Session 6: Foot and Ankle
16. November
11:00 - 12:00
Lokale: Vingsal 3
Chair: Marianne Vestermark and Kristian Behrndtz
Maria Swennergren Hansen¹ ², Jesper Bencke³, Morten Tange Kristensen 4 5, Thomas Kallemose6, Per Hölmich¹ , Kristoffer Weisskirchner Barfod¹
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark¹; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C); Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager- Hvidovre, Denmark²; Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark³; Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg, Denmark4; Department of Clinical Medicine, University of Copenhagen, Denmark5; Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Denmark6
Background: Individual treatment selection has been proposed as the key to optimized treatment for patients with an Achilles tendon rupture.
Aim: The purpose of the present study was to determine if gait dynamics, Achilles tendon elongation, and patient-reported outcome measures differ between patients using the individualized treatment algorithm Copenhagen Achilles Rupture Treatment Algorithm (CARTA) and patients treated as usual (operatively or non- operatively by default).
Materials and Methods: This exploratory study was performed as a three-armed randomized controlled trial with the patients randomized in a 1:1:1 order to one of three parallel groups: 1) intervention group: participants treated according to the individualized ultrasound based treatment algorithm CARTA, 2) control group: participants treated non-operatively, and 3) control group: participants treated operatively. Patients aged 18-65 years were eligible for inclusion. The primary outcome was ankle peak power push off during walking at 12 months, measured in a 3D gait laboratory. Secondary outcomes were ankle plantar flexor moment, peak dorsal flexion during stance, tendon elongation and Achilles tendon Total Rupture Score (ATRS). Analysis was conducted as intention-to-treat.
Results: One hundred and fifty-six patients were assessed for eligibility from June 2018 to September 2019. Twenty-one were allocated to the intervention group, 20 and 19 to the two control groups. The results indicated no statistically significant differences between the intervention group and the two control groups at six- and 12-month follow-ups. Our results suggest statistically significant tendon elongation and deficits in ankle plantar flexor power during walking in the injured compared to the healthy leg 12 months after injury.
Interpretation / Conclusion: Individualized treatment using CARTA did not result in less affected gait dynamics, less tendon elongation, or a higher ATRS than usual care. However, being an exploratory study, the results should be interpreted with care.
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark¹; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C); Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager- Hvidovre, Denmark²; Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Denmark³; Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg, Denmark4; Department of Clinical Medicine, University of Copenhagen, Denmark5; Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Denmark6
Background: Individual treatment selection has been proposed as the key to optimized treatment for patients with an Achilles tendon rupture.
Aim: The purpose of the present study was to determine if gait dynamics, Achilles tendon elongation, and patient-reported outcome measures differ between patients using the individualized treatment algorithm Copenhagen Achilles Rupture Treatment Algorithm (CARTA) and patients treated as usual (operatively or non- operatively by default).
Materials and Methods: This exploratory study was performed as a three-armed randomized controlled trial with the patients randomized in a 1:1:1 order to one of three parallel groups: 1) intervention group: participants treated according to the individualized ultrasound based treatment algorithm CARTA, 2) control group: participants treated non-operatively, and 3) control group: participants treated operatively. Patients aged 18-65 years were eligible for inclusion. The primary outcome was ankle peak power push off during walking at 12 months, measured in a 3D gait laboratory. Secondary outcomes were ankle plantar flexor moment, peak dorsal flexion during stance, tendon elongation and Achilles tendon Total Rupture Score (ATRS). Analysis was conducted as intention-to-treat.
Results: One hundred and fifty-six patients were assessed for eligibility from June 2018 to September 2019. Twenty-one were allocated to the intervention group, 20 and 19 to the two control groups. The results indicated no statistically significant differences between the intervention group and the two control groups at six- and 12-month follow-ups. Our results suggest statistically significant tendon elongation and deficits in ankle plantar flexor power during walking in the injured compared to the healthy leg 12 months after injury.
Interpretation / Conclusion: Individualized treatment using CARTA did not result in less affected gait dynamics, less tendon elongation, or a higher ATRS than usual care. However, being an exploratory study, the results should be interpreted with care.
