Musculotendinous ruptures of the achilles tendon had greater heel-rise height index compared with mid-substance rupture with non-operative management: A retrospective cohort study.

INTRODUCTION: Achilles tendon ruptures (ATRs) may occur at varying locations with ruptures at the mid-substance (MS) of the tendon most common, followed tears at the musculotendinous (MT) junction. There is scant literature about the outcome of MT ATR. This study compared the outcome of patients with a MT ATR with patients following a MS ATR. METHODS: The diagnostic features and clinical outcome of 37 patients with a MT ATR were compared with a cohort of 19 patients with a MS ATR. Patients in both groups were managed non-operatively and received the same rehabilitation protocol with weight-bearing rehabilitation in protective functional brace. RESULTS: From February 2009 to August 2023, 556 patients presented with an ATR. Of these, 37 (6.7 â€‹%) patients were diagnosed with a MT tear. At final follow-up, at 12 months following injury, the MT group reported an Achilles tendon total rupture score (ATRS) of mean (standard deviation (SD)) of 83.6 (3.5) (95 â€‹% confidence interval (CI) 81.8, 85.4) and median (inter-quartile range (IQR)) ATRS of 86 points (78-95.5) and the MS group mean (SD) of 80.3 (8.5) (95%CI) 76.1, 80.5) and median (IQR) of 87 points (59-95) (p â€‹= â€‹0.673). Functional evaluation, however, revealed statistically significant differences in mean (SD) heel-rise height index MT group 79 â€‹% (25) (95%CI 65.9, 92.1) and MS group 59 â€‹% (13) (95%CI 51.9, 67.1) (p â€‹= â€‹0.019). In the MT rupture group, there were considerably less complications than the MS rupture group. CONCLUSIONS: When managed non-operatively, with only a 6 weeks period of brace protection, patients have little limitation although have some residual reduction of single heel-rise at the one-year following MT ATR. LEVEL OF EVIDENCE: IV.

Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures - a systematic review.

INTRODUCTION: A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to summarize the outcomes of chronic ATR treated using either a gastrocnemius aponeurosis flap or semitendinosus tendon graft. METHODS: A systematic search was conducted in three databases (PubMed, Scopus and Cochrane), for studies describing outcomes after surgical treatment of chronic ATR using gastrocnemius aponeurosis flaps or semitendinosus tendon grafts with more than 10 patients included. The studies were assessed for quality and risk of bias using the Methodological Items used to assess risk of bias in Non-Randomized Studies (MINORS). RESULTS: Out of the 818 studies identified with the initial search, a total of 36 studies with 763 individual patients were included in this systematic review. Gastrocnemius aponeurosis flap was used in 21 and semitendinosus tendon graft was used in 13 of the studies. The mean (SD) postoperative Achilles tendon Total Rupture Score (ATRS) for patients treated with a gastrocnemius aponeurosis flap was 83 (14) points and the mean (SD) American Orthopaedic Foot and Ankle Score (AOFAS) was 96 (1.7) points compared with ATRS 88 (6.9) points and AOFAS 92 (5.6) points for patients treated with a semitendinosus tendon graft. The included studies generally had low-quality according to MINORS, with a median of 8 (range 2-13) for all studies. CONCLUSION: Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts give acceptable results with minimal complications and are valid methods for treating chronic ATR. The main difference is more wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries in patients treated with a semitendinosus grafts. The current literature on the subject is of mainly low quality and the absence of a patient-related outcome measure validated for chronic ATR makes comparisons between studies difficult. LEVEL OF EVIDENCE: Level IV.

The influence of the COVID pandemic on the epidemiology of Achilles tendon ruptures in east Shropshire, United Kingdom.

