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AbstractObjectiveTo determine whether an injection of platelet rich plasma improves outcomes after acute Achilles tendon rupture.DesignRandomised, placebo controlled, two arm, parallel group, participant and assessor masked, superiority trial.SettingSecondary care trauma units across 19 hospitals in the United Kingdom’s health service.ParticipantsRecruitment commenced in July 2015 and follow-up was completed in March 2018. 230 adults aged 18 years and over were included, with acute Achilles tendon rupture presenting within 12 days of injury and managed with non-surgical treatment. Exclusions were injury at the insertion or musculotendinous junction, major leg injury or deformity, diabetes mellitus, platelet or haematological disorder, systemic corticosteroids, anticoagulation treatment, and other contraindicating conditions.InterventionsParticipants were randomised 1:1 to platelet rich plasma (n=114) or placebo (dry needle; n=116) injection. All participants received standard rehabilitation care (ankle immobilisation followed by physiotherapy).Main outcomes and measuresPrimary outcome was muscle tendon function at 24 weeks, measured objectively with the limb symmetry index (injured/uninjured×100) in maximal work done during the heel rise endurance test (an instrumented measure of repeated single leg heel rises until fatigue). Secondary outcomes included patient reported function (Achilles tendon rupture score), quality of life (short form 12 version 2®), pain (visual analogue scale), goal attainment (patient specific functional scale), and adverse events. A central laboratory analysed the quality and content of platelet rich plasma. Analyses were by modified intention to treat.ResultsParticipants were 46 years old on average, and 57 (25%) of 230 were female. At 24 weeks, 202 (88%) participants completed the heel rise endurance test and 216 (94%) the patient reported outcomes. The platelet rich plasma was of good quality, with expected growth factor content. No difference was detected in muscle tendon function between participants receiving platelet rich plasma injections and those receiving placebo injections (limb symmetry index, mean 34.7% (standard deviation 17.7%) v 38.5% (22.8%); adjusted mean difference −3.9% (95% confidence interval −10.5% to 2.7%)) or in any secondary outcomes or adverse event rates. Complier average causal effect analyses gave similar findings.ConclusionsThere is no evidence to indicate that injections of platelet rich plasma can improve objective muscle tendon function, patient reported function, or quality of life after acute Achilles tendon rupture compared with placebo, or that they offer any patient benefit.Trial registrationISRCTN54992179.

Category: Sports, Ankle Keywords: Achilles, Achilles Tendon, Achilles Tendon Rupture Introduction/Purpose: Achilles tendon ruptures remain the most common tendon injury within the lower extremity. While the incidence continues to rise, changing immobilization protocols, techniques, and surgeon preferences have evolved over the past few decades. The purpose of this study was to characterize the complication rate in acute Achilles tendon repair by surgeon volume and location in a heterogenous major metropolitan area. Methods: Achilles tendon repairs (CPT27650) performed from January 2018 through December 2022 with a minimum two-month follow-up were retrospectively reviewed. Patients were excluded if they had chronic tears that required reconstruction, underwent a revision repair/reconstruction, or were initially treated nonoperatively. 1035 Achilles tendon ruptures met inclusion criteria. The primary outcome measure was total complication rate by surgeon volume. High volume surgeons were defined as if the surgeon completed 30 or more repairs within the five-year study period. Low volume surgeons performed 29 or less repairs over the same period. Major complication rate (reoperation, deep infection, tendon re-rupture, and loss of Achilles tension requiring re-operation) and minor complication rate (sural neuritis, superficial infection, delayed wound healing, heel pain, and loss of Achilles tension not requiring re-operation) were also documented by surgeon volume. Complication rates by geographic location of practice (Urban vs. Suburban) were recorded. Descriptive statistics and multivariate regression were utilized. Results: The overall complication rate was 15.8%—with 3% (N=31) having major complications. Patients were significantly less likely to encounter any complication (p=.017) or minor complication (p=.0091) with surgeons who performed 30 or more Achilles repairs over a five-year period. There was no difference in major complication rate (p>0.999) or re-operation rate (p=0.7337) between high and low volume surgeons. Urban-based practices experienced improved minor (p=0.031) and overall complication rates (p=0.0177) compared to suburban-based practices. There was no difference in major complication rate (p=0.3967). Conclusion: In this large community cohort, patients electing to have an acute, midsubstance Achilles tendon repair experienced fewer overall complications with high volume and urban-based surgeons. There was no difference in re-operation rate between high and low volume surgeons.

In this multicenter trial involving patients with acute Achilles’ tendon rupture, surgery (open repair or minimally invasive surgery) did not result in better outcomes than nonoperative treatment at 12 months.