Guðrun Henriksen¹, Allan Cramer¹, Per Hölmich¹, Maria Swennergren Hansen¹,², Jeanette Kaae Hansen³, Marianne Christensen4, Kristoffer Weisskirchner Barfod¹
Sports Orthopedic Research Center – Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark¹; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C); Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark²; Department of Physiotherapy and Occupational Therapy, Næstved- Slagelse-Ringsted Hospital, Denmark³; Department of Physiotherapy and Occupational Therapy; Interdiciplinary Orthopaedics, Aalborg University Hospital, Denmark4
Background: Choice of bandage is intensively discussed in acute Achilles tendon rupture treatment. We hypothesized that patients treated with cast had 10 points higher Achilles tendon Total Rupture Score (ATRS) at 1-year follow up compared to patients treated with walker.
Aim: To investigate if choice of bandage in the first 2-3 weeks of treatment affected patient reported outcome (ATRS), tendon elongation (Achilles Tendon Resting Angle (ATRA) and Heel Rise Height (HRH)) and re-rupture (RR).
Materials and Methods: The study was a registry study in the Danish Achilles tendon Database (DADB). Patients treated with cast and patients treated with walker in the first 2-3 weeks of treatment were compared using a linear mixed effects model with choice of bandage and confounding variables (sex, age group, baseline ATRS (prior to rupture), comorbidities, treatment regime, and time from injury to treatment start) as fixed effects and treating hospital as the random effect. The primary outcome was ATRS at 1 year follow-up. The secondary outcomes of the study were ATRS at 6 months and 2 years follow up, re-rupture at 1 year follow up, Achilles Tendon Resting Angle (ATRA) difference at 1-year follow-up and Heel-rise height (HRH) difference at 1 year follow up.
Results: 2162 patients were registered in DADB in the study period. 1304 had full baseline and follow up data and were included in the study (Cast group n=540, mean baseline ATRS 91, mean age (SD) 49.5 (14), gender (m/f) 435/105; Walker group n=764, mean baseline ATRS 90, mean age (SD) 51 (15), gender (m/f) 605/159). No statistically significant nor clinically relevant between- group difference was found in any of the outcomes: Adjusted mean difference (using walker the whole period as reference) (95% CI) ATRS after 1 year = 0.1 (-3.0 ; 4.1), ATRS after 6 months = 2.0 (-4.5 ; 5.8), ATRS after 2 years = 3.0 (-0.7 ; 7.0), HRH difference = 0.6 (-6.6 ; 8.2), ATRA difference = 0.03o (-1.5 ; 1.6), Re-rupture (odds ratio) = 0.812 (0.4 ; 1.61).
Interpretation / Conclusion: Patients treated with cast the first 2-3 weeks after acute Achilles tendon rupture did not have better treatment outcome than patients treated with walker.
Sports Orthopedic Research Center – Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark¹; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C); Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark²; Department of Physiotherapy and Occupational Therapy, Næstved- Slagelse-Ringsted Hospital, Denmark³; Department of Physiotherapy and Occupational Therapy; Interdiciplinary Orthopaedics, Aalborg University Hospital, Denmark4
Background: Choice of bandage is intensively discussed in acute Achilles tendon rupture treatment. We hypothesized that patients treated with cast had 10 points higher Achilles tendon Total Rupture Score (ATRS) at 1-year follow up compared to patients treated with walker.
Aim: To investigate if choice of bandage in the first 2-3 weeks of treatment affected patient reported outcome (ATRS), tendon elongation (Achilles Tendon Resting Angle (ATRA) and Heel Rise Height (HRH)) and re-rupture (RR).
Materials and Methods: The study was a registry study in the Danish Achilles tendon Database (DADB). Patients treated with cast and patients treated with walker in the first 2-3 weeks of treatment were compared using a linear mixed effects model with choice of bandage and confounding variables (sex, age group, baseline ATRS (prior to rupture), comorbidities, treatment regime, and time from injury to treatment start) as fixed effects and treating hospital as the random effect. The primary outcome was ATRS at 1 year follow-up. The secondary outcomes of the study were ATRS at 6 months and 2 years follow up, re-rupture at 1 year follow up, Achilles Tendon Resting Angle (ATRA) difference at 1-year follow-up and Heel-rise height (HRH) difference at 1 year follow up.
