Tag Archive | Achilles tendon

JBJS 100: Knee Hemarthrosis and Achilles Ruptures

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Arthroscopy in Acute Traumatic Hemarthrosis of the Knee
F R Noyes, R W Bassett, E S Grood, D L Butler: JBJS, 1980 July; 62 (5): 687
This paper was among the first to identify the high rate of serious knee injuries among patients with acute traumatic hemarthrosis (ATH). Noyes’ paper showed that 72% of knees with ATH also had some degree of ACL injury. While orthopaedists generally no longer use knee arthroscopy as a diagnostic tool in the setting of ATH, because of this article, they often order MRI when patients present with this acute knee injury.

Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures
K Willits, A Amendola, D Bryant, N Mohtadi, J R Giffin, P Fowler, C O Kean, A Kirkley: JBJS, 2010 December 1; 92 (17): 2767
This multicenter randomized trial was not the first to compare surgical treatment of Achilles tendon ruptures with nonoperative treatment that included early functional range of motion, but it confirmed that in patients treated nonoperatively, early functional treatment is preferable to cast immobilization. Since this paper was published, more than 20 studies investigating Achilles tendon ruptures have been published in JBJS, emphasizing that the search goes on for treatment protocols—surgical and nonoperative—that are effective and relatively free of complications.

After Achilles Repair, Musculotendinous Strength Remains a Big Challenge

Calf MRI for OBuzzAmid ongoing uncertainty regarding the optimum management of Achilles tendon ruptures, recent controlled trials seem to have moved the pendulum back toward nonsurgical treatment. Still, there are many people walking around on surgically repaired Achilles tendons, and in the September 20, 2017 issue of The Journal, Heikkinen et al. report on the 13+-year outcomes of operative repair followed by early functional postoperative management in 52 patients.

All orthopaedic surgeons who have treated patients with this tendon injury have noted the postoperative calf atrophy. Using carefully analyzed MRI studies, these authors found that the mean volumes of the soleus, medial gastrocnemius, and lateral gastrocnemius muscles were 13%, 13%, and 11% lower, respectively, in the affected legs than in the uninjured legs. The mean 6% elongation of the repaired tendon that Heikkinen et al. also found at this long-term follow-up makes sense, because we are repairing tendinous tissue whose inherent collagen bundle structure has been “overstretched” prior to total failure. It also makes sense that surgeons are often hesitant to shorten the ends of the tendon aggressively for fear of placing too great a tensile strain on the suture repair.

What is most impressive to me is the degree of calf-muscle atrophy revealed in these results. Whether the findings from future trials tilt us further toward nonoperative or back toward operative care, we need to solve the muscle atrophy issue. The solution will most likely come from even more aggressive rehabilitation. To date, many of us have erred on the side of not pushing these patients too far during rehab, out of concern for failure of repair or reinjury.

With solid surgical and nonsurgical treatments for fractures, we have solved many issues to achieve optimum bone healing with good anatomic and strength outcomes. However, we have not really begun to make gains on limiting muscle, ligament, and tendon atrophy in lower extremity injuries. This should be high on the agenda for the trauma research community during the next 2 to 3 decades.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Literature Update: Options for Treating Ankle Arthritis

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Christopher E. Gross, MD, in response to the May 18, 2016 JBJS Specialty Update on Foot and Ankle Surgery.

Ankle arthritis occurs along a spectrum of severity—ranging from minor cartilage lesions to significant degenerative disease.

To preserve ankle function and to prevent possible evolution into arthritic changes, osteochondral lesions should be treated as soon as they become symptomatic. In one prospective cohort study summarized by Lin and Yeranosian in the May 18, 2016 JBJS Specialty Update, thirty patients with talar osteochondral lesions underwent arthroscopic implantation of bone marrow-derived cells onto a collagen scaffold.  Patients who received adjunctive biophysical stimulation by pulsed electromagnetic fields (PEMFs) had higher AOFAS scores at one year post-operatively than those who did not.1 The proposed explanation for this outcome is that PEMFs decrease inflammatory cytokines and help differentiate stem cells into chondrocytes.

Total ankle replacements (TARs) have become a viable surgical option for patients with end-stage ankle arthritis. In a study comparing patients undergoing TAR with those undergoing  arthrodesis,2  TAR patients had higher expectations of their surgery than fusion patients and were more likely to have higher satisfaction scores post-operatively.  In a functional comparison of TAR and arthrodesis, Jastifer, et al. found that patients who received a TAR had an easier time walking uphill and down/upstairs.3  In another study evaluating functional biomechanics following TAR surgery, groups whose procedure included Achilles tendon lengthening were compared to those who had TAR alone.4  There were no between-group differences in functional outcomes or gait mechanics.

In a study comparing results and complications of TAR in patients with rheumatoid arthritis to patients who had ankle replacements due to either traumatic or primary arthritis, the authors found similar functional outcomes and complication rates.

