© 2010 The Journal of Bone and Joint Surgery, Inc.

Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures

A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation

Kevin Willits, MA, MD, FRCSC¹, Annunziato Amendola, MD, FRCSC²,Dianne Bryant, MSc, PhD³, Nicholas G. Mohtadi, MD, MSc, FRCSC⁴,J. Robert Giffin, MD, FRCSC¹, Peter Fowler, MD, FRCSC¹,Crystal O. Kean, MSc, PhD¹ and Alexandra Kirkley, MD, MSc, FRCSC⁵

¹ WOLF Orthopaedic Biomechanics Lab (C.O.K.), Fowler Kennedy Sport Medicine Clinic (K.W., J.R.G., and P.F.), 3M Centre, The University of Western Ontario, London, ON N6A 3K7, Canada. E-mail address for K. Willits: kwillit@uwo.ca. E-mail address for J.R. Giffin: rgiffin@uwo.ca. E-mail address for C.O. Kean: ckean@unimelb.edu.au. E-mail address for P. Fowler: pfowler@uwo.ca
² University of Iowa Sports Medicine, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242. E-mail address: ned-amendola@uiowa.edu
³ Orthopaedic Division, Department of Surgery, Elborn College, Room 1438, The University of Western Ontario, London, ON N6G 1H1, Canada. E-mail address: dianne.bryant@uwo.ca
⁴ University of Calgary Sport Medicine Centre, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada. E-mail address: mohtadi@ucalgary.ca
⁵ Deceased

A commentary by Michael S. Aronow, MD, is available at www.jbjs.org/commentary and is linked to the online version of this article.

Investigation performed at the Fowler Kennedy Sport Medicine Clinic, London, Ontario, and the University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from PhysiciansServices, Inc. (PSI) and Aircast, Inc. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

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Background To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In all but one study, the limb was immobilized for six to eight weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of the present study was to compare the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functionalrehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone.

Methods Patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. All patients underwent anaccelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The primary outcome was the rerupturerate as demonstrated by a positive Thompson squeeze test, the presence of a palpable gap, and loss of plantar flexion strength.Secondary outcomes included isokinetic strength, the Leppilahti score, range of motion, and calf circumference measured at three, six, twelve, and twenty-four months after injury.

Results A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized. There were118 males and twenty-six females, and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were thirteen complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group.

Conclusions This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. Allmeasured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management.

For further information: http://www.ejbjs.org/cgi/content/abstract/92/17/2767?etoc

KNEE

ORTHOPEDICS November 2010;33(11):832.

Graft Selection in Anterior Cruciate Ligament Surgery

by Matthew R. Poulsen, MD; Darren L. Johnson, MD

The ideal graft for ACL surgery should have similar anatomic and biomechanical characteristics to the native ACL, provide for strong initial fixation, allow for prompt biologic incorporation, and have minimal donor site morbidity for a particular athlete.

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly-performed orthopedic surgeries in this country. As ACL reconstruction techniques have evolved and improved dramatically over the past few years from nonanatomic to anatomic, controversies regarding graft selection remain. While conclusions drawn from past studies regarding graft choice in ACL surgery have resulted from predominantly nonanatomic surgical techniques, there are useful guiding principles that can be followed when determining which type of graft to use in ACL reconstruction.

Graft selection in ACL surgery should be individualized for each patient. It should be athlete-specific, male- and female-specific, and sport-specific. Desired timing for return to play and length of rehabilitation are other important considerations for the surgeon. Other variables to consider include donor site morbidity, graft fixation options, and differences in length of time required for graft incorporation and healing with subsequent return to play.

The ideal graft for ACL surgery should have similar anatomic and biomechanical characteristics to the native ACL, provide for strong initial fixation, allow for prompt biologic incorporation, and have minimal donor site morbidity for a particular athlete. It is generally believed that no one graft source optimally possesses all these characteristics for each patient. Thus, it is imperative that surgeons and patients discuss risks and benefits of all graft types, and then select a graft that is best for each particular clinical scenario.