OBJECTIVES: Management strategies of the COVID pandemic included isolation to prevent transmission. This study aimed to determine if the pandemic of 2020 influenced the epidemiology of Achilles tendon rupture (ATR). METHODS: The demographics of presentations from the local population to Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust hospital, Shropshire, United Kingdom, with an ATR were analysed and compared together with the season, month, and year of the injury. RESULTS: From 2009 to 2019, there was no significant change in the incidence of ATR over time with a mean (SD) incidence of 13.3 per 100,000. In 2020, there was a decrease in injuries with an incidence of 8.4 per 100,000, with an increase in 2021 to 22.4 per 100,000. In 2021, there was an increase in injuries from March with numbers maintained until October. The most common activity of ATR was team sport (36.2%), followed by the activities of daily living (28.9%), other physical activities (21.0%), and racket sports (13.9%). In 2020, there was the lowest number of injuries sustained in team and racket sports; however, in 2021, they accounted for over half of injuries. CONCLUSIONS: There were significantly more patients sustaining ATR in 2021, the year after the COVID pandemic and mandatory isolation. This was considered to be related to altered activity and team and racket sports during 2020. LEVELS OF EVIDENCE: IV case series.

Sex differences in patients' recovery following an acute Achilles tendon rupture - a large cohort study.

INTRODUCTION: The incidence of Achilles tendon ruptures (ATR) has increased over the past few decades. Treatment may be individualised based upon multiple factors including age, pre-injury activity level and the separation of the ruptured tendon ends. Several studies indicate that women may have a poorer self-reported and clinical outcome compared with men, but the number of women in these studies is often small due to the different incidence of ATR between the genders. AIMS: The primary aim of this study was to evaluate whether there is a difference in self-reported outcome after an acute ATR between women and men at one to five years following injury. The second aim was to compare the outcome between the surgically and non-surgically treated patients. METHODS: Data were obtained from the medical charts of patients treated for an acute ATR between 1 and 2015 and 31 December 2020 at Sahlgrenska University Hospital/Mölndal. The Achilles tendon total rupture score (ATRS) and additional questions relating to treatment and recovery were determined. A multiple regression analysis was performed to isolate the impact of sex when comparing the patient-reported outcome between women and men. RESULTS: A total of 856 patients were included of which 66% participated prospectively. Sex, BMI and age were found to be significant factors influencing the total ATRS score. Female gender resulted in a lower ATRS, 7.8 points (CI = 3.3 to 12.3), than male gender. It was found that treatment did not significantly predict the results of the ATRS. CONCLUSION: To our knowledge, this is the first report with a larger number of women included showing that female sex predicts inferior self-reported results after an acute ATR.

Achilles tendon resting angle is able to detect deficits after an Achilles tendon rupture, but it is not a surrogate for direct measurements of tendon elongation, function or symptoms.

PURPOSE: The aim of this study was to investigate how the Achilles tendon resting angle (ATRA), an indirect measurement of tendon elongation, correlates with ultrasonography (US) measurements of the Achilles tendon length 6 and 12 months after an acute ATR and relates to other clinical outcome measurements such as heel-rise height, jumping ability and patient-reported outcome measurements (PROMs). METHODS: Patients were included following acute Achilles tendon rupture (ATR). Achilles tendon length, ATRA, heel-rise height (HRH), drop countermovement jump (Drop CMJ) and PROMs (Achilles tendon total rupture score (ATRS) and physical activity scale (PAS)) were evaluated 6 and 12 months after injury. Achilles tendon length was evaluated using US, while the ATRA was measured with a goniometer. RESULTS: Sixty patients (13 women, 47 men), mean (SD) age 43 (9) years, with an acute ATR undergoing either surgical (35%) or non-surgical (65%) treatment were evaluated. A negative correlation (r = - 0.356, p = 0.010) between relative ATRA and tendon elongation was seen at 12 months after ATR. There were also significant positive correlations at 6 and 12 months between relative ATRA and HRH (r = 0.330, p = 0.011 and r = 0.379, p = 0.004). There were no correlations between ATRA and ATRS or ATRA and Drop CMJ, at either 6 or 12 months after the injury. CONCLUSION: In combination with other clinical evaluations such as HRH and US, ATRA could be a clinical tool for indirect measurements of tendon elongation. However, ATRA cannot be recommended as a direct surrogate for US for determining Achilles tendon length. LEVEL OF EVIDENCE: III.

