Nicklas Olsson

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.

Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture

This study evaluated the short‐term recovery of function after an acute Achilles tendon rupture, measured by a single‐legged heel‐rise test, with main emphasis on the relation to the patient‐reported outcomes and fear of physical activity and movement (kinesiophobia). Eighty‐one patients treated surgically or non‐surgically with early active rehabilitation after Achilles tendon rupture were included in the study. Patients ability to perform a single‐legged heel‐rise, physical activity level, patient‐reported symptoms, general health, and kinesiophobia was evaluated 12 weeks after the injury. The heel‐rise test showed that 40 out of 81 (49%) patients were unable to perform a single heel‐rise 12 weeks after the injury. We found that patients who were able to perform a heel‐rise were significantly younger, more often of male gender, reported a lesser degree of symptoms, and also had a higher degree of physical activity at 12 weeks. There was also a significant negative correlation between kinesiophobia and all the patient‐reported outcomes and the physical activity level. The heel‐rise ability appears to be an important early achievement and reflects the general level of healing, which influences patient‐reported outcome and physical activity. Future treatment protocols focusing on regaining strength early after the injury therefore seem to be of great importance. Kinesiophobia needs to be addressed early during the rehabilitation process.

Predictors of Clinical Outcome After Acute Achilles Tendon Ruptures

Background: In patients with an acute Achilles tendon rupture, it has not been possible to determine the superiority of a single specific treatment modality over other treatments with respect to symptoms and function. When several pertinent treatment protocols are available for an injury, it is of interest to understand how other variables, such as age, sex, or physical activity level, affect outcome to better individualize the treatment. Purpose: To investigate predictors of both symptomatic and functional outcomes after an acute Achilles tendon rupture. Study Design: Cohort study (Prognosis); Level of evidence, 2. Methods: Ninety-three patients (79 men and 14 women; mean age, 40 years) were evaluated prospectively at 3, 6, and 12 months. The main outcome measures in this study were the Achilles tendon Total Rupture Score (ATRS) for symptoms and maximum heel-rise height for function. The independent variables evaluated as possible predictors of outcome included treatment, sex, age, body mass index (BMI), physical activity level, symptoms, and quality of life. Results: Treatment, age, BMI, physical activity level, heel-rise height at 6 months, and the ATRS at 3 months were eligible for further analysis. Only male sex was included for the prediction models. The 4 different multiple linear regression models (predicting the ATRS at 6 and 12 months and heel-rise height at 6 and 12 months) were significant (P < .001-.002), and the R2 values for the models were 0.222 to 0.409. Surgical or nonsurgical treatment is a moderate predictor of symptoms and a weak predictor of heel-rise height after an acute Achilles tendon rupture. At the 6-month follow-up, surgical treatment was associated with a larger heel-rise height, but the opposite was seen at 12 months. Surgical treatment resulted in a lower degree of symptoms. Increasing age was a strong predictor of reduced heel-rise height, and an increase in age of 10 years reduced the expected heel-rise height by approximately 8%. A higher BMI was also a strong predictor of a greater degree of symptoms, and a 5-unit higher BMI predicted a reduction of approximately 10 points in the ATRS. Conclusion: The present study identified important possible predictors of outcome. Despite having a wide range of clinically relevant variables, the models had a limited ability to predict the final individual outcome. In general, the models appear to be better at predicting function than symptoms.

Sex Differences in Outcome After an Acute Achilles Tendon Rupture

Background: Tendon healing differs between the sexes. Comparisons in outcome between the sexes after an Achilles tendon rupture are often not possible because of the small cohort (<20%) of women. Purpose: To evaluate whether there are any differences in outcome between the sexes by combining the data from 2 large randomized controlled trials that used identical outcome measures. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the evaluation were patients from 2 consecutive randomized controlled trials comparing surgical and nonsurgical treatment performed at our research laboratory. Patients who had a rerupture were excluded from analysis. A total of 182 patients (152 males, 30 females), with mean ± SD age of 40 ± 11 years, were included; 94 (76 males, 18 females) were treated with surgery and 88 (76 males, 12 females) nonsurgically. Patient-reported outcome was evaluated using the Achilles tendon Total Rupture Score (ATRS), and the functional outcome was measured with a heel-rise test (measurement of muscular endurance and heel-rise height) at 6 and 12 months after injury. Results: Male patients had a greater improvement in heel-rise height at 12 months (P = .004). When each treatment group was analyzed separately, it was found that female patients had significantly (P < .03) more symptoms after surgical treatment (mean ± SD ATRS, 59 ± 24) compared with males at 6 (73 ± 19) and 12 months (74 ± 27 vs 86.5 ± 17). This sex difference was not found in the nonsurgical treatment group. For the entire group, there were no significant differences between treatments on ATRS at 6 and 12 months. The surgical group had significantly better results compared with the nonsurgical group in heel-rise endurance at 6 and 12 months and in heel-rise height recovery at 6 months (P < .03 for both). Conclusion: Sex differences were demonstrated, and female patients had a greater degree of deficit in heel-rise height as compared with males, irrespective of treatment. Females had more symptoms after surgery both at 6 and 12 months, but this difference was not found when treated nonsurgically. Clinical Relevance: Further research is needed to determine whether women will benefit more from nonsurgical compared with surgical treatment after an Achilles tendon rupture.