Despite these many examples of TAR success in the recent literature, the procedure is not without its shortcomings. Rahm, et al.5 compared patients who underwent primary ankle fusion to those who underwent salvage ankle arthrodesis because of a failed TAR.  Those who had a salvage procedure had more pain and decreased functionality compared to those who underwent a primary fusion.

Christopher E. Gross, MD is an orthopaedic surgeon specializing in foot and ankle disorders at the Medical University of South Carolina in Charleston.

References

  1. Cadossi M, Buda RE, Ramponi L, Sambri A, Natali S, Giannini S. Bone marrow-derived cells and biophysical stimulation for talar osteochondral lesions: a randomized controlled study. Foot Ankle Int. 2014 Oct;35(10):981-7.
  2. Younger AS, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, et al. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
  3. Jastifer J, Coughlin MJ, Hirose C. Performance of total ankle arthroplasty and ankle arthrodesis on uneven surfaces, stairs, and inclines: a prospective study. Foot Ankle Int. 2015 Jan;36(1):11-7.
  4. Queen RM, Grier AJ, Butler RJ, Nunley JA, Easley ME, Adams SB, Jr., et al. The influence of concomitant triceps surae lengthening at the time of total ankle arthroplasty on postoperative outcomes. Foot Ankle Int. 2014 Sep;35(9):863-70.
  5. Rahm S, Klammer G, Benninger E, Gerber F, Farshad M, Espinosa N. Inferior results of salvage arthrodesis after failed ankle replacement compared to primary arthrodesis. Foot Ankle Int. 2015 Apr;36(4):349-59.

What’s New in Orthopaedic Rehabilitation: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of key findings from Level I and II studies cited in the November 18, 2015 Specialty Update on orthopaedic rehabilitation:

General Orthopaedics/Arthroplasty

  • A prospective comparison of patients who received either skilled physical therapy (PT) or a standardized home exercise program after total knee arthroplasty (TKA) found that range of motion and functional outcome were similar in the two groups after two years, but the home program was nearly half the cost of PT.1
  • A randomized trial of 198 patients who underwent TKA compared telerehabilitation with face-to-face rehab. After two months, WOMAC and KOOS scores and functional and range-of-motion tests were all noninferior for telerehabilitation.
  • A randomized trial of community-dwelling elderly patients who had undergone hip fracture surgery found that an individualized home-based rehab program produced superior functional outcomes, balance, and mobility recovery when compared with a standard, non-structured home exercise program.2
  • A claims-data study of 4733 people who underwent hip or knee replacement found a 29% decrease in postoperative acute service utilization among those who had preoperative PT.
  • A randomized trial comparing active transcutaneous nerve stimulation (TENS), placebo TENS, and standard care during rehab for TKA found that adding either active or placebo TENS to standard care significantly reduced movement pain in the immediate postoperative period.3
  • A randomized study found that in-hospital sling-based range-of-motion therapy had a clinically beneficial effect up to three months after TKA surgery in terms of passive knee flexion range of motion, compared with an in-hospital continuous passive motion protocol.4

Achilles Tendon

  • A randomized trial comparing weight-bearing and non-weight-bearing for nonoperative treatment of Achilles tendon ruptures found no significant between-group differences in the Total Rupture Score or heel-rise strength.
  • A systematic review and meta-analysis comprising 402 patients who had undergone surgical Achilles tendon repair found that postoperative early weight-bearing and early ankle motion exercises were associated with a lower minor complication rate and greater functional recovery when compared with conventional immobilization.5

Pediatrics

  • A randomized trial comparing 12 weeks of individualized resistance training to physiotherapy without resistance training in adolescents and young adults with bilateral spastic cerebral palsy found that neither group demonstrated improvements in performance of daily physical activity.6

Motion Analysis

  • A randomized trial of three methods of weight-bearing training (verbal instruction, bathroom scale training, and haptic biofeedback) found that haptic feedback was superior to the other methods at helping patients maintain weight-bearing status.7

Amputation and Prosthetics

  • A systematic review of studies comparing rigid versus soft dressings after amputation determined that rigid dressings resulted in significantly shorter time from amputation to fitting of a prosthesis.8
  • A randomized trial of phantom pain found that a protocol of progressive muscle relaxation, mental imagery, and phantom exercises yielded more significant reductions in the rate and intensity of phantom pain than a program of standard physical therapy.9

Low Back Pain

  • Among patients with low back pain, a three-way randomized trial (standard care, standard care + extensible lumbosacral orthoses, and standard care + inextensible lumbosacral orthoses) found that inextensible lumbar orthoses led to a greater improvement in Oswestry Disability Index scores than the other two approaches.10