Research Type: Level 4 – Case series Introduction/Purpose: Intramedullary screws are becoming a fixation option for management of metatarsal fractures, though there has been limited literature to date on their use. One potential complication associated with their use is the possibility of flexor tendon injury. The purpose of this study is to determine the frequency and amount of flexor tendon disruption associated with intramedullary screw fixation for metatarsal fractures. Methods: Seven left and right lower extremity cadaver specimens were procured. The 2nd through 5th metatarsals (MT) were pinned with a guidewire, and drilled retrograde with a 2.7 millimeter (mm) drill. A 3.6 mm metatarsal screw was then inserted. The plantar surface of the specimens was then exposed to visualize the flexor tendons. The tendon location relative to the drill hole, incidence of tendon disruption, percentage of tendon disruption, and the distance between the tendon and the drill hole were measured. Results: Overall, 21/56 (37.5%) flexor tendons were damaged, 5 in the 2nd MT, 7 in the 3rd, 9 in the 4th, and 0 in the 5th. The hit rates for the 2nd, 3rd, 4th, and 5th MT were 35.7%, 50%, 64.3%, and 0%, and the percentage of tendon disruption was 15%, 11%, 11%, and 0%, respectively. The mean distance from uninjured tendons to the drill hole was 1.07 mm, 0.94 mm, 0.9 mm, and 2.03 mm in the 2nd-5th MT, respectively. The majority of flexor tendons were found medial to the drill hole across all metatarsals. Conclusion: The insertion of intramedullary screws for fixation of metatarsal fractures is associated with a high rate of flexor tendon injury (37.5%), most commonly in the 4th metatarsal. No flexor tendon injuries were observed in the 5th MT. The percentage of flexor tendon injury involves roughly 10-20% of the width of the tendon. Adjusting the start point to a slightly more lateral position if possible may minimize the risk of flexor tendon injury, and patients should be counseled on the possibility of flexor tendon rupture postoperatively. Flexor Tendon Disruption and Location Relative to Screw Hole

Background Flexor tendon injuries are common and lead to over 3200 admissions for specialist surgical repair annually in England and Wales. Surgery to repair complete division of both flexor tendons in zone 2 of the hand is technically challenging. There is variation in surgical repair techniques with no high-quality evidence to support decision-making. In particular, the decision to repair both tendons or just one is contested. Surgery is followed by specialist rehabilitation, which takes at least 12 weeks. The resulting hand function can impact the patient’s income, life satisfaction, well-being, self-worth, and mental health. The FLARE trial aims to determine the clinical and cost-effectiveness of repairing the flexor digitorum profundus (FDP) alone (intervention) versus the repair of both FDP and flexor digitorum superficialis (FDS) (control) for the treatment of complete zone 2, single-digit flexor tendon injuries in adults. Methods A multi-centre, two-arm, blinded, non-inferiority, parallel group, randomised controlled trial with an internal pilot, economic evaluation, and nested qualitative study. Participants will be randomised 1:1 to receive either repair of FDP alone or repair of both FDP and FDS. A total of 310 adults will be recruited from NHS Trusts within the UK, randomised at surgery, and followed up within 7 days, 6 weeks, 3 months, and 6 months post-randomisation. The primary outcome measure is the patient evaluation measure (PEM) administered 6 months post-randomisation. Secondary outcomes include the PEM at other timepoints, Patient Related Wrist/Hand Evaluation (PRWHE), EuroQol 5 Dimensions Score (EQ-5D-5L), complications, total range of motion, grip strength, adherence to splint and therapy regimens, work outcomes, treatment and outcome satisfaction, and healthcare resource use. Discussion FLARE is designed with sufficient power and rigour to provide evidence on the clinical and cost-effectiveness of two surgical repair methods for single-digit, complete zone 2 flexor tendon injuries in adults. If the repair of FDP alone is as beneficial to the patient as the repair of FDP and FDS, this could save the NHS £1.8 million annually through reduced time and material costs. Furthermore, the trial findings will facilitate better shared decision-making discussions between clinicians and patients. Trial registration ISRCTN 10918157. Prospectively registered: 12.01.2023.