Endoscopically assisted reconstruction of chronic Achilles tendon ruptures and re-ruptures using a semitendinosus autograft is a viable alternative to pre-existing techniques.

PURPOSE: Achilles tendon ruptures are termed chronic after a delay in treatment for more than 4 weeks. The literature advocates surgical treatment with reconstruction to regain ankle push-off strength. The preferred technique is, however, still unknown and is often individualized. This study aims to present the technique and clinical outcome of an endoscopically assisted free semitendinosus reconstruction of chronic Achilles tendon rupture and Achilles tendon re-ruptures with delayed representation. It is hypothesized that the presented technique is a viable and safe alternative for distal Achilles tendon ruptures and ruptures with large tendon gaps. METHOD: Twenty-two patients (13 males and 9 females) with a median (range) age of 64 (34-73) treated surgically with endoscopically assisted Achilles tendon reconstruction using a semitendinosus autograft were included. The patients were evaluated at 12 months post-operatively for Achilles tendon Total Rupture Score (ATRS), calf circumference, Achilles Tendon Resting Angle (ATRA), heel-rise height and repetitions together with tendon length determined by ultrasonography, concentric heel-rise power and heel-rise work. RESULTS: The patients reported a median (range) ATRS of 76 (45-99) out of 100. The median (range) ATRA on the injured side was 60° (49°-75°) compared with 49.5° (40-61°), p < 0.001, on the non-injured side. Eighteen out of 22 patients were able to perform a single-leg heel-rise on the non-injured side. Sixteen patients out of those 18 (89%) were also able to perform a single heel-rise on the injured side. They did, however, perform significantly lower number of repetitions compared with the non-injured side with a median (range) heel-rise repetitions of 11 (2-22) compared with 26 (2-27), (p < 0.001), and a median (range) heel-rise height of 5.5 cm (1.0-11.0 cm) compared with 9.0 cm (5.0-11.5 cm), (p < 0.001). The median calf circumference was 1.5 cm smaller on the injured side, 37.5 cm compared with 39 cm, when medians were compared. The median (range) tendon length of the injured side was 24.8 cm (20-28.2 cm) compared with 22 cm (18.4-24.2 cm), (p < 0.001), on the non-injured side. CONCLUSION: The study shows that endoscopically assisted reconstruction using a semitendinosus graft to treat chronic Achilles tendon ruptures and re-ruptures with delayed representation produces a satisfactory outcome. The technique can restore heel-rise height in patients with more distal ruptures or large tendon defects and is therefore a viable technique for Achilles tendon reconstruction. LEVEL OF EVIDENCE: IV.

Do the heel-rise test and isometric strength improve after Achilles tendon repair using Dresden technique?

BACKGROUND: Achilles' tendon ruptures result in impaired plantar flexion strength and endurance. It is interesting to know the plantar flexion strength, the number of heel-rise repetitions, and the maximal calf circumference following Achilles' tendon ruptures repair. METHODS: Both the injured and non-injured legs of thirty male patients with Achilles' tendon ruptures treated with the percutaneous Dresden technique were compared with the ankle function of 30 healthy participants. Rehabilitation involved partial weight-bearing for three weeks and then increased to full weight-bearing and ankle exercises. RESULTS: The injured legs had weaker plantar flexion strength (1.64 ± 0.17 Nm/kg) compared with the non-injured legs (1.91 ± 0.24 Nm/kg; p = 0.002) and the healthy participants' legs (1.93 ± 0.32 Nm/kg; p < 0.001). The non-injured leg had greater ability in doing heel-rise repetitions (39.4 ± 6.1 rep.) compared with the injured legs (37.2 ± 5.7 rep.; p < 0.023) and the healthy participants' legs (31.0 ± 13.0 rep.; p < 0.001). CONCLUSIONS: The injured leg had not recovered full isometric strength but had improved heel-rise repetition.

The release of adhesions improves outcome following minimally invasive repair of Achilles tendon rupture.

