Early Tensile Loading in Nonsurgically Treated Achilles Tendon Ruptures Leads to a Larger Tendon Callus and a Lower Elastic Modulus: A Randomized Controlled Trial.

BACKGROUND: Early tensile loading improves material properties of healing Achilles tendon ruptures in animal models and in surgically treated human ruptures. However, the effect of such rehabilitation in patients who are nonsurgically treated remains unknown. HYPOTHESIS: In nonsurgically treated Achilles tendon ruptures, early tensile loading would lead to higher elastic modulus 19 weeks after the injury compared with controls. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Between October 2015 and November 2018, a total of 40 nonsurgically treated patients with acute Achilles tendon rupture were randomized to an early tensile loading (loaded group) or control group. Tantalum bead markers were inserted percutaneously into the tendon stumps 2 weeks after the injury to allow high-precision measurements of callus deformation under mechanical testing. The loaded group used a training pedal twice daily to produce a gradual increase in tensile load during the following 5 weeks. Both groups were allowed full weightbearing in an ankle orthosis and unloaded range of motion exercises. Patients were followed clinically and via roentgen stereophotogrammetric analysis and computed tomography at 7, 19, and 52 weeks after the injury. RESULTS: The mean ± standard deviation elastic modulus at 19 weeks was 95.6 ± 38.2 MPa in the loaded group and 108 ± 45.2 MPa in controls (P = .37). The elastic modulus increased in both groups, although it was lower in the loaded group at all time points. Tendon cross-sectional area increased from 7 weeks to 19 weeks, from 231 ± 99.5 to 388 ± 142 mm2 in the loaded group and from 188 ± 65.4 to 335 ± 87.2 mm2 in controls (P < .001 for the effect of time). Cross-sectional area for the loaded group versus controls at 52 weeks was 302 ± 62.4 mm2 versus 252 ± 49.2 mm2, respectively (P = .03). Gap elongation was 7.35 ± 13.9 mm in the loaded group versus 2.86 ± 5.52 mm in controls (P = .27). CONCLUSION: Early tensile loading in nonsurgically treated Achilles tendon ruptures did not lead to higher elastic modulus in the healing tendon but altered the structural properties of the tendon via an increased tendon thickness. REGISTRATION: NCT0280575 (ClinicalTrials.gov identifier).

Solely sutures is a reliable fixation for valgus-impacted proximal humeral fractures.

PURPOSE: Valgus impacted proximal humeral fractures with substantial displacement may severely compromise shoulder function and open reduction can therefore be considered. Internal fixation hardware may eventually however constitute problems. In a small subset of these fractures, in which there is no medial comminution and intact blood supply it is possible to use a least possible fixation method with solely sutures through the tendons of the rotator cuff and the shaft as described by Bigliani 1990. The aim of the present study was to investigate the outcome of this fixation method in a retrospective series of patients. METHODS: Twenty-seven patients, 23 women and 4 men, with a mean age of 66 years (53-83) and minimum follow-up time of 2 years (2-11 years) accepted follow-up with standard shoulder radiographs and 22 were examined with Oxford Shoulder Score (OSS), Constant-Murley (CM) shoulder score and Numeric Rating Scale for pain (NRS). Reoperations or adverse events were recorded. RESULTS: The median OSS was 45 (range 5-48) and CM 63 (range 21-98). The relative CM score was 81% of the uninjured side and median NRS 0 (range 0-5). No reoperations were undertaken. One patient had a complete avascular necrosis (AVN), 3 patients had a partial AVN of the humeral head and two a partial resorption of the greater tuberosity. CONCLUSION: The use of sutures only for fixation of displaced valgus-impacted proximal humeral fractures provided a relatively reliable outcome with good functional scores and no reoperations. There appears to be no need for the use of hardware for fixation of this rare subset of fractures.

Influence of a lower leg brace on traction force in healthy and ruptured Achilles tendons.

BACKGROUND: we investigated how ruptured Achilles tendons are loaded in a brace. There is an ongoing discussion whether patients should be recommended to bear weight on the injured limb. However, little is known about the effects of bracing on tensional loading of the healing Achilles tendon: it is uncertain if load-bearing actually stresses the Achilles tendon inside a brace. METHODS: we measured plantar flexion moment inside the brace, in order to estimate tensional loading of the tendon, by use of an insole with pressure transducers. RESULTS: after wearing the brace for 1 hour, young healthy individuals reduced their maximum flexion moment during gait by half. Patients with Achilles tendon rupture showed no measurable flexion moment during gait with the brace, 4 or 7 weeks after injury. Only when specifically instructed, they could produce a considerable plantar flexion moment. We noted that gait speed with the brace at 4 weeks correlated with a heel-raise functional test at 1 year: the higher the spontaneous gait speed, the less the functional difference between the injured and the uninjured leg (r(2)=0.68; p=0.002). CONCLUSION: the correlation with gait speed suggests that the patients' general physical aptness has an impact on the end result.