Michael Möller

Acute rupture of tendo Achillis: A PROSPECTIVE, RANDOMISED STUDY OF COMPARISON BETWEEN SURGICAL AND NON-SURGICAL TREATMENT

In a prospective, randomised, multicentre study, 112 patients (99 men and 13 women, aged between 21 and 63 years) with acute, complete rupture of tendo Achillis were allocated either to surgical treatment followed by early functional rehabilitation, using a brace, or to non-surgical treatment, with plaster splintage for eight weeks. The period of follow-up was for two years. Evaluation was undertaken by independent observers and comprised interviews, clinical measurements, isokinetic muscle performance tests, heel-raise tests and an overall outcome score. The rate of rerupture was 20.8% after non-surgical and 1.7% after surgical treatment (p < 0.001). Surgical and non-surgical treatment produced equally good functional results if complications were avoided. However, the rate of rerupture after non-surgical treatment was unacceptably high.In a prospective, randomised, multicentre study, 112 patients (99 men and 13 women, aged between 21 and 63 years) with acute, complete rupture of tendo Achillis were allocated either to surgical treatment followed by early functional rehabilitation, using a brace, or to non-surgical treatment, with plaster splintage for eight weeks. The period of follow-up was for two years. Evaluation was undertaken by independent observers and comprised interviews, clinical measurements, isokinetic muscle performance tests, heel-raise tests and an overall outcome score. The rate of rerupture was 20.8% after non-surgical and 1.7% after surgical treatment (p < 0.001). Surgical and non-surgical treatment produced equally good functional results if complications were avoided. However, the rate of rerupture after non-surgical treatment was unacceptably high.

The reliability of isokinetic testing of the ankle joint and a heel-raise test for endurance

The aim of the present study was to investigate the reliability of different methods used for isokinetic testing of calf muscle strength and endurance. The detailed evaluation of test-retest reliability serves the purpose of establishing reliable research tools when evaluating patients who have sustained an Achilles tendon rupture. The test-retest reliability of isokinetic measurements at the ankle for eccentric and concentric muscle action was calculated in ten healthy male volunteers using intra-class correlation (ICC) and coefficient of variation (CV). Three different positions were compared at the angular velocities of 30°/s and 180°/s for right and left ankles. The ICC for plantar flexion was 0.37–0.95, whilst it was 0.00–0.96 for dorsiflexion. The corresponding CVs were 4.0–19.9 and 2.4–19.8 respectively. The test-retest reliability of standardised heel-raises, Achilles tendon width, calf circumference and ankle range of motion revealed ICC values of 0.71–0.98 and CVs of 0.67–19.1. The test-retest interval was 5 to 7 days. We conclude that all three positions studied for the isokinetic evaluation of calf muscle function are equally reliable concerning plantar flexion at the ankle joint. The same level of reliability was also found in the evaluation of the standing heel-raise test and the isokinetic dorsiflexion test, except for dorsiflexion in the supine position. The reliability of the investigated methods was only fair despite the use of a detailed and standardised test protocol.

Calf muscle function after Achilles tendon rupture. A prospective, randomised study comparing surgical and non-surgical treatment.

In a prospective, randomised, multicentre study, 112 patients with Achilles tendon rupture (ATR) were allocated to surgical treatment (n=59), followed by early functional rehabilitation using a brace, and non‐surgical treatment (n=53), i.e. eight weeks of plaster treatment. In this study, the results of the isokinetic muscle strength evaluation are presented for contractions in both the concentric and the eccentric mode, plantar flexion and dorsiflexion, two angular velocities and three different positions of the subject. The heel‐raise test for endurance, maximum calf circumference and tendon width were also evaluated. The re‐rupture rate was 20.8% in the non‐surgically‐treated group and 1.7% in the surgically‐treated group. No significant differences were found between the treatment groups in terms of the isokinetic strength measurements and the endurance test among the patients who did not sustain a re‐rupture. If a re‐rupture is avoided, both surgical and non‐surgical treatment for ATR produce good functional outcome; however, the muscle function was not restored after two years in either group.

Acute rupture of tendo Achillis

In a prospective, randomised, multicentre study, 112 patients (99 men and 13 women, aged between 21 and 63 years) with acute, complete rupture of tendo Achillis were allocated either to surgical treatment followed by early functional rehabilitation, using a brace, or to non-surgical treatment, with plaster splintage for eight weeks. The period of follow-up was for two years. Evaluation was undertaken by independent observers and comprised interviews, clinical measurements, isokinetic muscle performance tests, heel-raise tests and an overall outcome score. The rate of rerupture was 20.8% after non-surgical and 1.7% after surgical treatment (p < 0.001). Surgical and non-surgical treatment produced equally good functional results if complications were avoided. However, the rate of rerupture after non-surgical treatment was unacceptably high.In a prospective, randomised, multicentre study, 112 patients (99 men and 13 women, aged between 21 and 63 years) with acute, complete rupture of tendo Achillis were allocated either to surgical treatment followed by early functional rehabilitation, using a brace, or to non-surgical treatment, with plaster splintage for eight weeks. The period of follow-up was for two years. Evaluation was undertaken by independent observers and comprised interviews, clinical measurements, isokinetic muscle performance tests, heel-raise tests and an overall outcome score. The rate of rerupture was 20.8% after non-surgical and 1.7% after surgical treatment (p < 0.001). Surgical and non-surgical treatment produced equally good functional results if complications were avoided. However, the rate of rerupture after non-surgical treatment was unacceptably high.

