Orthopaedic surgery

The reliability, reproducibility and utilization of the radiographic Achilles Tendon Loading Angle in the management of Achilles Tendon rupture (2021)

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Type of publication:
Journal article

Author(s):
*Carmont M.R.; *Littlehales J.; Brorsson A.; Karlsson J.; Nilsson-Helander K.; Barfod K.W.; Ginder L.

Citation:
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons; Oct 2021; vol. 27 (no. 7); p. 760-766

Abstract:
Background: During management of Achilles tendon rupture, determination of tendon-end approximation, either clinically or by ultrasound is difficult, following brace application of during loading. The Radiographic Achilles Tendon Loading Angle (RadATLA) is proposed as a method of measuring ankle position whilst loading in a brace during the management of Achilles tendon rupture. This study aims to determine the reliability and reproducibility of the RadATLA. Method(s): A loaded true lateral ankle radiograph including the fifth metatarsal head was taken when wearing a brace at the 6-week time point in 18 patients (19 ankles). following Achilles tendon repair or reconstruction. The RadATLA was compared with the Tibio-talar angle, other radiographic and clinical measures used to quantify foot and ankle position during the first 6 weeks of early rehabilitation in a resting position and during loading. Result(s): The intra-rater reliability of both angles was found to be good (>0.8). The RadATLA was found to have an excellent intra-rater reliability with Intra-class correlation of (ICC) 0.992-0.996 (95%CI 0.889-0.999), standard error of the measurement (SEM) 1.03-3.65 and Minimal Detectable Change (MDC) 2.86-10.12. The inter-rater reliability was good with ICC of 0.798-0.969 (95%CI-0.03 to 0.964), SEM 2.9-7.6, and MDC 8.1-20.9. The RadATLA loaded at 6 weeks in all patients was at mean (SD) (range) 41.9 (16.5), (18.5-75.9). There was a significant difference between the patients in the Repair group compared with patients in the Reconstruction group both in RadATLA loaded at 6 weeks: 35.6 (11.2), (18.5-56.5) versus 55.5 (19), (20-75.9), (p = 0.01). The amount loaded in all patients was at mean (SD) (range) 29.2Kg (17.7), (2-56) and the percentage Body Weight was 30.7% (19), (2.1-63.2). There were no differences between the groups neither in amount loaded nor in percentage Body weight (p = 0.614-0.651). Conclusion(s): The RadATLA is a reliable and reproducible angle and can be used to determine the position of the ankle, when loaded in a brace during rehabilitation following Achilles tendon rupture.

Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair (2018)

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Type of publication:
Journal article

Author(s):
Braunstein, Mareen; Baumbach, Sebastian F; Boecker, Wolfgang; *Carmont, Mike R; Polzer, Hans

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA; Mar 2018; vol. 26 (no. 3); p. 846-853

Abstract:
PURPOSE Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair. METHODS A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included. RESULTS One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment. CONCLUSION Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician. LEVEL OF EVIDENCE II.

Tendon end separation with loading in an Achilles tendon repair model: comparison of non-absorbable vs. absorbable sutures (2017)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R; Kuiper, Jan Herman; Grävare Silbernagel, Karin; Karlsson, Jón; Nilsson-Helander, Katarina

Citation:
of experimental orthopaedics; Dec 2017; vol. 4 (no. 1); p. 26

Abstract:
BACKGROUND Rupture of the Achilles tendon often leads to long-term morbidity, particularly calf weakness associated with tendon elongation. Operative repair of Achilles tendon ruptures leads to reduced tendon elongation. Tendon lengthening is a key problem in the restoration of function following Achilles tendon rupture. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading.METHODSNineteen bovine Achilles tendons were repaired using a percutaneous/ minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally, using non-absorbable 4-strand 6-strand repairs and absorbable 8-strand sutures. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with  early range of motion training and weight-bearing, before being loaded to failure.RESULTS Pre-conditioning of 10 cycles of 100 N resulted in separations of 4 mm for 6-strand, 5.9 mm for 4-strand, but 11.5 mm in 8-strand repairs, this comprised 48.5, 68.6 and 72.7% of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for 4-strand repairs, 16.6 mm for 6-strand repairs and 26.6 mm for 8-strand repairs. There were significant differences between the groups (p < 0.0001). Four and six strand non-absorbable repairs had significantly less separation than 8-strand absorbable repairs (p = 0.017 and p = 0.04 respectively). The mean (SEM) ultimate tensile strengths were 4-strand 464.8 N (27.4), 6-strand 543.5 N (49.6) and 8-strand 422.1 N (80.5). Regression analysis reveals no significant difference between the overall strength of the 3 repair models (p = 0.32) (4 vs. 6: p = 0.30, 4 vs. 8: p = 0.87; 6 vs. 8: p = 0.39). The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7% of specimens. CONCLUSION The use of a non-absorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. Ultimate failure occurred more commonly at the distal Kessler suture end although this occurred with separations in excess of clinical failure. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.

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Functional outcomes of achilles tendon minimally invasive repair using 4- and 6-strand nonabsorbable suture: A cohort comparison study (2017)

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Type of publication:
Journal article

Author(s):
*Carmont M.R.; Brorsson A.; Olsson N.; Nilsson-Helander K.; Karlsson J.; Zellers J.A.; Silbernagel K.G.

Citation:
Orthopaedic Journal of Sports Medicine; Jan 2017; vol. 5 (no. 8)

Abstract:
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 (58males, 12 females) with amean 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 -13.1degree (6.6degree) (dorsiflexion) following injury; this was reduced to 7.6degree (4.8degree) (plantar flexion) directly after surgery. During initial rehabilitation at 6 weeks, the relative ATRA was 0.6degree (7.4degree) (neutral) and -7.0degree (5.3degree) (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 3months after surgery correlated with heel-rise height at 12 months.

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