Results: 2162 patients were registered in DADB in the study period. 1304 had full baseline and follow up data and were included in the study (Cast group n=540, mean baseline ATRS 91, mean age (SD) 49.5 (14), gender (m/f) 435/105; Walker group n=764, mean baseline ATRS 90, mean age (SD) 51 (15), gender (m/f) 605/159). No statistically significant nor clinically relevant between- group difference was found in any of the outcomes: Adjusted mean difference (using walker the whole period as reference) (95% CI) ATRS after 1 year = 0.1 (-3.0 ; 4.1), ATRS after 6 months = 2.0 (-4.5 ; 5.8), ATRS after 2 years = 3.0 (-0.7 ; 7.0), HRH difference = 0.6 (-6.6 ; 8.2), ATRA difference = 0.03o (-1.5 ; 1.6), Re-rupture (odds ratio) = 0.812 (0.4 ; 1.61).
Interpretation / Conclusion: Patients treated with cast the first 2-3 weeks after acute Achilles tendon rupture did not have better treatment outcome than patients treated with walker.
Allan Cramer¹, Grith Højfeldt², Peter Schjerling², Jakob Agergaard², Per Hölmich¹, Michael Kjær², Kristoffer Weisskirchner Barfod¹
¹Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark. ²Institute of Sports Medicine, Department of Orthopedic Surgery M81, Bispebjerg Hospital, Copenhagen, Denmark
Background: The etiology of acute Achilles tendon rupture (ATR) is unknown but is suggested to be associated with pre-existing pathological alterations similar to tendinopathic changes. Healthy Achilles tendons have limited collagen turnover. It is known that an abnormally high rate of collagen turnover precedes symptoms of tendinopathy, however this has not been studied in ATRs.
Aim: To describe the collagen metabolism (1) prior to an ATR, (2) in the days immediately after ATR, and (3) on the day of surgery.
Materials and Methods: The study was a prospective cross-sectional study including patients eligible for operation of ATR. At inclusion (<5 days after injury), patients ingested deuterium oxide (²H2O). On the day of surgery (<15 days after injury), patients got a 3- hours flood-primed infusion of a ¹5N-proline tracer. During surgery, patients had one biopsy taken from the ruptured part of the Achilles tendon and one biopsy from intact Achilles tendon tissue proximal to the rupture as a control. The biopsies were analyzed for level of carbon-14 (¹4C), and incorporation of ²H-alanine (from ²H2O) and ¹5N-proline to calculate integrated and acute fractional synthesis rate (FSR).
Results: Eighteen patients were included. Both rupture and control samples showed consistently lower levels of ¹4C (indicating increased collagen turnover) compared to previously published data from healthy Achilles tendons. There was no difference between the ruptured and the control site. Assuming the turnover leading to the lower ¹4C levels occurred during the year preceding the rupture, 56% of the collagen tissue in average were newly synthesized. No difference was found between the ruptured and the control site in the FSR from inclusion to surgery or acutely on the day of surgery. The mean FSR on the day of surgery was 0.025%/hour (95% CI 0.020-0.029) and was comparable to the FSR found in previous studies of healthy tendons.
Interpretation / Conclusion: The results show a substantial proportion of newly synthesized collagen in ruptured Achilles tendons. The formation of collagen in the initial healing phase could not account for this finding. Therefore, the results suggest that ATR is preceded by an abnormally high level of collagen turnover in the tendon.
¹Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark. ²Institute of Sports Medicine, Department of Orthopedic Surgery M81, Bispebjerg Hospital, Copenhagen, Denmark
Background: The etiology of acute Achilles tendon rupture (ATR) is unknown but is suggested to be associated with pre-existing pathological alterations similar to tendinopathic changes. Healthy Achilles tendons have limited collagen turnover. It is known that an abnormally high rate of collagen turnover precedes symptoms of tendinopathy, however this has not been studied in ATRs.
Aim: To describe the collagen metabolism (1) prior to an ATR, (2) in the days immediately after ATR, and (3) on the day of surgery.
