Katarina Nilsson-Helander

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.

Stable Surgical Repair With Accelerated Rehabilitation Versus Nonsurgical Treatment for Acute Achilles Tendon Ruptures A Randomized Controlled Study

Background: The optimal treatment for acute Achilles tendon ruptures is still a subject of debate. Early loading of the tendon is a factor that has been shown to be beneficial to recovery and to minimize complications. The main outcome of previous studies has been complications such as reruptures and deep infections, without focusing on the functional outcome relevant to the majority of patients who do not experience these complications. Purpose: To evaluate whether stable surgical repair and early loading of the tendon could improve patient-reported outcome and function after an acute Achilles tendon rupture. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 100 patients (86 men, 14 women; mean age, 40 years) with an acute total Achilles tendon rupture were randomized to either surgical treatment, including an accelerated rehabilitation protocol, or nonsurgical treatment. The primary outcome was the Achilles tendon Total Rupture Score (ATRS). The patients were evaluated at 3, 6, and 12 months for symptoms, physical activity level, and function. Results: There were no significant differences between the groups in terms of symptoms, physical activity level, or quality of life. There was a trend toward improved function in surgically treated patients; the results were significantly superior when assessed by the drop countermovement jump (95% CI, 0.03-0.15; P = .003) and hopping (95% CI, 0.01-0.33; P = .040). No reruptures occurred in the surgical group, while there were 5 in the nonsurgical group (P = .06). There were 6 superficial infections in the surgically treated group; however, these superficial infections had no bearing on the final outcome. Symptoms, reduced quality of life, and functional deficits still existed 12 months after injury on the injured side in both groups. Conclusion: The results of the present study demonstrate that stable surgical repair with accelerated tendon loading could be performed in all (n = 49) patients without reruptures and major soft tissue–related complications. However, this treatment was not significantly superior to nonsurgical treatment in terms of functional results, physical activity, or quality of life.

Treatment of patellar tendinopathy—a systematic review of randomized controlled trials

PurposePatellar tendinopathy is a common, painful, overuse disorder. Although many different treatment methods have been described, there is no consensus regarding the optimal treatment for this condition. The purpose of this study was to systematically review, summarize, and compare treatments for patellar tendinopathy from published randomized controlled trials.MethodsDatabase searches were performed for randomized prospective controlled trials comparing treatment methods for patellar tendinopathy. The thirteen articles considered relevant were scrutinized according to quality assessment guidelines and levels of evidence.ResultsStrong evidence was found for the use of eccentric training to treat patellar tendinopathy. Moderate evidence was found for conservative treatment (heavy slow resistance training) as an alternative to eccentric training. Moderate evidence suggests that low-intensity pulsed ultrasound treatment did not influence treatment outcomes. Limited evidence was found for surgery, sclerosing injections, and shockwave therapy.ConclusionPhysical training, and particularly eccentric training, appears to be the treatment of choice for patients suffering from patellar tendinopathy. However, type of exercise, frequency, load, and dosage must also be analyzed. Other treatment methods, such as surgical treatment, sclerosing injections, and shockwave therapy, must be investigated further before recommendations can be made regarding their use. Ultrasound can likely be excluded as a treatment for patellar tendinopathy. There is a persistent lack of well-designed studies with sufficiently long-term follow-up and number of patients to draw strong conclusions regarding therapy.Level of evidence II.

Recovery of calf muscle endurance 3 months after an Achilles tendon rupture

The purpose of this study was to evaluate calf muscle endurance in a seated position 3 months after an Achilles tendon rupture and to evaluate how the ability to perform standardized seated heel‐rises correlated to the single‐leg standing heel‐rise test and to patient‐reported symptoms evaluated with the Achilles tendon Total Rupture Score (ATRS) 3 and 6 months after the injury. Ninety‐three patients were included from a cohort of 101 patients participating in a prospective, randomized controlled trial comparing surgical and nonsurgical treatment after Achilles tendon rupture. Forty‐seven patients were treated surgically and 46 nonsurgically. Ninety‐one patients out of 93 (98%) could perform the standardized seated heel‐rises. At the 3‐month follow‐up, there was a significant difference (P < 0.001) between the injured and the healthy side performing standardized seated heel‐rises. There were also significant correlations (r = 0.29–0.37, P = < 0.05) between the standardized seated heel‐rises and ATRS 3 and 6 months after injury in the group who could not perform single‐leg standing heel‐rises. There were no significant differences between the surgical and nonsurgical treatment groups. The evaluation of standardized seated heel‐rises appears to be a useful tool to quantify progress and predict future functional performance and patient‐reported symptoms.