PURPOSE: Operative repair of Achilles tendon rupture may lead to complications, which influence outcome adversely. The aim of this study was to determine the incidence, impact and response to treatment of post-operative adhesions. METHODS: From February 2009 to 2021, 248 patients operated on with percutaneous or minimally invasive surgical repair have been prospectively evaluated using the Achilles tendon Total Rupture Score (ATRS) and Heel-Rise Height Index (HRHI), following acute Achilles tendon rupture. RESULTS: Fourteen (5.6%) patients were identified as having adhesions. Four patients reported superficial adhesions and ten patients reported a deeper tightness of the tendon. At a mean (SD) of 10.5 (2.3) months following repair, the overall ATRS was at a median (IQR) 65 (44.5-78) points and (HRHI) was mean (SD) 81.5 (13.5)%. Of those deemed to have deep adhesions the antero-posterior diameter of the tendon was at mean (SD) 15.6 (4.6) mm. Open release of superficial adhesions resulted in improved ATRS in all patients. Endoscopic debridement anterior to the Achilles tendon led to alleviation of symptoms of tightness and discomfort from deep adhesions and improved outcome in terms of the ATRS score. At a mean (SD) of 15.9 (3.3)-month follow-up from initial rupture and repair, the patients reported at median (IQR) ATRS scores of 85 (64.8-92.8) points, Tegner level 5 (3-9) and mean (SD) HRHI 86.2 (9.5)%. Patients significantly improved both ATRS and HRHI following release at median (IQR) of 16.5 (- 1.8-29.3) points (p = 0.041) and mean (SD) 5.6 (8.3)% (p = 0.043). CONCLUSIONS: The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. The occurrence of superficial adhesions was associated with a lower outcome scores as well as symptoms of anterior tendon tightness and stiffness were associated with a lower score in most patients. Surgical release of adhesions led to a significant improvement in outcome.

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

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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Interassociation consensus recommendations for pitch-side emergency care and personal protective equipment for elite sport during the COVID-19 pandemic.

The COVID-19 pandemic has necessitated many novel responses in healthcare including sport and exercise medicine. The cessation of elite sport almost globally has had significant economic implications and resulted in pressure to resume sport in very controlled conditions. This includes protecting pitch-side medical staff and players from infection. The ongoing prevalence of SARS-CoV-2 and the desire to resume professional sport required urgent best practice guidelines to be developed so that sport could be resumed as safely as possible. This set of best practice recommendations assembles early evidence for managing SARS-CoV-2 and integrates expert opinion to provide a uniform and pragmatic approach to enhance on-field and pitch-side safety for the clinician and player. The nature of SARS-CoV-2 transmission creates new hazards during resuscitation and emergency care and procedures. Recommendations for the use and type of personal protective equipment during on-field or pitch-side emergency medical care is provided based on the clinical scenario and projected risk of viral transmission.

Age and Tightness of Repair Are Predictors of Heel-Rise Height After Achilles Tendon Rupture.

BACKGROUND: Achilles tendon rupture leads to weakness of ankle plantarflexion. Treatment of Achilles tendon rupture should aim to restore function while minimizing weakness and complications of management. PURPOSE: To determine the influence of factors (age, sex, body mass index [BMI], weight, time from injury to operative repair, and tightness of repair) in the initial surgical management of patients after an acute Achilles tendon rupture on 12-month functional outcome assessment after percutaneous and minimally invasive repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: From May 2012 to January 2018, patients sustaining an Achilles tendon rupture receiving operative repair were prospectively evaluated. Tightness of repair was quantified using the intraoperative Achilles tendon resting angle (ATRA). Heel-rise height index (HRHI) was used as the primary 12-month outcome variable. Secondary outcome measures included Achilles tendon total rupture score (ATRS) and Tegner score. Stepwise multiple regression was used to create a model to predict 12-month HRHI. RESULTS: A total of 122 patients met the inclusion criteria for data analysis (mean ± SD age, 44.1 ± 10.8 years; 78% male; mean ± SD BMI, 28.1 ± 4.3 kg/m2). The elapsed time to surgery was 6.5 ± 4.0 days. At 12-month follow-up, patients had an HRHI of 82% ± 16% and performed 82% ± 17% of repetitions compared with the noninjured side. Participants had a mean ATRS of 87 ± 15 and a median Tegner score of 5 (range, 1-9), with a reduction in Tegner score of 2 from preinjury levels. The relative ATRA at 12 months was -4.8° ± 3.9°. Multiple regression identified younger age (B = ±0.006; P < .001) and greater intraoperative ATRA (B = 0.005; P = .053) as predictors of more symmetrical 12-month HRHI (R 2 = 0.19; P < .001; n = 120). CONCLUSION: Age was found to be the strongest predictor of outcome after Achilles tendon rupture. The most important modifiable risk factor was the tightness of repair. It is recommended that repair be performed as tight as possible to optimize heel-rise height 1 year after Achilles tendon rupture and possibly to reduce tendon elongation.