Graft Options

There are multiple autograft and allograft options for ACL reconstruction. The most common autografts used are bone–patellar tendon–bone and quadrupled-hamstring (gracilis and semitendinosus tendons). Common allograft tendons used include hamstring (usually semitendinosus), Achilles (with or without a bone block), bone–patellar tendon–bone, anterior tibialis, and posterior tibialis. Quadriceps tendon autograft or allograft, with or without a patellar bone block, may also be used.

When selecting a graft for ACL surgery, there are important biologic and scientific concerns to consider. These include bone versus soft tissue healing in bone tunnels, incorporation of allograft versus autograft tissue, ideal fixation options for a particular graft, and ultimate return to play and at what competitive level.

Bone–Patellar Tendon–Bone Autograft

Bone–patellar tendon–bone autograft has been considered the gold standard for ACL reconstruction for many years. One reason is that bone–patellar tendon–bone autograft has the most peer-reviewed data in the literature, with the longest follow-up (compared to other types of ACL grafts). Another reason is that bone-to-bone tunnel healing seen with bone–patellar tendon–bone autograft is more optimal than soft-tissue-to-bone healing seen with most other types of grafts. Also, rigid initial fixation seen with bone-to-bone fixation is superior to other fixation techniques used with all soft tissue grafts (autografts and allografts). With bone–patellar tendon–bone grafts, fixation points are closer together than those seen in suspensory soft tissue fixation, which enhances overall graft stiffness, an important variable that prevents early and late stretching of the graft during the incorporation process.

Furthermore, many studies advocate possible earlier return to play with use of a bone–patellar tendon–bone autograft. Multiple studies have also shown an increased frequency of return to preinjury level of activity after use of bone–patellar tendon–bone autograft, particularly in young athletes who participate in Level 1 sports year round. In a recent study by Mascarenhas et al¹ comparing bone–patellar tendon–bone autograft to bone–patellar tendon–bone allograft, twice as many autograft patients were able to return to very strenuous (jumping or pivoting) activities without the sense of instability.

Additionally, instrumented laxity measurements in bone–patellar tendon–bone autograft patients have shown less laxity than those for allograft patients.² And in a recent metaanalysis by Prodromos et al³comparing stability of autograft to allograft tissue after ACL reconstruction, allograft resulted in significantly more knee laxity compared to autograft. In this study, abnormal stability was 2 to 3 times more frequent after allograft ACL reconstruction.

However, potential disadvantages to using bone–patellar tendon–bone autograft exist. These generally relate to donor site morbidity and include anterior knee pain, patella fracture, decreased knee extension, and a potential adverse effect on the extensor mechanism of the knee.^4-6 Patients who have low pain tolerance, are nonmotivated, or are too busy to participate in vigorous postoperative rehabilitation may have increased morbidity if bone–patellar tendon–bone autograft is used. The majority of the donor-site morbidity issues with this graft are a nonissue in a patient that is well-engaged in the rehabilitation process and achieves normal knee range of motion and patellar mobility within 6 weeks of the index operation.

Hamstring Autograft

Quadrupled-hamstring autograft is frequently used in ACL surgery. It has been shown to be the strongest of all grafts in the laboratory, if equal tension can be applied to each strand.⁷ Also, it is generally considered to have less donor site morbidity compared to bone–patellar tendon–bone autograft. However, tendon-to-bone graft incorporation is slower than bone-to-bone healing (approximately 4 weeks longer). Other potential disadvantages include graft laxity, tunnel osteolysis, and hamstring weakness (particularly with terminal knee flexion).⁶

Both bone–patellar tendon–bone and hamstring autografts for ACL reconstruction have shown adequate clinical results in the literature for the majority of patients. However, in a recent systematic review of the literature by Reinhardt et al,⁸ hamstring autograft was found to result in graft failure more often than bone–patellar tendon–bone autograft. In this study, results were combined from 6 randomized controlled trials comparing bone–patellar tendon–bone and hamstring autografts. There were 11 failures out of 153 bone–patellar tendon–bone autograft reconstructions (7.2%), and 26 failures out of 165 hamstring autograft reconstructions (15.8%) (P=.02).