Materials and Methods: The study was a prospective cross-sectional study including patients eligible for operation of ATR. At inclusion (<5 days after injury), patients ingested deuterium oxide (²H2O). On the day of surgery (<15 days after injury), patients got a 3- hours flood-primed infusion of a ¹5N-proline tracer. During surgery, patients had one biopsy taken from the ruptured part of the Achilles tendon and one biopsy from intact Achilles tendon tissue proximal to the rupture as a control. The biopsies were analyzed for level of carbon-14 (¹4C), and incorporation of ²H-alanine (from ²H2O) and ¹5N-proline to calculate integrated and acute fractional synthesis rate (FSR).
Results: Eighteen patients were included. Both rupture and control samples showed consistently lower levels of ¹4C (indicating increased collagen turnover) compared to previously published data from healthy Achilles tendons. There was no difference between the ruptured and the control site. Assuming the turnover leading to the lower ¹4C levels occurred during the year preceding the rupture, 56% of the collagen tissue in average were newly synthesized. No difference was found between the ruptured and the control site in the FSR from inclusion to surgery or acutely on the day of surgery. The mean FSR on the day of surgery was 0.025%/hour (95% CI 0.020-0.029) and was comparable to the FSR found in previous studies of healthy tendons.
Interpretation / Conclusion: The results show a substantial proportion of newly synthesized collagen in ruptured Achilles tendons. The formation of collagen in the initial healing phase could not account for this finding. Therefore, the results suggest that ATR is preceded by an abnormally high level of collagen turnover in the tendon.
Allan Cramer¹, Claus Moser²³, Blaine Gabriel Fritz³, Per Hölmich¹, Kristoffer Weisskirchner Barfod¹
Sports Orthopedic Research Center – Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark¹ Department of Clinical Microbiology, Rigshospitalet, University Hospital of Copenhagen² Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen³
Background: The source of the pathological changes that occur prior to an acute Achilles tendon rupture (ATR) is not fully understood. Bacterial DNA has previously been detected in samples from ruptured Achilles tendons, suggesting a pathogenic role of bacteria in ATR.
Aim: The purpose was to investigate if DNA from bacteria was present in acutely ruptured Achilles tendons. It was hypothesized that 20-30% of the samples from the rupture site and no samples from healthy tissue would be positive for bacterial DNA.
Materials and Methods: Twenty consecutive patients scheduled for surgical repair of an acute Achilles tendon rupture were included. Tendon biopsies were taken from the rupture site and from the healthy tendon tissue proximal to the rupture as a control. Samples were blinded to the technician and analyzed by 16S rDNA PCR and Sanger sequencing to identify the bacterial species present. A McNemars test for paired proportions was performed to test for statistically significant differences in the number of samples positive for bacterial DNA between the ruptured and control regions of the Achilles tendon.
Results: One of the 20 patients (5%) had a positive sample with bacterial DNA from the ruptured part of the Achilles tendon. The same patient also had a positive, but with different DNA, control sample. Additionally, one patient had a positive control sample. There was no statistically significant difference in the number of bacterial-DNA positive samples between the ruptured and control regions of the Achilles tendon (p>0.05). The bacteria found (Staphylococcus sp., Micrococcus sp., and Staphylococcus epidermidis) are normal commensal organisms on the human skin.
Interpretation / Conclusion: Bacterial DNA is infrequent in tissue from ruptured Achilles tendons and if identified, likely is a result of contamination. This suggests that bacteria are not involved in the pathological changes occurring prior to rupture of the Achilles tendon.
Sports Orthopedic Research Center – Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark¹ Department of Clinical Microbiology, Rigshospitalet, University Hospital of Copenhagen² Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen³
Background: The source of the pathological changes that occur prior to an acute Achilles tendon rupture (ATR) is not fully understood. Bacterial DNA has previously been detected in samples from ruptured Achilles tendons, suggesting a pathogenic role of bacteria in ATR.
Aim: The purpose was to investigate if DNA from bacteria was present in acutely ruptured Achilles tendons. It was hypothesized that 20-30% of the samples from the rupture site and no samples from healthy tissue would be positive for bacterial DNA.