The Swedish fracture register: 103,000 fractures registered

BackgroundAlthough fractures consume large social and financial resources, little is known about their actual numbers, treatment methods or outcomes. The scarcity of data calls for a high-quality, population-based register. No previous registers have prospectively collected data and patient-reported outcome measures (PROMs) on fractures of all types. The Swedish Fracture Register was recently created to fill this gap in knowledge. Its purpose is to provide information on fractures of all types, whether treated by surgery or otherwise. The aim of this article is to describe how the register was developed and its current use.DescriptionThe Swedish Fracture Register was developed during a 4-year period, 2007–2010. Data collection started in 2011. The register currently collects data on all extremity, pelvic and spine fractures in adults who have been diagnosed or treated at the affiliated departments. Data entry is fully web based, including date, cause of injury, classification and treatment. It is performed by the attending physician. Patients fill out PROMs – EQ-5D-3L and the Short Musculoskeletal Function Assessment (SMFA) – relating to health status and level of functioning before the fracture and one year later. Surgeon-reported outcome measures are registered as reoperation rates. The Swedish Fracture Register is now functioning effectively and is used in clinical routine. From January 2011 to September 2015, more than 103,000 fractures have been entered at 26 Swedish orthopedic departments.ConclusionsThe Swedish Fracture Register is already a well-functioning, population-based fracture register that covers fractures of all types, regardless of treatment, and collects both surgeon- and patient-reported outcome measures. In the future the Swedish Fracture Register will be able to present both results of fracture treatment and valuable epidemiological data.

High reliability in classification of tibia fractures in the Swedish Fracture Register

INTRODUCTION The Swedish Fracture Register (SFR) was started in 2011 and registers fractures of all types, treated either surgically or non-surgically. Twenty-six orthopaedic departments in Sweden are affiliated and a total of 84,000 fractures have been registered. The physician who establishes the diagnosis of the fracture registers and classifies it according to the AO/OTA classification. The accuracy of the classification of fractures is important for the reliability of the data in the SFR. This study aimed to evaluate how accurate the classification of tibia fractures in the register is. METHODS Three experienced trauma surgeons (raters) were presented with the radiographs of 114 patients with tibia fractures randomly allocated from the SFR. The raters classified the fractures independently and blinded to clinical patient information in two classification sessions with a time interval of one month. The AO/OTA classification coded by the three expert raters (our predefined gold standard) was compared with the classifications in the SFR. Inter- and intra-observer agreement was evaluated. The degree of agreement was reported using the approach of Landis and Koch. RESULTS The accuracy of the SFR, defined as agreement between the SFR and the gold standard classification, was kappa=0.75 for the AO/OTA type and 0.56 for the AO/OTA group, corresponding to substantial and moderate agreement, respectively. Inter-observer agreement across the three expert raters was kappa=0.74 for the AO/OTA type and 0.53 for the AO/OTA group. Intra-observer agreement was kappa=0.74-0.79 for the AO/OTA type and 0.62-0.64 for the AO/OTA group. CONCLUSION This study shows that the accuracy of classification of tibia fractures in the SFR was substantial for the AO/OTA type (kappa=0.75) and moderate for the AO/OTA group (kappa=0.56) as defined by Landis and Koch. This degree of accuracy is similar to that in previous studies. We interpret this as meaning that the results of this study demonstrate the high reliability of the data in the SFR and enable the SFR to be used for further scientific analysis.

Tissue expansion for repair of severely complicated Achilles tendon ruptures.

We report on two patients with severely complicated Achilles tendon ruptures (ATR), including re-rupture, postoperative deep infection and subsequent tissue loss. Tissue expansion was used to facilitate tendon reconstruction and to ensure good healing potential with skin closure without tension. Tissue expansion is a valid option in patients with complicated ATR. The outcome for the two patients described here was good, with improved function and no major complications.