In addition, Kim et al⁹ recently showed that in patients with excessive joint laxity, including hyperextension, bone–patellar tendon–bone autograft performed better than hamstring autograft at 2-year follow-up. This was especially true in women. In this study, testing of anterior tibial translation with a KT-2000 arthrometer (MEDmetric, San Diego, California) showed significantly increased anterior laxity after use of hamstring autograft. Lysholm clinical scores were also significantly better for bone–patellar tendon–bone patients. These results should be strongly considered when selecting appropriate ACL grafts in female athletes with knee hyperextension, especially those involved in high level sports at high risk for ACL injury (eg, soccer, basketball, volleyball, field hockey, and softball).

Allograft

Allografts are commonly used in primary and revision ACL surgeries. The use of allograft tissue in primary ACL surgery has become more common than in the past, largely because of increased availability, better safety of tissues, and no donor site morbidity.

It is important to understand that use of different allograft tissue types may produce different clinical results. This has not been adequately discussed in the orthopedic literature. The majority of the published literature discussing allograft tissue use in ACL surgery relates to bone–patellar tendon–bone allograft, not all-soft-tissue allograft. Currently, more all-soft-tissue allografts are being used for ACL surgery than bone–patellar tendon–bone allografts. Surgeons must be careful not to “lump” all allograft tissue results as the same. It is imperative that each orthopedic surgeon know what is written in the literature regarding a particular type of allograft tissue selected for ACL reconstruction in a particular patient for which allograft is being considered.

The use of allograft tissue in ACL surgery has been shown to yield adequate clinical results in certain patients. However, a high allograft failure rate after ACL surgery has been demonstrated in young active patients.^10-12 Additionally, Borchers et al¹³ recently showed a significantly higher ACL reconstruction failure-rate after use of allograft, and also after return to a higher activity level. In patients with both characteristics (ie, allograft was used and they returned to higher activity levels), failure of ACL reconstruction was even more significant.

Furthermore, a study by Singhal et al¹² showed an unacceptably high failure rate of an all-soft-tissue allograft (anterior tibialis), particularly in young patients (<25 years).And, as mentioned previously, increased knee laxity has been demonstrated after allograft ACL surgery, compared with the use of autograft.^2,3

The secondary sterilization processing of allograft tissue is important to reduce the incidence of disease transmission and eliminate infection, but many of these processes decrease mechanical properties. For example, Rappe et al¹⁴ showed a significantly higher failure rate with Achilles allograft that had been irradiated with 2 to 2.5 Mrad (2.4% failure rate for nonirradiated grafts, and 33% failure rate for irradiated grafts).¹⁴

Sterilization processes vary tremendously among tissue banks and distributors, and thus surgeons must be familiar with those used by the American Association of Tissue Banks-certified musculoskeletal tissue banks they select. The surgeon is the ultimate tissue bank for the patient. Much remains to be learned about these companies’ proprietary sterilization processes and resultant effects on biologic graft incorporation. Basic science data is severely lacking in this respect, particularly as it relates to animal and human studies with Level 1 evidence.

Conclusion/Authors’ Recommendations

It is imperative to match length of rehabilitation and timing for return-to-play to the biology of the graft incorporation process and timeline (for whichever graft is selected for ACL surgery). Rehabilitation-specific guidelines should be graft-specific. Bone–patellar tendon–bone autograft provides optimal graft incorporation because of bone-to-bone healing. Thus, rehabilitation and return-to-play are optimized with bone–patellar tendon–bone autograft. If soft tissue autograft is used, graft incorporation takes longer because soft-tissue-to-bone tunnel healing is required. Rehabilitation should be lengthened in this scenario, particularly within the first 12 weeks, which is critical for soft tissue healing in a bone tunnel. In addition, rehabilitation and return to play should also be extended if allograft tissue is used, because of the extended graft incorporation time required when compared to autograft tissue.

