Kristoffer Weisskirchner Barfod

Nonoperative dynamic treatment of acute achilles tendon rupture: the influence of early weight-bearing on clinical outcome: a blinded, randomized controlled trial.

BACKGROUND Dynamic rehabilitation has been suggested to be an important part of nonoperative treatment of acute Achilles tendon rupture that results in functional outcome and rerupture rates comparable with those of operative treatment. However, the optimal role of weight-bearing during early rehabilitation remains unclear. The purpose of this study was to compare immediate weight-bearing with non-weight-bearing in a nonoperative dynamic treatment protocol for Achilles tendon rupture. METHODS The study was conducted as a blinded, randomized, controlled, parallel superiority trial. Patients eighteen to sixty years of age were eligible for inclusion. Both groups were treated nonoperatively with controlled early motion. The intervention group was allowed full weight-bearing from day one, and the control group was non-weight-bearing for six weeks. The primary outcome was the Achilles tendon Total Rupture Score (ATRS) after one year. Secondary outcomes included heel-rise work, health-related quality of life, and the rerupture rate. Outcome assessors were blinded to the intervention. RESULTS Thirty patients were randomized to each group; twenty-nine in the weight-bearing group and twenty-seven in the control group were analyzed. The only significant difference between the groups was better health-related quality of life in the weight-bearing group at twelve months (p = 0.009). The mean ATRS at twelve months was 73 in the weight-bearing group and 74 in the control group (p = 0.81). At twelve months, the total heel-rise work performed by the injured limb relative to that by the uninjured limb was 53% in the weight-bearing group and 58% in the control group (p = 0.37). There were three reruptures in the weight-bearing group and two in the control group (p = 1.0). CONCLUSIONS The ATRS and heel-rise work results did not differ significantly between the groups. The rerupture rate was 9% overall, and both groups had substantial functional deficits in the injured limb compared with the uninjured limb. Immediate weight-bearing can be recommended as an option in the nonoperative treatment of Achilles tendon rupture.

Validity and Reliability of the Achilles Tendon Total Rupture Score

The best treatment of acute Achilles tendon rupture remains debated. Patient-reported outcome measures have become cornerstones in treatment evaluations. The Achilles tendon total rupture score (ATRS) has been developed for this purpose but requires additional validation. The purpose of the present study was to validate a Danish translation of the ATRS. The ATRS was translated into Danish according to internationally adopted standards. Of 142 patients, 90 with previous rupture of the Achilles tendon participated in the validity study and 52 in the reliability study. The ATRS showed moderately strong correlations with the physical subscores of the Medical Outcomes Study 36-item Short-Form Health Survey (r = .70 to .75; p < .0001) and Victorian Institute of Sports Assessment-Achilles questionnaire (r = .71; p < .0001). Test-retest of the ATRS showed no significant difference in the mean (2.41; p = .07). The limits of agreement were ±18.53. A strong correlation was found between test and retest (intercorrelation coefficient .908); the standard error of measurement was 6.7, and the minimal detectable change was 18.5. The Danish version of the ATRS showed moderately strong criterion validity. For study and follow-up purposes, the ATRS seems reliable for comparisons of groups of patients. Its usability is limited for repeated assessment of individual patients. The development of analysis guidelines would be desirable.

Treatment of Acute Achilles Tendon Rupture in Scandinavia Does Not Adhere to Evidence-based Guidelines: A Cross-sectional Questionnaire-based Study of 138 Departments

The best treatment of acute Achilles tendon rupture has been discussed for decades. During the past half decade, evidence has increased in favor of nonoperative treatment and dynamic and weightbearing rehabilitation. We hypothesized that the treatment strategies would show great variation and that adherence to evidence-based recommendations would not be as good as desired. The purpose of the present study was to investigate how acute Achilles tendon rupture is treated in Scandinavia. A questionnaire was distributed to all orthopedic departments treating acute Achilles tendon ruptures in Denmark, Sweden, Norway, and Finland. The questionnaire was returned by 138 of 148 departments (response rate 93%). Two-way tables with Fishers exact test were used for statistical analysis. In Denmark, Norway, Sweden, and Finland, 19 of 23 (83%), 44 of 48 (92%), 26 of 40 (65%), and 8 of 27 (30%) departments recommended surgical treatment (p < .001). Dynamic rehabilitation was used significantly less often in Denmark (5 of 23 [22%]), Norway (17 of 45 [38%]), and Sweden (11 of 40 [28%]) than in Finland (15 of 26 [58%]; p = .015). A significant difference was found among the countries in the educational level of the performing surgeons (p < .001). Surgical treatment was the treatment of choice in Danish, Norwegian, and Swedish hospitals regardless of the increasing evidence favoring nonoperative treatment. Although increasing evidence has favored dynamic rehabilitation, it has gained limited use across Scandinavia. Weightbearing was used in most hospitals. Surgery was performed by junior surgeons in most hospitals across Scandinavia. Treatment algorithms showed considerable variation and often did not adhere to the clinical evidence.