Acute Ultrasonography Investigation to Predict Reruptures and Outcomes in Patients With an Achilles Tendon Rupture

Background: The optimal treatment for acute Achilles tendon ruptures is still an ongoing debate. Acute ultrasonography (US) investigation to measure the diastasis between the tendon ends has previously been used to classify acute Achilles tendon ruptures; however, no study has used US to predict reruptures and functional outcomes. Purpose: To investigate whether acute US can be used to predict the risk of reruptures and outcomes after treatment of an acute Achilles tendon rupture. Study Design: Cohort study; Level of evidence, 2. Methods: Forty-five patients (37 men, 8 women) with a mean age of 39 ± 9.2 years (range, 23-59 years) from a cohort of 97 patients participating in a randomized controlled study comparing surgical and nonsurgical treatment were included. US was performed within 72 hours from the index injury. Diastasis between the tendon ends was documented. Reruptures were documented, and the patients’ functional outcomes were measured 12 months after injury. Results: Patients with a diastasis of >10 mm treated nonsurgically had a higher degree of rerupture. In the nonsurgically treated group, 3 of 4 patients with a diastasis of >10 mm suffered from rerupture (P < .001). Moreover, in the nonsurgical group, there was significantly worse outcomes in patients with a diastasis of >5 mm in terms of patient-reported outcomes using the Achilles tendon Total Rupture Score (ATRS) (P = .004) and heel-rise height at 12 months (P = .048) compared with the group with a lesser degree of tendon separation. Conclusion: US may be a useful tool to predict the risk of rerupture and greater degree of functional deficit. It may be an important measure in a clinical treatment algorithm for deciding whether a patient will benefit from surgical intervention after an acute Achilles tendon rupture.

Substantial accuracy of fracture classification in the Swedish Fracture Register: Evaluation of AO/OTA-classification in 152 ankle fractures

INTRODUCTION Since 2011 the Swedish Fracture Register (SFR) has collected information on fracture epidemiology, treatment and outcome. More than 112 000 fractures, including 11 600 ankle fractures, have been registered so far. The accuracy of the classification is crucial when using the register in future research and quality improvement of care. In this study we examine the degree of accuracy of the AO/OTA-classification in which ankle fractures are recorded in the SFR. METHODS 152 randomly selected ankle fractures registered in the SFR were classified independently by a reference group of three orthopedic surgeons on two occasions. The agreed AO/OTA-classification of the reference group was regarded as the gold standard classification for each case. The originally recorded classification in the SFR was subsequently compared with the classification of the reference group and accuracy calculated. RESULTS The agreement between the classification in the SFR and of the reference group was 74%, corresponding to kappa 0.67, 95% CI (0.58-0.76) for AO/OTA group level. An agreement of 88% equivalent to kappa 0.77, 95% CI (0.67-0.87) was noted for AO/OTA type level. The agreement corresponds to substantial according to Landis and Koch. The kappa value of inter- and intraobserver agreement ranged from 0.67 to 0.93. CONCLUSIONS The study results show substantial agreement between classifications made in the SFR and gold standard classification. The finding is equivalent to or higher than in previous studies. Consequently, we conclude that classifications of ankle fractures in the SFR are accurate and valid.

Epidemiology and incidence of tibia fractures in the Swedish Fracture Register

INTRODUCTION There is a lack of epidemiological studies of fractures in all segments of the tibia classified by orthopaedic surgeons according to the AO/OTA classification. Since 2011, the Swedish Fracture Register (SFR) has provided prospectively collected, population-based data on fractures of all types, treated both surgically and non-surgically. The aim of this study was to describe the epidemiology and incidence of fractures in all segments of the tibia in a cohort of consecutive tibia fractures over a period of five years at Sahlgrenska University Hospital, Gothenburg, Sweden. METHODS Information on age, gender, date and mechanism of injury, fracture classification according to AO/OTA, affected side and high- or low-energy trauma was extracted from the SFR for all patients, aged 16 years and above, with tibia fractures treated at Sahlgrenska University Hospital, Gothenburg, during the five-year period 1 January 2011 to 31 December 2015. RESULTS 1325 patients sustained 1371 tibia fractures. There were 712 proximal tibia fractures, 417 tibial shaft fractures and 242 distal tibia fractures. Patients with proximal tibia fractures had a higher mean age (54.3) and 58% were women, whereas patients with shaft and distal fractures had a slightly lower mean age (47.0 and 48.7 respectively) and a dominance of men (59% and 54% respectively). The overall incidence of tibia fractures was 51.7 per 100,000 and year. The incidence of proximal, diaphyseal and distal tibia fractures was 26.9, 15.7 and 9.1 respectively per 100,000 and year. Among women, tibia fractures showed an increasing incidence with age in all segments, whereas men had a fairly flat incidence curve, except for tibial shaft fractures, which displayed a peak among young males. The incidence of tibia fractures and graphs for age-specific incidence for each segment of the tibia are presented. CONCLUSIONS This study describes the epidemiology and incidence of fractures in the whole of the tibia classified by orthopaedic surgeons according to the AO/OTA classification.