Young, active patients (<22>

For patients younger than 40 years, who are active but not involved in highly competitive athletics year round, we prefer hamstring autograft (quadrupled gracilis and semitendinosus tendons). In our experience, hamstring autograft has been extremely successful in these patients.

In patients older than 40 years, we feel that allograft and hamstring autograft both produce excellent results. If a patient older than 40 years is highly active, we prefer hamstring autograft. However, based on patient preference and clinical scenario, we have experienced good results with both allograft and hamstring autograft in this age group. In addition, we prefer allograft tissue for revision ACL reconstruction as well as multi-ligamentous knee surgery.

Finally, the most important variable control led by the surgeon in ACL surgery is anatomic graft placement. Anatomic techniques must be used (ie, the femoral and tibial tunnels must be properly positioned) (Figure).¹⁵ If nonanatomic techniques are used; it makes no difference which type of graft is used, the risk of graft failure is highly increased.

Figure: AP and lateral radiographs showing tunnel placement after bilateral ACL reconstructions (each performed by a different surgeon). Tunnels were placed anatomically for the right knee (A, B), while nonanatomic and vertical tunnels were used for the left knee (C,D).

For further information: http://www.orthosupersite.com/view.aspx?rid=76738

Countrywide Campaign to Prevent Soccer Injuries in Swiss Amateur Players

1. Astrid Junge, PhD (astrid.junge@kws.ch)

1. FIFA–Medical Assessment and Research Centre (F-MARC), Schulthess Clinic, Zurich, Switzerland

1. Markus Lamprecht, PhD

1. Lamprecht & Stamm, Sozialforschung und Beratung AG, Zurich, Switzerland

1. Hanspeter Stamm, PhD

1. Lamprecht & Stamm, Sozialforschung und Beratung AG, Zurich, Switzerland

1. Hansruedi Hasler

1. Schweizerischer Fussballverband (SFV), Bern, Switzerland

1. Mario Bizzini, PhD

1. FIFA–Medical Assessment and Research Centre (F-MARC), Schulthess Clinic, Zurich, Switzerland

1. Markus Tschopp, MD

1. Bundesamt für Sport, Magglingen, Switzerland

1. Harald Reuter, Dipl Psych

1. Institut für Sozial- und Präventivmedizin, University Zurich, Zurich, Switzerland

1. Heinz Wyss

1. Schweizerische Unfallversicherungsanstalt (SUVA), Luzern, Switzerland

1. Chris Chilvers

1. Schweizerische Unfallversicherungsanstalt (SUVA), Luzern, Switzerland

1. Jiri Dvorak, MD, PhD

1. FIFA–Medical Assessment and Research Centre (F-MARC), Schulthess Clinic, Zurich, Switzerland

Abstract

Background: In Switzerland, the national accident insurance company registered a total of 42 262 soccer injuries, resulting in costs of approximately 145 million Swiss francs (~US$130 million) in 2003. Research on injury prevention has shown that exercise-based programs can reduce the incidence of soccer injuries.

Purpose: This study was conducted to assess the implementation and effects of a countrywide campaign to reduce the incidence of soccer injuries in Swiss amateur players.

Study Design: Cohort study; Level of evidence, 3.

Methods: All coaches of the Schweizerischer Fussballverband (SFV) received information material and were instructed to implement the injury prevention program “The 11” in their training of amateur players. After the instruction, the coaches were asked to rate the quality and the feasibility of “The 11.” Before the start of the intervention and 4 years later, a representative sample of about 1000 Swiss soccer coaches were interviewed about the frequency and characteristics of injuries in their teams. Teams that did or did not practice “The 11” were compared with respect to the incidence of soccer injuries.

Results: A total of 5549 coaches for amateur players were instructed to perform “The 11” in the training with their teams. The ratings of the teaching session and the prevention program were overall very positive. In 2008, 80% of all SFV coaches knew the prevention campaign “The 11” and 57% performed the program or most parts of it. Teams performing “The 11” had an 11.5% lower incidence of match injuries and a 25.3% lower incidence of training injuries than other teams; noncontact injuries in particular were prevented by the program.