Materials and Methods: Twenty consecutive patients scheduled for surgical repair of an acute Achilles tendon rupture were included. Tendon biopsies were taken from the rupture site and from the healthy tendon tissue proximal to the rupture as a control. Samples were blinded to the technician and analyzed by 16S rDNA PCR and Sanger sequencing to identify the bacterial species present. A McNemars test for paired proportions was performed to test for statistically significant differences in the number of samples positive for bacterial DNA between the ruptured and control regions of the Achilles tendon.
Results: One of the 20 patients (5%) had a positive sample with bacterial DNA from the ruptured part of the Achilles tendon. The same patient also had a positive, but with different DNA, control sample. Additionally, one patient had a positive control sample. There was no statistically significant difference in the number of bacterial-DNA positive samples between the ruptured and control regions of the Achilles tendon (p>0.05). The bacteria found (Staphylococcus sp., Micrococcus sp., and Staphylococcus epidermidis) are normal commensal organisms on the human skin.
Interpretation / Conclusion: Bacterial DNA is infrequent in tissue from ruptured Achilles tendons and if identified, likely is a result of contamination. This suggests that bacteria are not involved in the pathological changes occurring prior to rupture of the Achilles tendon.
Josephine Galsklint, Søren Kold, Søren Kristensen, Marianne Severinsen, Inger Lise Gade
Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark; Department of Hematology and Clinical Cancer Research, Aalborg University Hospital, Aalborg, Denmark; Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
Background: Healthcare databases can be a valuable source of epidemiological research regarding postoperative venous thromboembolism (VTE), ie, deep vein thrombosis (DVT) and pulmonary embolism (PE), following orthopedic procedures, but only if the diagnoses are valid.
Aim: We examined the validity of VTE diagnosis codes in the Danish National Patient Registry (DNPR) by calculating their positive predictive value (PPV) and negative predictive value (NPV) versus actual medical records
Materials and Methods: We identified patients who had undergone lower limb surgery during the period 2009– 2019 at a hospital in the North Denmark Region. Of these, 420 patients had at least one VTE diagnosis registered in the DNPR within 180 days after lower limb surgery. Each patient with a VTE diagnosis was matched with two patients on age and sex, as well as type, location and period of surgery. The entire medical record and diagnostic imaging were reviewed to confirm VTE diagnosis.
Results: The overall PPVs was 85.2% (95% CI: 81.5– 88.5%) for first time VTE diagnosis following lower limb surgery, 82.6% (95% CI: 77.5– 82.8%) for DVT, and 90.3% (95% CI: 84.3– 94.6%) for PE. We found improvement in PPV during the study period when stratifying for three periods of the whole period. There were no significant differences when stratifying for sex, age, or surgery site. All negative predictive values were higher than 99%. A total of 113 additional VTE diagnoses were registered among 88 VTE patients during follow-up. Only four of the suspected recurrent VTEs were confirmed to be true recurrent VTEs.
Interpretation / Conclusion: The VTE diagnosis codes in the DNPR after lower limb orthopedic surgery were highly valid against the actual medical records, and we observed better PPV over recent years.
Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark; Department of Hematology and Clinical Cancer Research, Aalborg University Hospital, Aalborg, Denmark; Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
Background: Healthcare databases can be a valuable source of epidemiological research regarding postoperative venous thromboembolism (VTE), ie, deep vein thrombosis (DVT) and pulmonary embolism (PE), following orthopedic procedures, but only if the diagnoses are valid.
Aim: We examined the validity of VTE diagnosis codes in the Danish National Patient Registry (DNPR) by calculating their positive predictive value (PPV) and negative predictive value (NPV) versus actual medical records
Materials and Methods: We identified patients who had undergone lower limb surgery during the period 2009– 2019 at a hospital in the North Denmark Region. Of these, 420 patients had at least one VTE diagnosis registered in the DNPR within 180 days after lower limb surgery. Each patient with a VTE diagnosis was matched with two patients on age and sex, as well as type, location and period of surgery. The entire medical record and diagnostic imaging were reviewed to confirm VTE diagnosis.