Purpose The purpose of this prospective randomized controlled study was to evaluate the long-term results after an acute Achilles tendon rupture in patients treated surgically or non-surgically. The focus was to evaluate whether any improvements occurred between the one and 2-year evaluation. Method Eighty-one patients (67 men, 14 women) with a mean (SD) age of 42 (9.1) were included in this study. Forty-two patients were treated surgically, and 39 treated non-surgically otherwise the treatment was identical for the two groups. All patients were evaluated using the Achilles tendon Total Rupture Score (ATRS), the Physical Activity Scale (PAS) and validated functional tests one and 2 years after injury. Results There were significant functional deficits on the injured side compared with the contralateral side 2 years after Achilles tendon rupture, regardless of treatment. Only minor improvements, even though statistically significant, occurred between the 1- and 2-year evaluations. The physical activity level remained significantly reduced as compared with prior to injury, but the ATRS mean was relatively high in both groups (89 and 90). Conclusion This long-term follow-up indicates that the majority of patients with an Achilles tendon rupture have not fully recovered (in regards to symptoms, physical activity level and function) 2 years after injury regardless of surgical or non-surgical treatment. Furthermore, only minor improvements occur between the 1- and 2-year evaluations. This indicates that to enhance the final outcome the focus should be on improvements in treatment within the first year. The patients appear to have adjusted to their impairments since the patient-reported outcome is relatively high in spite of functional deficits and lower activity level compared with pre-injury. Level of evidence Prospective randomized study, Level I.

BackgroundAcute Achilles tendon rupture (ATR) can be treated operatively or non-operatively. An evidence based selection tool is needed to guide choice of treatment.PurposeTo investigate if treatment selection in patients with ATR can be guided by Amlang’s ultrasound classification (AmC) or the Copenhagen Achilles Length Measurement (CALM).MethodsThe study was performed as a prospective cohort study. Patient were 18 to 70 years and treated non-operatively. AmC and CALM were performed at baseline and correlated to outcome at 1 year. The primary outcome was the Achilles tendon Total Rupture Score (ATRS). Secondary outcomes were: heel-rise-work test, re-rupture rate and CALM at 1 year. ROC analysis was performed to determine a cut off for acceptable elongation of CALM at baseline given that elongation at 1 year was not to exceed 10%. ClinicalTrial.gov Identifier: NCT02062567.ResultsCALM was performed at baseline in 130 patients and AmC in 109. AmC showed no statistically significant correlation to any outcome parameter. CALM at baseline correlated to CALM at 1 year r=0.214 (p<0.01). The ROC model had AUC=0.67. An elongation of 7% at baseline had a sensitivity of 0.77 and specificity of 0.50.ConclusionsElongation of the Achilles tendon at baseline measured with CALM was weakly correlated to elongation at 1 year follow up suggesting that CALM at base line can predict elongation at one year. A cut off of 7% elongation at baseline would have caught 77% of patients who ended up with an elongation above 10% at 1 year.

IntroductionElongation of the Achilles tendon after rupture is a frequent and overlooked complication. The Achilles Tendon Length Measure (ATLM) and the Achilles Tendon Resting Angle (ATRA) are indirect length measures using the resting angle of the ankle. Copenhagen Achilles Length Measure (CALM) is a direct ultrasound measure. Examination of the association of elongation to valid clinical measures of the length of the Achilles tendon are needed. The purpose was to examine the concurrent validity of ATLM and ATRA in relation to CALM within one year of rupture.Materials and methodsThe study was performed as a validity study. Data were collected from patients included in a randomized controlled trial. Mixed linear regression, controlling for time after injury, age and gender, was performed investigating the three models (dependent-independent): CALM-ATRA, CALM-ATLM and ATRA-ATLM.Results130 patients were included (23 women, 107 men) mean age 41.8 years (SD 10.5). All three regression models demonstrated a statistical significant (p<0.01) linear relationship. For each degree ATRA increased, CALM increased with 0.39 mm. For each cm ATLM increased, CALM increased with 1.7 mm. For each cm ATLM increase, ATRA increase with 1,6 degrees.ConclusionATRA and ATLM were found to have a linear relationship to CALM and seems valid as surrogate measurements for the assessment of tendon elongation after an Achilles tendon rupture.

IntroductionThe Achilles tendon Total Rupture Score (ATRS) is the most commonly used patient reported outcome in patients with an acute Achilles tendon rupture. The score contains ten items of which the last three concerns tasks that some patients cannot and some do not perform. No manual for the use of ATRS has been developed. The purpose was to investigate how ATRS responds at 4, 6 and 12 months after rupture and develop a manual for the use of ATRS.Materials and methodsThis study was performed as a retrospective registry study analysing prospectively gathered data from the Danish Achilles tendon Database. The data was gathered 4, 6 and 12 months after rupture. The original score based on 10 items was compared with a score based on the first 7 items adjusted to the same scale as the original score. Density- and scatterplots were made and differences between the scores were tested by t-test or Mann–Whitney U test.Results2790 completed ATRS scores were included. The 7-item score statistically significantly overestimated the value of the 10 items score at all time points (p<0.001) but only at 4 months the difference was clinical relevant (9.7points).ConclusionThe ATRS cannot be recommended for use at 4 months past rupture, as the last 3 items skew the score. If the ATRS is used before 6 months the last three items could be omitted. A manual for the use of the ATRS will be developed defining how and when the score should be applied.