Conclusion: “The 11” was successfully implemented in a countrywide campaign and proved effective in reducing soccer injuries in amateur players. An effect of the prevention program was also observed in the population-based insurance data and health-care costs.

For further information: http://ajs.sagepub.com/content/early/2010/10/16/0363546510377424.abstract

Biomechanical Measures During Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury After Anterior Cruciate Ligament Reconstruction and Return to Sport

1. Mark V. Paterno, PT, MS, SCS, ATC*†‡§‖¶,
2. Laura C. Schmitt, PT, PhD†‡§#,
3. Kevin R. Ford, PhD, FACSM†‡‖,
4. Mitchell J. Rauh, PT, PhD, MPH, FACSM¶,
5. Gregory D. Myer, MS, CSCS†‡,a,
6. Bin Huang, PhD†,b and
7. Timothy E. Hewett, PhD, FACSM†‡‖,c

+Author Affiliations

1. ^†Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
2. ^‡Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati, Ohio
3. ^§Division of Occupational Therapy and Physical Therapy, Cincinnati, Ohio
4. ^‖Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
5. ^¶Graduate Program in Orthopaedic and Sports Sciences, Rocky Mountain University of Health Professions, Provo, Utah
6. ^#Department of Physical Therapy, Ohio State University, Columbus, Ohio
7. ^aGraduate Program in Athletic Training, Rocky Mountain University of Health Professions, Provo, Utah
8. ^bDepartment of Epidemiology and Biostatistics, Cincinnati, Ohio
9. ^cDepartments of Orthopaedic Surgery, College of Medicine and the Department of Biomedical Engineering, University of Cincinnati, Cincinnati, Ohio and The Ohio State University

1. *Mark V. Paterno, PT, MS, SCS, ATC, Cincinnati Children’s Hospital, 3333 Burnet Avenue, MLC 10001, Cincinnati, OH 45229 (e-mail: mark.paterno@cchmc.org).

Abstract

Background: Athletes who return to sport participation after anterior cruciate ligament reconstruction (ACLR) have a higher risk of a second anterior cruciate ligament injury (either reinjury or contralateral injury) compared with non–anterior cruciate ligament–injured athletes.

Hypotheses: Prospective measures of neuromuscular control and postural stability after ACLR will predict relative increased risk for a second anterior cruciate ligament injury.

Study Design: Cohort study (prognosis); Level of evidence, 2.

Methods: Fifty-six athletes underwent a prospective biomechanical screening after ACLR using 3-dimensional motion analysis during a drop vertical jump maneuver and postural stability assessment before return to pivoting and cutting sports. After the initial test session, each subject was followed for 12 months for occurrence of a second anterior cruciate ligament injury. Lower extremity joint kinematics, kinetics, and postural stability were assessed and analyzed. Analysis of variance and logistic regression were used to identify predictors of a second anterior cruciate ligament injury.

Results: Thirteen athletes suffered a subsequent second anterior cruciate ligament injury. Transverse plane hip kinetics and frontal plane knee kinematics during landing, sagittal plane knee moments at landing, and deficits in postural stability predicted a second injury in this population (C statistic = 0.94) with excellent sensitivity (0.92) and specificity (0.88). Specific predictive parameters included an increase in total frontal plane (valgus) movement, greater asymmetry in internal knee extensor moment at initial contact, and a deficit in single-leg postural stability of the involved limb, as measured by the Biodex stability system. Hip rotation moment independently predicted second anterior cruciate ligament injury (C = 0.81) with high sensitivity (0.77) and specificity (0.81).

Conclusion: Altered neuromuscular control of the hip and knee during a dynamic landing task and postural stability deficits after ACLR are predictors of a second anterior cruciate ligament injury after an athlete is released to return to sport.

For further information: http://ajs.sagepub.com/content/38/10/1968.abstract