval [CI], -0.1 to 8.8 points). The surgical technique did not have an impact on strength parameters, with a mean peak torque of 112.6 Nm after the nonaugmented repairs and 107.3 Nm after the augmented repairs (mean difference, 5.3 Nm [95% CI, -22.2 to 11.6 Nm]) and a median work-displacement deficit of 6.7% to 20.3% after the nonaugmented repairs and 12.8% to 18.0% after the augmented repairs (p = 0.9). Strength did not significantly change between the twelve-month and fourteen-year follow-up examinations. At a mean of fourteen years, the injured side showed a 12.2% to 18.0% median work-displacement deficit compared with the unaffected side (p < 0.001). RAND-36 scores indicated no between-group difference in health domains. CONCLUSIONS Augmented repair of total Achilles tendon ruptures provided no advantage over simple end-to-end repair. Achilles tendon ruptures result in a permanent calf muscle strength deficit, but its clinical relevance remains unclear. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI.

BACKGROUND This prospective diagnostic study assessed the utility of MRI (magnetic resonance imaging) findings for the deep aspect of the deltoid ligament in evaluating the stability of the ankle mortise in patients who have an SER (supination-external rotation)-type lateral malleolar fracture with no widening of the medial clear space. METHODS Sixty-one patients with a unilateral lateral malleolar fracture resulting from an SER mechanism were enrolled. Two surgeons assessed the stability of the ankle mortise with use of an external-rotation stress test. The anterior and posterior parts of the deep deltoid ligament were investigated with 3.0-T MRI and were graded (as normal, edematous, partial tear, or complete tear) by two musculoskeletal radiologists. The medial clear space was measured and compared with the MRI findings for the deep deltoid ligament in stable and unstable injuries. Interobserver reliability was calculated for both external-rotation stress testing and MRI assessment. RESULTS Thirty-three patients had a medial clear space of ≥ 5 mm in the external-rotation stress test. According to MRI, all of these patients had an injury involving the deep deltoid ligament (an edematous ligament in five, a partial tear in twenty-six, and a total tear in two). Twenty-eight patients had a medial clear space of <5 mm, and MRI indicated a deep deltoid ligament injury in all of these patients as well (an edematous ligament in nine and a partial tear in nineteen). The medial clear space increased according to the severity of the deep deltoid ligament injury as indicated by MRI (p < 0.001). The interobserver agreement of the external-rotation stress test was excellent (94% agreement; kappa = 0.87), whereas the interobserver reliability of the MRI assessments by the two musculoskeletal radiologists was fair to moderate (72% agreement for the posterior part of the deep deltoid ligament and 56% for the anterior part; kappa = 0.46 and 0.22, respectively). CONCLUSIONS On the basis of the study results, we do not recommend the use of MRI when choosing between operative and nonoperative treatment of an SER-type ankle fracture.

Soleus Atrophy Is Common After the Nonsurgical Treatment of Acute Achilles Tendon Ruptures: A Randomized Clinical Trial Comparing Surgical and Nonsurgical Functional Treatments:

Background: It remains controversial whether nonsurgical or surgical treatment provides better calf muscle strength recovery after an acute Achilles tendon rupture (ATR). Recent evidence has suggested that surgery might surpass nonsurgical treatment in restoring strength after an ATR. Purpose: To assess whether magnetic resonance imaging (MRI) findings could explain calf muscle strength deficits and the difference between nonsurgical and surgical treatments in restoring calf muscle strength. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: From 2009 to 2013, 60 patients with acute ATRs were randomized to surgery or nonsurgical treatment with an identical rehabilitation protocol. The primary outcome measure was the volume of calf muscles assessed using MRI at 3 and 18 months. The secondary outcome measures included fatty degeneration of the calf muscles and length of the affected Achilles tendon. Additionally, isokinetic plantarflexion strength was measured in both legs. Results: At 3 months, the study groups showed no differences in muscle volumes or fatty degeneration. However, at 18 months, the mean differences between affected and healthy soleus muscle volumes were 83.2 cm3 (17.7%) after surgery and 115.5 cm3 (24.8%) after nonsurgical treatment (difference between means, 33.1 cm3; 95% CI, 1.3-65.0; P = .042). The study groups were not substantially different in the volumes or fatty degeneration of other muscles. From 3 to 18 months, compensatory hypertrophy was detected in the flexor hallucis longus (FHL) and deep flexors in both groups. In the nonsurgical treatment group, the mean difference between affected and healthy FHL muscle volumes was −9.3 cm3 (12%) and in the surgical treatment group was −8.4 cm3 (10%) (P ≤ .001). At 18 months, Achilles tendons were, on average, 19 mm longer in patients treated nonsurgically compared with patients treated surgically (P < .001). At 18 months, surgically treated patients demonstrated 10% to 18% greater strength results (P = .037). Calf muscle isokinetic strength deficits for the entire range of ankle motion correlated with soleus atrophy (ρ = 0.449-0.611; P < .001). Conclusion: Treating ATRs nonsurgically with a functional rehabilitation protocol resulted in greater soleus muscle atrophy compared with surgical treatment. The mean Achilles tendon length was 19 mm longer after nonsurgical treatment than after the surgical treatment of ATRs. These structural changes partly explained the 10% to 18% greater calf muscle strength observed in patients treated with surgery compared with those treated nonsurgically. Registration: NCT02012803 (ClinicalTrials.gov identifier).

Diagnostic accuracy of the gravity stress test and clinical signs in cases of isolated supination–external rotation-type lateral malleolar fractures

We prospectively assessed the diagnostic accuracy of the gravity stress test and clinical findings to evaluate the stability of the ankle mortise in patients with supination-external rotation-type fractures of the lateral malleolus without widening of the medial clear space. The cohort included 79 patients with a mean age of 44 years (16 to 82). Two surgeons assessed medial tenderness, swelling and ecchymosis and performed the external rotation (ER) stress test (a reference standard). A diagnostic radiographer performed the gravity stress test. For the gravity stress test, the positive likelihood ratio (LR) was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate change from the pre-test probability. Medial tenderness, both alone and in combination with swelling and/or ecchymosis, indicated a small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47), whereas swelling and ecchymosis indicated only minimal changes (positive LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). In conclusion, when gravity stress test results are in agreement with clinical findings, the result is likely to predict stability of the ankle mortise with an accuracy equivalent to ER stress test results. When clinical examination suggests a medial-side injury, however, the gravity stress test may give a false negative result.

Drug treatments associated with Achilles tendon rupture. A case-control study involving 1118 Achilles tendon ruptures

The incidence of Achilles tendon (AT) rupture, especially nonsport‐related rupture, is increasing, while the reasons for this increase are largely unknown. The association between the AT rupture and the use of various drug treatments was studied. We collected AT rupture patients from the Finnish Hospital Discharge Register. We also acquired information about all the doctor‐prescribed drugs they had purchased within 1 year before the rupture. For comparison, we randomly selected age‐ and sex‐matched controls from the Finnish Population Register. There were 1118 AT rupture patients. Several drug groups had a statistically significant association with the AT rupture. Our study confirmed an association between fluoroquinolone antibiotics and AT rupture (OR 2.20, P = 0.005). A statistically significant association of renin‐angiotensin II receptor antagonists with tendon rupture (OR 7.59, P = 0.003) was a previously unreported finding. The increasing incidence of AT rupture, especially in middle‐aged and elderly patients, might partially be a consequence of the increased use of certain drug treatments. Some associations are probably explained by the symptomatic treatment of the painful tendon before the rupture.