Functional rehabilitation of patients with acute Achilles tendon rupture: a meta-analysis of current evidence

AbstractPurpose The optimal treatment for acute Achilles tendon rupture (ATR) is continuously debated. Recent studies have proposed that the choice of either operative or non-operative treatment may not be as important as rehabilitation, suggesting that functional rehabilitation should be preferred over traditional immobilization. The purpose of this meta-analysis of randomized controlled trials (RCTs) was to compare functional rehabilitation to immobilization in the treatment of ATR. MethodThis meta-analysis was conducted using the databases: PubMed, EMBASE, Rehabilitation and Sports Medicine Source, AMED, CINAHL, Cochrane Library and PEDro using the search terms: “Achilles tendon,” “rupture,” “mobilization” and “immobilization”. Seven RCTs involving 427 participants were eligible for inclusion, with a total of 211 participants treated with functional rehabilitation and 216 treated with immobilization.ResultsRe-rupture rate, other complications, strength, range of motion, duration of sick leave, return to sport and patient satisfaction were examined. There were no statistically significant differences between groups. A trend favoring functional rehabilitation was seen regarding the examined outcomes.ConclusionFunctional rehabilitation after acute Achilles tendon rupture does not increase the rate of re-rupture or other complications. A trend toward earlier return to work and sport, and increased patient satisfaction was found when functional rehabilitation was used. The present literature is of low-to-average quality, and the basic constructs of the examined treatment and study protocols vary considerably. Larger, randomized controlled trials using validated outcome measures are needed to confirm the findings.Level of evidenceII.

Good validity and reliability of the forgotten joint score in evaluating the outcome of total knee arthroplasty

Background and purpose — When evaluating the outcome after total knee arthroplasty (TKA), increasing emphasis has been put on patient satisfaction and ability to perform activities of daily living. To address this, the forgotten joint score (FJS) for assessment of knee awareness has been developed. We investigated the validity and reliability of the FJS. Patients and methods — A Danish version of the FJS questionnaire was created according to internationally accepted standards. 360 participants who underwent primary TKA were invited to participate in the study. Of these, 315 were included in a validity study and 150 in a reliability study. Correlation between the Oxford knee score (OKS) and the FJS was examined and test-retest evaluation was performed. A ceiling effect was defined as participants reaching a score within 15% of the maximum achievable score. Results — The validity study revealed a strong correlation between the FJS and the OKS (intraclass correlation coefficient (ICC) = 0.81, 95% CI: 0.77–0.85; p < 0.001). The test-retest evaluation showed almost perfect reliability for the FJS total score (ICC = 0.91, 95% CI: 0.88–0.94) and substantial reliability or better for individual items of the FJS (ICC? 0.79). We found a high level of internal consistency (Cronbach’s? = 0.96). The ceiling effect for the FJS was 16%, as compared to 37% for the OKS. Interpretation — The FJS showed good construct validity and test-retest reliability. It had a lower ceiling effect than the OKS. The FJS appears to be a promising tool for evaluation of small differences in knee performance in groups of patients with good clinical results after TKA.

Nonoperative, Dynamic Treatment of Acute Achilles Tendon Rupture: Influence of Early Weightbearing on Biomechanical Properties of the Plantar Flexor Muscle–Tendon Complex—A Blinded, Randomized, Controlled Trial

Acute Achilles tendon rupture alters the biomechanical properties of the plantar flexor muscle-tendon complex that can affect functional performance and the risk of repeat injury. The purpose of the present study was to compare the biomechanical properties of the plantar flexor muscle-tendon complex in patients randomized to early weightbearing or non-weightbearing in the nonoperative treatment of Achilles tendon rupture. A total of 60 patients were randomized to full weightbearing from day 1 of treatment or non-weightbearing for 6 weeks. After 6 and 12 months, the peak passive torque at 20° dorsiflexion, the stiffness during slow stretching, and the maximal strength were measured in both limbs. The stiffness of the plantar flexor muscle-tendon complex in the terminal part of dorsiflexion was significantly increased (p = .024) in the non-weightbearing group at 12 months. The peak passive torque was significantly lower for the affected limb at 6 months (91%; p = .01), and the stiffness was significantly lower for the affected limb during the early part of dorsiflexion at 6 (67%; p < .001) and 12 (77%; p < .001) months. In conclusion, an increased stiffness of the plantar flexor muscle-tendon complex in the terminal part of dorsiflexion was found in the non-weightbearing group. The altered stiffness and strength in the affected limb could affect the coordination of gait and running.

Quality assessment of radiological measurements of trochlear dysplasia; a literature review

PurposeTo make a systematic review with quality assessments of the known measurements used to describe trochlear dysplasia.MethodsA systematic literature search was conducted in the databases PubMed and Embase using the search string “trochlea dysplasia OR trochlear dysplasia”. Papers were screened for their relevance based on predefined parameters, and all measurements showing a statistical association between trochlear dysplasia and patellar instability were presented. Four experts evaluated the quality of the measures using a purpose-made quality scale.ResultsThe search generated 600 papers of which eight were chosen for review. Thirty-three unique measurements were identified and described in order of their date of publication. The lateral trochlea inclination was rated highest by the expert panel. The crossing sign, the trochlea bump, the TT–TG distance, the trochlea depth and the ventral trochlea prominence also had high ratings.ConclusionThirty-three unique measurements were identified with the lateral trochlea inclination as the highest rated measurement by the expert panel, and it is recommended for use in assessment of trochlear dysplasia. The crossing sign, the trochlea bump, the TT–TG, the trochlea depth and the ventral trochlea prominence were also rated well and can be recommended for use.Level of evidenceV.