Functional Outcomes of Achilles Tendon Minimally Invasive Repair Using 4- and 6-Strand Nonabsorbable Suture: A Cohort Comparison Study

Background: The aim of management of Achilles tendon rupture is to reduce tendon lengthening and maximize function while reducing the rerupture rate and minimizing other complications. Purpose: To determine changes in Achilles tendon resting angle (ATRA), heel-rise height, patient-reported outcomes, return to play, and occurrence of complications after minimally invasive repair of Achilles tendon ruptures using nonabsorbable sutures. Study Design: Cohort study; Level of evidence, 3. Methods: Between March 2013 and August 2015, a total of 70 patients (58 males, 12 females) with a mean age of 42 ± 8 years were included and evaluated at 6 weeks and 3, 6, 9, and 12 months after repair of an Achilles tendon rupture. Surgical repair was performed using either 4-strand or 6-strand nonabsorbable sutures. After surgery, patients were mobilized, fully weightbearing using a functional brace. Early active movement was permitted starting at 2 weeks. Results: There were no significant differences in the ATRA, Achilles Tendon Total Rupture Score (ATRS), and Heel-Rise Height Index (HRHI) between the 4- and 6-strand repairs. The mean (SD) relative ATRA was –13.1° (6.6°) (dorsiflexion) following injury; this was reduced to 7.6° (4.8°) (plantar flexion) directly after surgery. During initial rehabilitation at 6 weeks, the relative ATRA was 0.6° (7.4°) (neutral) and –7.0° (5.3°) (dorsiflexion) at 3 months, after which ATRA improved significantly with time to 12 months (P = .005). At 12 months, the median ATRS was 93 (range, 35-100), and the mean (SD) HRHI and Heel-Rise Repetition Index were 81% (0.22%) and 82.9% (0.17%), respectively. The relative ATRA at 3 and 12 months correlated with HRHI (r = 0.617, P < .001 and r = 0.535, P < .001, respectively). Conclusion: Increasing the number of suture strands from 4 to 6 does not alter the ATRA or HRHI after minimally invasive Achilles tendon repair. The use of a nonabsorbable suture during minimally invasive repair when used together with accelerated rehabilitation did not prevent the development of an increased relative ATRA. The ATRA at 3 months after surgery correlated with heel-rise height at 12 months.

Free/Turndown Gastrocnemius Flap Augmentation

Surgical treatment is recommended for a chronic Achilles tendon rupture, as well as a re-rupture. Chronic Achilles tendon ruptures are referred to those more than 4 weeks after initial injury. An end-to-end repair is considered insufficient for tendons with a chronic injury or re-rupture and reinforcement is recommended. Fascial reinforcement has not been shown to improve outcome for acute ruptures.

Free Hamstring Open Augmentation for Delayed Achilles Tendon Rupture

Open reconstruction of the Achilles tendon may be considered to be a relatively simple technique and may be easily performed by surgeons less familiar with more complex Achilles reconstruction. The technique may be used for both chronic rupture greater than 4 weeks following injury and cases of re-rupture.

Open Standard Technique

Acute Achilles tendon rupture usually occurs in the midportion 2–6 cm proximal from the insertion site of calcaneus. In general there are usually no warning symptoms and the injury frequently occurs with a very distinct ankle trauma. The rupture is generally total and partial Achilles tendon rupture is very rare in the cases of specific pop sensed and localized to the midportion of the tendon. The diagnosis is clinical with positive Thompson’s test (calf squeeze test), reduced plantar flexion strength, and a palpable gap in the tendon. Surgical and nonsurgical treatment is still debated, together with the timing of the key components of rehabilitation, e.g., weight-bearing, movement, and functional bracing [1]. Open surgery (end-to-end repair) may be considered the gold standard surgical procedure. There has been shown no advantage in a fascial turndown over end-to-end appositional repair for acute ruptures [2]. Primary repair without an augmentation can be performed approximately within 3 weeks. Contraindications include peripheral vascular diseases, skin affections, and systemic diseases with high risk of infection.

Open Debridement of Mid-Portion Achilles Tendinopathy

Achilles tendinopathy, defined as the occurrence of pain, swelling and impaired performance, has incidence 0.2% in the general population. However, the incidence is much higher in recreational runners (9%).