Total knee arthroplasty reduces knee extension torque in-vitro and patellofemoral arthroplasty does not.

Patients often have difficulty recovering knee extension strength post total knee arthroplasty (TKA), and that may reflect alteration of the mechanics including geometry and rollback kinematics, so the purpose of this work was to explore this by comparing the knee extension torque (KET) of the native knee, TKA and patellofemoral arthroplasty (PFA) in response to quadriceps tension. Eight fresh-frozen knees were mounted in a knee extension rig with quadriceps loading and tibial extension torque measurement. Each knee was subject to four conditions: native knee, PFA, cruciate-retaining (CR) and posterior-stabilized (PS) TKA. The KET was measured from 120° to 0° knee flexion. Data were analyzed using one-way ANOVA and post-hoc paired t-tests. The native KET was lowest in terminal extension and 70-100° flexion, and maximal at 20-30° flexion. PFA produced the greatest KET (p < 0.008) compared with native, CR- and PS-TKA, at 30-40° flexion. CR- and PS-TKA had lower KET across 0-50° flexion (p < 0.001 across 0-30°), falling to 25% of the native knee KET or the PFA at full extension. PFA had the highest KET in early flexion possibly due to increased trochlear offset and/or preservation of the cruciate mechanism, so PFA may be more beneficial during the functional range of motion. The claimed benefits of PS- over CR-TKA in deep flexion were not detected. Both CR- and PS-TKAs led to lower KET than the native and PFA knee states across 0-50° flexion. This mechanical effect may help to explain clinical findings of knee extension weakness post-TKA.

No difference in strength and clinical outcome between early and late repair after Achilles tendon rupture.

PURPOSE: This retrospective study aimed to determine the patient-reported and functional outcome of patients with delayed presentation, who had received no treatment until 14 days following injury of Achilles tendon rupture repaired with minimally invasive surgery and were compared with a group of sex- and age-matched patients presenting acutely. Based on the outcomes following delayed presentation reported in the literature, it was hypothesized that outcomes would be inferior for self-reported outcome, tendon elongation, heel-rise performance, ability to return to play, and complication rates than for acutely managed patients. METHODS: Repair was performed through an incision large enough to permit mobilisation of the tendon ends, core suture repair consisting of a modified Bunnell suture proximally and a Kessler suture distally and circumferential running suture augmentation. RESULTS: Nine patients presented 21.8 (14.9) days (range 14-42 days) after rupture. The rate of delayed presentation was estimated to be 1 in 10. At 12 months following repair, patients with delayed treatment had median (range) ATRS score of 90 (69-99) compared with 94 (75-100) in patients treated acutely presenting 0.66 (1.7) (0-5) days. There were no significant differences between groups: ATRA [mean (SD) delayed: - 6.9° (5.5), acute: - 6° (4.7)], heel-rise height index [delayed: 79% (20), acute: 74% (14)], or heel-rise repetition index [delayed: 77% (20), acute: 71% (20)]. In the delayed presentation group, two patients had wound infection and one iatrogenic sural nerve injury. CONCLUSIONS: Patients presenting more than 2 weeks after Achilles tendon rupture may be successfully treated with minimally invasive repair. LEVEL OF EVIDENCE: III.