High incidence of acute and recurrent patellar dislocations: a retrospective nationwide epidemiological study involving 24.154 primary dislocations

PurposeThe purpose of this study was to investigate the Danish population as a whole from 1994 to 2013 to find the incidence of acute and recurrent patellar dislocation.MethodsThe study was performed as a descriptive epidemiological study. The Danish National Patient Registry was retrospectively searched from 1994 to 2013 to find the number of acute and recurrent patellar dislocation. National population data were collected from Statistics Denmark.ResultsThe period 1994–2013 saw a total registration of 24,154 primary patellar dislocations. A mean incidence of 42 (95% CI 37–47) per 100,000 person-years at risk was found, and young females aged 10–17 had the highest incidence of 108 (95% CI 101–116). In a 10-year follow-up, patients were at an overall risk of 22.7% (95% CI 22.2–23.2) of suffering a recurrent dislocation, with young girls aged 10–17 experiencing the highest risk, namely 36.8% (95% CI 35.5–38.0). The overall risk of suffering a patellar dislocation in the contralateral knee was 5.8% (95% CI 5.5–6.1) and 11.1% (95% CI 10.4–11.7) for patients aged 10–17.ConclusionA high incidence rate of primary patellar dislocation was found both as a mean in the population (42/100,000), and particularly in patients aged 10–17 (108/100,000). The risk of recurrent dislocation in the affected knee (22.7%) and the contralateral knee (5.8%) was high, which could indicate the influence of an underlying pathomorphology. This is relevant knowledge to the clinician, as he/she should be aware of the high risk of recurrent dislocation when deciding on treatment, especially in young patients.Level of evidenceIV.

Severe Functional Debilitations After Complications Associated With Acute Achilles Tendon Rupture With 9 Years of Follow-Up

ABSTRACT The purpose of the present study was to investigate the long‐term effect of deep infection, sural nerve injury, and repeat rupture in the treatment of acute Achilles tendon rupture. A total of 324 patients had made a claim to the Danish Patient Insurance Association from 1992 to 2010 for a complication after acute Achilles tendon rupture. Of the 324 patients, 119 (36.7%) (77 [64.7%] males and 42 [35.3%] females) returned the Achilles tendon total rupture score and the 36‐item short‐form survey questionnaires. Patients with deep infection (n = 10), sural nerve injury (n = 10), and repeat rupture (n = 16) participated in a follow‐up investigation. The mean follow‐up period was 8.9 (range 3 to 21) years. The mean Achilles tendon total rupture score was 49 ± 27. The summary scores of the physical component and mental components scales of the 36‐item Short Form Survey were 43 ± 11 and 52 ± 11, respectively. No significant differences were found among the subpopulations with deep infection, injury to the sural nerve, or repeat rupture. The physical evaluation investigating tendon length and heel rise work revealed a statistically significant difference between the affected and unaffected limb after repeat rupture (p < .01) but not after injury to the sural nerve (p > .05) or deep infection (p > .05). In conclusion, patients with from a complication after acute Achilles tendon rupture had a remarkable reduction of the Achilles tendon total rupture score and physical component scale score at mean follow‐up point of 9 years. Patients with repeat rupture had a significant elongation of the tendon and reduction of strength in the affected limb.

Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis

&NA; Achilles tendon ruptures can be either surgically or conservatively treated with either early functional mobilization or cast immobilization. The purpose of the present study was to conduct a meta‐analysis comparing the effect of early versus late weightbearing in conservatively treated adult patients, including only randomized controlled trials (RCTs). The primary endpoint was rerupture, and the secondary endpoints were strength, quality of life during treatment, range of motion, deep venous thrombosis, return to sports, and return to work. The search for studies was conducted using PubMed, EMBASE, and the Cochrane Central Register of Controlled trials. A search was performed, and 2 reviewers independently screened the studies by title, abstract, and, finally, by reading the full text. Four studies met the inclusion criteria. The reference lists of the included studies were scanned and 1 additional RCT study was included. The critical appraisal skills program checklist was applied for study appraisal. A statistician performed the data management and analysis. No statistically significant differences were found between the 2 treatment groups concerning rerupture (p = .796), return to sports (p = .455), or return to work (p = .888). One RCT found 1 case of deep venous thrombosis in the late weightbearing group. One RCT reported significant improvement in quality of life and one reported a significantly improved range of dorsiflexion in the early weightbearing group. No statistically significant difference was found between early and late weightbearing with conservative treatment regarding the rerupture rate. The results of the other outcomes were limited by the low number of studies included in the present meta‐analysis. Larger randomized studies are needed to investigate these outcomes. From the results in the present study, we would recommend early weightbearing when an Achilles tendon rupture is treated conservatively. &NA; Level of Clinical Evidence: 1