References

  1. Büker N,,Akkaya S, Akkaya N, Gökalp O, Kavlak E, Ok N, Kıter AE, Kitiş A.Comparison of effects of supervised physiotherapy and a standardized home program on functional status in patients with total knee arthroplasty: a prospective study. J Phys Ther Sci. 2014 Oct;26(10):1531-6. Epub 2014 Oct 28.
  2. Salpakoski A, Törmäkangas T, Edgren J, Kallinen M, Sihvonen SE, Pesola M,Vanhatalo J, Arkela M, Rantanen T, Sipilä S. Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial. J Am Med Dir Assoc. 2014 May;15(5):361-8. Epub 2014 Feb 20.
  3. Rakel BA, Zimmerman MB, Geasland K, Embree J, Clark CR, Noiseux NO,Callaghan JJ, Herr K, Walsh D, Sluka KA. Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial. Pain. 2014 Dec;155(12):2599-611.Epub 2014 Sep 28.
  4. Mau-Moeller A, Behrens M, Finze S, Bruhn S, Bader R, Mittelmeier W. The effect of continuous passive motion and sling exercise training on clinical and functional outcomes following total knee arthroplasty: a randomized active-controlled clinical study. Health Qual Life Outcomes. 2014 May 9;12:68.
  5. Huang J, Wang C, Ma X, Wang X, Zhang C, Chen L. Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis. Am J Sports Med. 2015 Apr;43(4):1008-16. Epub 2014 May 2.
  6. Bania TA, Dodd KJ, Baker RJ, Graham HK, Taylor NF. The effects of progressive resistance training on daily physical activity in young people with cerebral palsy: a randomised controlled trial. Disabil Rehabil. 2015 Jun 9:1-7. [Epub ahead of print].
  7. Fu MC, DeLuke L, Buerba RA, Fan RE, Zheng YJ, Leslie MP, Baumgaertner MR, Grauer JN. Haptic biofeedback for improving compliance with lower-extremity partial weight bearing. Orthopedics. 2014 Nov;37(11):e993-8.
  8. Churilov I, Churilov L, Murphy D. Do rigid dressings reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Ann Vasc Surg. 2014 Oct;28(7):1801-8. Epub 2014 Jun 6.
  9. Brunelli S, Morone G, Iosa M, Ciotti C, De Giorgi R, Foti C, Traballesi M. Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial. Arch Phys Med Rehabil. 2015Feb;96(2):181-7. Epub 2014 Oct 23.
  10. Morrisette DC, Cholewicki J, Logan S, Seif G, McGowan S. A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain. Spine (Phila Pa 1976). 2014 Oct 1;39(21):1733-42.

What’s New in Sports Medicine: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the April 15, 2015 Specialty Update on sports medicine:

Shoulder

–A systematic review of Level-I and II studies suggests that the structural integrity of rotator cuff repairs (or lack thereof) does not correlate with validated patient subjective outcome measures.

–Authors of a randomized clinical trial comparing open and arthroscopic stabilization for recurrent anterior shoulder instability concluded that young male patients with visible Hill-Sachs lesions on radiographs may fare better with open repairs.

–A quantitative literature synthesis of 31 studies (2,813 shoulders) supported primary surgery for highly active young adults who sustain an anterior shoulder dislocation.

–Following rotator cuff surgery, patients randomized to receive a combined axillary and suprascapular nerve block experienced less pain and a lower frequency of rebound pain in the first 36 hours than those receiving only a suprascapular nerve block.

–A Level-II meta-analysis of early passive motion versus strict sling immobilization after arthroscopic rotator cuff repair found that early passive motion resulted in improved forward flexion at 6 and 12 months, with no apparent increased retear rate.

Knee

–A randomized trial comparing single- and double-bundle ACL reconstruction with the use of hamstring autograft found no differences in pivot shift or clinical scores at two years.

–Twenty patients with subacute ACL injuries were randomized to “prehabilitation” or control groups. At 12 weeks after surgery, the prehab group showed sustained improvements in single-leg hop and Cincinnati scores, but peak torque and muscle-mass gains had regressed to levels similar to those in the control group.

–A randomized study comparing contralateral versus ipsilateral hamstring tendon harvest for ACL repair identified neither drawbacks nor advantages with the contralateral approach.

–Sixty patients who’d received an isolated meniscal repair were randomized to get either a traditional rehab protocol (brace and toe-touch weigh bearing) or “free rehabilitation.” Based on MRI, partial healing or lack of healing occurred in 28% of the free rehabilitation group and in 36% of the traditional group.

–Authors of a systematic review concluded that nonirradiated allogenic tissue may be superior to radiated allografts for primary ACL reconstruction.

Cartilage Regeneration

–A randomized controlled trail comparing microfracture alone to microfracture plus application of a novel chitosan-based device demonstrated greater lesion filling and superior repair tissue with the novel device, although there were no differences in clinical benefit and safety at 12 months.