Results: The overall PPVs was 85.2% (95% CI: 81.5– 88.5%) for first time VTE diagnosis following lower limb surgery, 82.6% (95% CI: 77.5– 82.8%) for DVT, and 90.3% (95% CI: 84.3– 94.6%) for PE. We found improvement in PPV during the study period when stratifying for three periods of the whole period. There were no significant differences when stratifying for sex, age, or surgery site. All negative predictive values were higher than 99%. A total of 113 additional VTE diagnoses were registered among 88 VTE patients during follow-up. Only four of the suspected recurrent VTEs were confirmed to be true recurrent VTEs.
Interpretation / Conclusion: The VTE diagnosis codes in the DNPR after lower limb orthopedic surgery were highly valid against the actual medical records, and we observed better PPV over recent years.
Rikke Høffner, Anne-Sofie Agergaard, Michael Boesen, Philip Hansen, Rene Svensson, Mikkel Haglund, Jesper Petersen, Peter Rasmussrn, Rasmus Mikkelsen, Lars Konradsen, Michael Krogsgaard, Michael Kjær, Peter Magnusson
1Institute of Sports Medicine Copenhagen, Bispebjerg and Frederiksberg Hospital 2Department of Orthopedic Surgery, Bispebjerg and Frederiksberg Hospital 3Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital 4Department of Radiology, Bispebjerg and Frederiksberg Hospital
Background: The optimal management of Achilles tendon ruptures remains an enigma, and various factors such as optimal tendon healing, muscle strength recovery and surgery technique probably affects the clinical outcome and the structure of the muscle and tendon.
Aim: To measure gastrocnemius and soleus tendon length on the injured and uninjured side within a week after surgery.
Materials and Methods: This was a preliminary analysis of 48 patients from an ongoing clinical trial. All patients were treated surgically and subsequently had a non-weightbearing below-knee plaster cast applied with the ankle in approximately 30o of plantar flexion. The surgeon sutured the tendon (modified Kessler) and aimed to restore the original anatomical length by tightening the sutures until both feet had an equal resting angle while in the prone position. A 3D magnetic resonance image was obtained within a week after surgery to measure gastrocnemius and soleus tendon length on the injured and uninjured side.
Results: The calcaneus-soleus length (uninjured- injured) was -19.4 mm (95%CI: -24.2 to -14.6), P value <0.0001. The calcaneus- gastrocnemius length (uninjured-injured) was -2.5 mm (95%CI: -7.3 to 2.3), P value = 0.415.
Interpretation / Conclusion: Measurements using 3D MRI within the first week after Achilles tendon repair revealed a significant elongation (38%) of the calcaneus-soleus ‘free’ tendon, while the calcaneus-gastrocnemius was not elongated.
1Institute of Sports Medicine Copenhagen, Bispebjerg and Frederiksberg Hospital 2Department of Orthopedic Surgery, Bispebjerg and Frederiksberg Hospital 3Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital 4Department of Radiology, Bispebjerg and Frederiksberg Hospital
Background: The optimal management of Achilles tendon ruptures remains an enigma, and various factors such as optimal tendon healing, muscle strength recovery and surgery technique probably affects the clinical outcome and the structure of the muscle and tendon.
Aim: To measure gastrocnemius and soleus tendon length on the injured and uninjured side within a week after surgery.
Materials and Methods: This was a preliminary analysis of 48 patients from an ongoing clinical trial. All patients were treated surgically and subsequently had a non-weightbearing below-knee plaster cast applied with the ankle in approximately 30o of plantar flexion. The surgeon sutured the tendon (modified Kessler) and aimed to restore the original anatomical length by tightening the sutures until both feet had an equal resting angle while in the prone position. A 3D magnetic resonance image was obtained within a week after surgery to measure gastrocnemius and soleus tendon length on the injured and uninjured side.
Results: The calcaneus-soleus length (uninjured- injured) was -19.4 mm (95%CI: -24.2 to -14.6), P value <0.0001. The calcaneus- gastrocnemius length (uninjured-injured) was -2.5 mm (95%CI: -7.3 to 2.3), P value = 0.415.