Achilles Tendon Resting Angle Relates to Tendon Length and Function.

BACKGROUND: Following Achilles tendon rupture, tendon elongation leads to long term deficits in calf function. A surrogate measure of Achilles tendon length, Achilles tendon resting angle (ATRA), has been described but has not been validated against length measured using ultrasound. Therefore, the purpose of this study was to validate the ATRA against ultrasound. Secondarily, this study aimed to identify the relationship of other factors (tendon mechanical properties, heel-rise test performance) to the ATRA. METHODS: Individuals following unilateral Achilles tendon rupture were included. ATRA was measured in knee flexed and extended positions. Tendon elongation was measured using extended field of view ultrasound imaging. Continuous shear wave elastography quantified tendon mechanical properties. The relationship between variables was tested using Spearman's ρ. Subgroup analysis was used to compare subjects with less then or greater than 1 year following rupture. A total of 42 participants (with a mean of 18.2 months following rupture [SD = 35.9]) were included. RESULTS: Tendon elongation related with relative ATRA with knee flexed (ρ = .491, P = .001) and knee extended (ρ = 0.501, P = .001) positions. In individuals greater than 1 year following rupture, relative ATRA with the knee flexed related to shear modulus (ρ = .800, P = .01) and total work on the heel-rise test (ρ = -.782, P = .008) relative to the uninjured side. CONCLUSION: Relative ATRA in both knee flexed and knee extended positions has a moderate relationship to tendon elongation within the first year following rupture. After 1 year, the relative ATRA with knee flexed may be a better indicator of tendon elongation and also related to tendon mechanical properties and heel-rise test performance. LEVEL OF EVIDENCE: Level III, case-control study.

Longer duration of operative time enhances healing metabolites and improves patient outcome after Achilles tendon rupture surgery.

PURPOSE: The relationship between the duration of operative time (DOT), healing response and patient outcome has not been previously investigated. An enhanced healing response related to DOT may potentiate repair processes, especially in hypovascular and sparsely metabolized musculoskeletal tissues such as tendons. This study aimed to investigate the association between DOT and the metabolic healing response, patient-reported outcome and the rate of post-operative complications after acute Achilles tendon injury. METHODS: Observational cohort, cross-sectional study with observers blinded to patient grouping. A total of two-hundred and fifty-six prospectively randomized patients (210 men, 46 women; mean age 41 years) with an acute total Achilles tendon rupture all operated on with uniform anaesthetic and surgical technique were retrospectively assessed. At 2 weeks post-operatively, six metabolites were quantified using microdialysis. At 3, 6 and 12 months, patient-reported pain, walking ability and physical activity were examined using self-reported questionnaires, Achilles tendon total rupture score, foot and ankle outcome score and physical activity scale. At 12 months, functional outcome was assessed using the heel-rise test. Complications, such as deep venous thrombosis, infections and re-operations, were recorded throughout the study. RESULTS: Patients who underwent longer DOT exhibited higher levels of glutamate (p = 0.026) and glycerol (p = 0.023) at 2 weeks. At the 1-year follow-up, longer DOT was associated with significantly less loss in physical activity (p = 0.003), less pain (p = 0.009), less walking limitations (p = 0.022) and better functional outcome (p = 0.014). DOT did not significantly correlate with the rate of adverse events, such as deep venous thrombosis, infections or re-ruptures. Higher glutamate levels were associated with less loss in physical activity (p = 0.017). All correlations were confirmed by multiple linear regressions taking confounding factors into consideration. CONCLUSION: The results from this study suggest a previously unknown mechanism, increased metabolic response associated with longer DOT, which may improve patient outcome after Achilles tendon rupture surgery. Allowing for a higher amount of traumatized tissue, as reflected by up-regulation of glycerol in patients with longer DOT, may prove to be an important surgical tip for stimulation of repair of hypometabolic soft tissue injuries, such as Achilles tendon ruptures. LEVEL OF EVIDENCE: II.

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.