–A randomized controlled trial comparing accelerated with conventional rehabilitation following cartilage repair found that the accelerated group reached full weight-bearing two weeks earlier than the conventional group and reported higher quality-of-life scores.

Hip

–In a Level-II study of a population with acute hamstring injuries, those who received a single autologous platelet-rich plasma injection plus rehab had significantly reduced return-to-play time than a group that received rehab without the injection.

Elbow

–A randomized study of 230 patients with chronic lateral epicondylitis found that those receiving leukocyte-enriched platelet-rich plasma had “clinically meaningful improvement” in pain at 24 weeks, compared to those in an “active control” group.

Foot & Ankle

–A randomized study of 84 patients with nonsurgically treated Achilles tendon tears showed no significant differences in rerupture rates or return-to-work times between a group given a weight-bearing cast and a group given a non-weight-bearing cast.

–A randomized trial of 200 patients with Achilles ruptures compared stable surgical repair and accelerated rehabilitation to nonoperative management. Surgical repair was not found to be superior to nonoperative treatment in terms of functional results, physical activity, or quality of life.

JBJS Reviews Editor’s Choice–Achilles Tendon Ruptures

Among the topics that consistently stimulate debate among orthopaedic surgeons is the treatment of acute Achilles tendon rupture. The central question is typically, “Should this injury be treated operatively or nonoperatively?” In the April 2015 issue of JBJS Reviews, Guss et al. tackle this question.

The decision to treat acute Achilles tendon rupture has always been a trade-off between wound complications (associated with operative treatment) and the risk of rerupture (associated with both nonoperative and operative treatment but more commonly associated with nonoperative treatment). While the authors quote numerous reports, an important observation among all of the reports cited is that rehabilitation protocols for nonoperative treatment were not uniform across cohorts. Considering recent findings, the debate about operative vs. nonoperative intervention apparently has shifted from a focus on rerupture and infection to a focus on functional outcomes. Functional rehabilitation protocols have decreased the rerupture rate historically seen in association with the nonoperative treatment of these injuries. Operative treatment may provide some functional benefits, but recent studies suggest that many of these benefits are transient or subtle.

Guss at al. also point out that the rate of deep-vein thrombosis after Achilles tendon rupture may be higher than that observed in association with many other foot and ankle conditions. Indeed, the incidence of deep-vein thrombosis in patients with acute Achilles tendon rupture is possibly as high as one in three, but the vast majority of deep-vein thromboses are asymptomatic and are unlikely to be clinically relevant. Prophylactic anticoagulation should be considered for older patients with Achilles tendon rupture, including those managed nonoperatively, as well as for patients with other known risk factors.

In summary, recent reports have suggested that the use of functional rehabilitation in lieu of cast immobilization has, to a certain extent, reduced the higher rates of rerupture that historically have been associated with nonoperative treatment. Moreover, functional rehabilitation protocols are not associated with the wound complications that are inherently associated with operative repair. Operative repair may provide functional benefits, but reports have suggested that these benefits may be transient or incremental and limited to those patients who participate in more intense athletic endeavors. Indeed, more research with well-designed, randomized clinical trials is necessary to clarify the potential for incremental functional gain following operative repair as well as to identify those patients in whom nonoperative treatment is more likely to fail.

Thomas A. Einhorn, MD, Editor

Click here for another OrthoBuzz post about this JBJS Reviews article.

Functional Rehab Key to Nonoperative Management for Achilles Ruptures

The fact that 12 of the 16 AAOS clinical practice guidelines for treating Achilles tendon ruptures are supported by “weak” or “inconclusive” evidence makes the recent JBJS Reviews article by Guss et al. on this subject all the more welcome.

The most emphatic point made by these authors is that functional rehabilitation protocols with early motion (and an associated shift away from long-term post-injury immobilization) have made a dent in the re-rupture rates historically seen with nonoperative treatment of Achilles tendon injuries, the incidence of which has increased in recent decades. The authors emphasize, however, that the delicate balance between loading and unloading of a healing Achilles tendon remains a rehabilitative challenge, and they encourage further research to identify which patients are more or less likely to experience success with nonoperative management.

The authors note also that the focus of outcomes research of different management methods has shifted from rates of re-rupture and infection to more specific functional measures—and, in some cases, to direct and indirect cost measures. For example, Guss et al. cite one meta-analysis that found that operatively treated patients returned to work almost three weeks earlier than those treated nonoperatively.

The authors also observe that the rate of deep vein thrombosis after Achilles rupture seems to be higher than that seen in other foot/ankle conditions, but they add that the majority of those thrombotic events are “unlikely to be clinically important.” Still, Guss et al. conclude that “prophylactic anticoagulation should be considered for older patients with an Achilles tendon rupture, including those treated nonsurgically.”