Interpretation / Conclusion: Measurements using 3D MRI within the first week after Achilles tendon repair revealed a significant elongation (38%) of the calcaneus-soleus ‘free’ tendon, while the calcaneus-gastrocnemius was not elongated.
Julia Lazarow¹, Signe Steenstrup Jensen², Bjarke Viberg² ³
Faculty of Health Sciences, University of Southern Denmark¹; Dept. of Orthopedic Surgery and Traumatology, Hospital Lillebaelt – University Hospital of Southern Denmark, Kolding, Denmark²; Dept. of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark³.
Background: The past 30 years, several studies have compared early versus late weight-bearing (WB), following open reduction and internal fixation of ankle fractures. However, no review strictly including patients with ankle fractures and complete syndesmotic disruption has been performed.
Aim: The objective of this systematic review was to compare early versus late WB following surgery for ankle fractures with syndesmotic injury regarding clinical and functional outcomes.
Materials and Methods: A comprehensive search strategy was developed with the aid of a scientific librarian and applied to the Cochrane Library, MEDLINE, Embase, CINAHL and PubMed from their inception to the 17th of January 2022. The articles were screened independently by two blinded reviewers using the Covidence® software. Data were extracted by one author, then cross- checked and approved by the other. Early WB was defined as any WB within four weeks postoperatively. There were no comparative studies, therefore studies describing either early or late WB were included. It was therefore not possible to perform a meta-analysis. Risk of bias analysis were performed using tools from the Joanna Briggs Institute.
Results: Eleven studies and 751 patients were included. Three studies used an early partial WB protocol (253 patients) and eight studies (498 patients) a late. The early WB studies were primarily randomized controlled trials (RCT). Functional outcomes suggested that there were no clear differences between early and late WB after one year. None of the late WB studies had a shorter follow-up time than one year. There were 9-31% reoperations in the early and 0- 11% in the late WB group. Superficial wound infections occurred in four percent in the early and 1-3% in the late WB. There were similar results for loss of syndesmotic reduction, malreduction, infection and fixation failure. Overall, the studies had a moderate to high risk of bias.
Interpretation / Conclusion: There are pros and cons for early and late WB, but the evidence is very limited due to the noncomparative studies. High-quality comparative studies focusing on functional outcomes within six months postoperatively are needed.
Faculty of Health Sciences, University of Southern Denmark¹; Dept. of Orthopedic Surgery and Traumatology, Hospital Lillebaelt – University Hospital of Southern Denmark, Kolding, Denmark²; Dept. of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark³.
Background: The past 30 years, several studies have compared early versus late weight-bearing (WB), following open reduction and internal fixation of ankle fractures. However, no review strictly including patients with ankle fractures and complete syndesmotic disruption has been performed.
Aim: The objective of this systematic review was to compare early versus late WB following surgery for ankle fractures with syndesmotic injury regarding clinical and functional outcomes.
Materials and Methods: A comprehensive search strategy was developed with the aid of a scientific librarian and applied to the Cochrane Library, MEDLINE, Embase, CINAHL and PubMed from their inception to the 17th of January 2022. The articles were screened independently by two blinded reviewers using the Covidence® software. Data were extracted by one author, then cross- checked and approved by the other. Early WB was defined as any WB within four weeks postoperatively. There were no comparative studies, therefore studies describing either early or late WB were included. It was therefore not possible to perform a meta-analysis. Risk of bias analysis were performed using tools from the Joanna Briggs Institute.
Results: Eleven studies and 751 patients were included. Three studies used an early partial WB protocol (253 patients) and eight studies (498 patients) a late. The early WB studies were primarily randomized controlled trials (RCT). Functional outcomes suggested that there were no clear differences between early and late WB after one year. None of the late WB studies had a shorter follow-up time than one year. There were 9-31% reoperations in the early and 0- 11% in the late WB group. Superficial wound infections occurred in four percent in the early and 1-3% in the late WB. There were similar results for loss of syndesmotic reduction, malreduction, infection and fixation failure. Overall, the studies had a moderate to high risk of bias.
Interpretation / Conclusion: There are pros and cons for early and late WB, but the evidence is very limited due to the noncomparative studies. High-quality comparative studies focusing on functional outcomes within six months postoperatively are needed.