The Achilles tendon resting angle as an indirect measure of Achilles tendon length following rupture, repair, and rehabilitation

Background Rupture of the Achilles tendon may result in reduced functional activity and reduced plantar flexion strength. These changes may arise from elongation of the Achilles tendon. An observational study was performed to quantify the Achilles tendon resting angle (ATRA) in patients following Achilles tendon rupture, surgical repair, and rehabilitation, respectively. Methods Between May 2012 and January 2013, 26 consecutive patients (17 men), with a mean (standard deviation, SD) age of 42 (8) years were included and evaluated following injury, repair, and at 6 weeks, 3 months, 6 months, 9 months, and 12 months, respectively (rehabilitation period). The outcome was measured using the ATRA, Achilles tendon total rupture score (ATRS), and heel-rise test. Results Following rupture, the mean (SD) absolute ATRA was 55 (8)° for the injured side compared with 43 (7)° (p < 0.001) for the noninjured side. Immediately after repair, the angle reduced to 37 (9)° (p < 0.001). The difference between the injured and noninjured sides, the relative ATRA, was −12.5 (4.3)° following injury; this was reduced to 7 (7.9)° following surgery (p < 0.001). During initial rehabilitation, at the 6-week time point, the relative ATRA was 2.6 (6.2)° (p = 0.04) and at 3 months it was −6.5 (6.5)° (p < 0.001). After the 3-month time point, there were no significant changes in the resting angle. The ATRS improved significantly (p < 0.001) during each period up to 9 months following surgery, where a score of 85 (10)° was reported. The heel-rise limb symmetry index was 66 (22)% at 9 months and 82 (14)% at 12 months. At 3 months and 6 months, the absolute ATRA correlated with the ATRS (r = 0.63, p = 0.001, N = 26 and r = 0.46, p = 0.027, N = 23, respectively). At 12 months, the absolute ATRA correlated with the heel-rise height (r = −0.63, p = 0.002, N = 22). Conclusion The ATRA increases following injury, is reduced by surgery, and then increases again during initial rehabilitation. The angle also correlates with patient-reported symptoms early in the rehabilitation phase and with heel-rise height after 1 year. The ATRA might be considered a simple and effective means to evaluate Achilles tendon function 1 year after the rupture.

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.

Calf Muscle Performance Deficits Remain 7 Years After an Achilles Tendon Rupture

Background: Optimizing calf muscle performance seems to play an important role in minimizing impairments and symptoms after an Achilles tendon rupture (ATR). The literature lacks long-term follow-up studies after ATR that describe calf muscle performance over time. Purpose: The primary aim was to evaluate calf muscle performance and patient-reported outcomes at a mean of 7 years after ATR in patients included in a prospective, randomized controlled trial. A secondary aim was to evaluate whether improvement in calf muscle performance continued after the 2-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Sixty-six subjects (13 women, 53 men) with a mean age of 50 years (SD, 8.5 years) were evaluated at a mean of 7 years (SD, 1 year) years after their ATR. Thirty-four subjects had surgical treatment and 32 had nonsurgical treatment. Patient-reported outcomes were evaluated with Achilles tendon Total Rupture Score (ATRS) and Physical Activity Scale (PAS). Calf muscle performance was evaluated with single-leg standing heel-rise test, concentric strength power heel-rise test, and single-legged hop for distance. Limb Symmetry Index (LSI = injured side/healthy side × 100) was calculated for side-to-side differences. Results: Seven years after ATR, the injured side showed decreased values in all calf muscle performance tests (P < .001-.012). Significant improvement in calf muscle performance did not continue after the 2-year follow-up. Heel-rise height increased significantly (P = .002) between the 1-year (10.8 cm) and the 7-year (11.5 cm) follow-up assessments. The median ATRS was 96 (of a possible score of 100) and the median PAS was 4 (of a possible score of 6), indicating minor patient-reported symptoms and fairly high physical activity. No significant differences were found in calf muscle performance or patient-reported outcomes between the treatment groups except for the LSI for heel-rise repetitions. Conclusion: Continued deficits in calf muscle endurance and strength remained 7 years after ATR. No continued improvement in calf muscle performance occurred after the 2-year follow-up except for heel-rise height.

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.